The advise on Primary Care Networks (PCNs) is a muddle of organisational form. To prevent the old world of hierarchy biting back we need to understand their purpose and how to organise.
The language and guidance veers between:
- The PCN as a delivery organisation (social enterprise/ company) with a Board managing the business and a responsible officer to meet the workload/ workforce crisis in general practice
- The PCN as a network where knowledge is key, where the work is innovation, where leadership is distributed and members are facilitated by the network leader to meet increasingly complex inter-dependent need.
These two forms are different and the confusion arises from a lack of clarity of the problem PCNs are the solution for and the purpose of PCNs.
The difficulty for PCNs is that, dependent on the work, they could well need both ways of organizing for different types of work and they are doing this within an NHS struggling to break away from the dominance of its hierarchical culture.
Here is an example of the confusion:
“Practices may wish to consider how similar staff working in different practices and settings might want to interact at network level (e.g. a board for nurses, a board for GPs, a board for practice managers) to share ideas, best practice, etc. However, this needs to be developed in line with available resources.” (BMA 2019 p6)
Boards are for governance not for learning and development, if the PCN is going to focus on sharing ideas, best practice and spreading innovation (i.e. making sure that ideas are applied in practice, rather than ideas as entertainment – the talking shop version) it will need a learning network methodology for example a Community of Practice. But I’m getting ahead of myself.
What are Networks?
Networks are innovation spaces. They are the form of choice for complex ‘wicked’ issues where you can only solve the problems together through creative means. They are great for collaboration and learning. They are no good where the solutions are known – here you just need straightforward hierarchy and performance management (Malby and Anderson-Wallace 2016). So if the problem is not enough staff and the solution is known to be more staff then don’t choose a network.
As you can already see the issue for PCNs is that they are the organisational solution to multiple and opaque purpose which leads to a whole range of form of organising.
The starting point for any organisational form is the work it’s trying to do i.e. its purpose. Here is where the difficulties start. The literature on PCNs is focusing on solutions not purpose. Here are the range if aims of PCNs:
- BMA: To bring care closer to communities – but it doesn’t say what will be better as a result (which is the purpose). This is followed by more solutions – one stop shops, different care models, influencing STPs to shape strategic direction. (BMA 2019)
- NAPC has a more focused proposition for population health management – that ‘established’ PCNs are primary care homes which “provide enhanced personalised and preventative care for their local community. Staff come together as a complete care community – drawn from GP surgeries, community, mental health and acute trusts, social care and the voluntary sector – to focus on local population needs and provide care closer to patients’ homes” So for NAPC the aim is to meet population needs closer to patients homes in service to better population health outcomes. This last phrase is a purpose. They go onto say that the PCHs provide an integrated workforce and I have to assume that is to meet complex needs as for NAPC the workforce includes social care, third sectors, mental health as well as general practice. (NAPC 2019)
- NHS England describes “key themes of integration of services, population health management, care focussed on the needs of their local populations, with the potential for shared assets and workforce”, in order to provide “care on a scale which is small enough for patients to get the continuous and personalised care they value, but large enough – in their partnership with others in the local health and care system – to be resilient.” NHS England 2019 . For NHS England this reads as a workforce issue to solve the crisis of workload in general practice. And if you read the GP contract you could assume that PCNs provide extra/ different staff so general practices can carry on being viable.
At the same time CCGs continue to measure PC performance in terms of reducing admits to A&E despite the fantastic research showing that A&E breaches are related to increasing acuity/ complexity, increased length of stay, staffing and facilities out of pace with the changes in need in A&E, increase in case management within A&E, not as the dominant narrative suggests, as a result of increased numbers and poor primary care (Wyatt 2019). We can expect more of the same for PCNs.
If we look at the examples of teams working together at population scale to meet population health need (Intermountain, Nuka, Buurtzorg) we see their purpose covers these areas:
- Meeting the needs of people with complex needs at the point they arise – so that people with complex needs don’t revolve round the system with their needs unmet, having multiple touch points with little improvement in their care.
- Reducing demand on health services – working together with people and communities and meeting needs early on will reduce demand
- Ensuring everyone has an equal opportunity for good health – reducing inequalities in provision, and working with people to maintain and optimise their health.
And as all these high performing systems have shown this leads to reduce costs, and the knock on effect of reducing hospital and other service touch points, and the need for more and more clinical staff (Riess Brennen 2016, Circovic 2018, Gottlieb 2013). Here is an example from Intermountain
These organisations use a network model that has distributed leadership and a high knowledge management function.
All of these systems started with purpose and then identified and addressed need. Nowhere in any of the documents about PCNs do I see a real clarity on developing data teams to support PCNs in understanding need (not demand, need). And as you can see the purposes above are not solely biomedical.
From Purpose to ‘How’
Once the purpose of PCNs is agreed then we can move onto the ‘how. At the moment the range of guidance looks familiarly like a range of solutions looking for a problems.
(a) Purpose: Workforce Crisis
If the purpose is to meet the workforce crisis then the solution is a hierarchical delivery organisation that sits alongside general practice and plugs the gaps. So set up a company and contract to the GPs to do just that.
(b) Purpose: Meeting Needs/ Reducing demand
If the purpose is to meet needs at the point they arise then you have two types of need to address:
- Those that can be met at practice level with a wider range of services – here the PCN might be the vehicle for sharing skills across practices – this is economies of scale. For this you need a collaborative delivery network with governance through a lead organisation model.
- Those that are complex but can be supported with the help of the community (at GP scale)
- Those that are complex and require multiple collaborating agencies (best provided at PCN / PCH scale) – this is working at scale and the governance will depend on the volume of that work in the PCN
If the purpose is to meet complex need then the organisational form will be multifaceted. To meet complex needs you need the following:
- To understand these needs – data and ethnography. As you can see from a previous blog a lot of complex needs arise from ‘struggling with life’ not biomedical co-morbidities.
- To determine the mix of services to meet these needs and the anticipated plan of care. This isn’t rocket science. If all General practices looked at the pattern of people who turn up frequently in their practices (more than 3x a month), looked at their presenting health needs, rated their ability to cope with their lives, and interviewed a range of them you would quickly find out a good enough set of needs. I bet they fall into the following categories:
- People struggling with life and verging on chaotic lives. These folk need at the early stages support from their community (or social prescribing) which can be provide in the GP practice population; and at the high need stages an intensive intervention team which would need to work across the PCN population. Learn the lessons from the Troubled Families Programme (Bate and Bellis 2018) here
- People who are getting old and frail. It is possible to anticipate the trajectory of these folk and how best to meet their needs. Anticipatory care planning is possible without ‘starting from scratch’ each time, and again you can work out at what point of need the practice needs a wider range of collaborating services (integrated care)
- People coping with both physical and mental health needs. Again algorithms of complexity have been developed by Intermountain that describe the increasing levels of intervention needed (Reiss-Brennen 2016)
- Young people presenting with early signs of distress (e.g. self harm)
- Once you understand the need and what it takes to meet this need you can work out who can be best served within the GP practice team working with the local community and who needs a broader mix of skills across multiple agencies which is better provided through the PCN. This approach is called ‘Working at Scale’.
(c) Purpose: Equality and reducing health inequalities
To secure equality and reduce inequalities then you will need different data. Firstly to find out who doesn’t get any primary care at all – we know it’s pretty much anyone between the ages of small child to mid 20s, and then to see how services are distributed. For instance we found working with one health system that people who have depression and heart conditions are discharged from hospital earlier than those with just heard conditions.
From here on we are back to ‘what scale for what work’ i.e. always do the work at the lowest possible scale, pushing work up to a larger population scale only where It cannot be done at GP scale.
PCNs that create and innovate
Once you have agreed the purpose of the PCN, and what work happens at what scale (practice and PCN scales – and of course ICS too) you then have to work on the type of network you are setting up. This relates to how you see yourselves meeting that purpose. If PCNs are delivery networks they still need business intelligence and learning functions i.e. to meet complex need you will have to innovate and learn together, and you will need to be able to access the best intelligence to do that. Again there are different scales :
- General practice needs to be constantly developing its capacity to meet need by sorting flow, how it generates work, and its collaboration with the local community through asset based working.
- PCNs will need to be learning internally about generating collaborative cultures, and what it needs from robust PC in general practice
- PCNs together across a borough will need to be sharing practices, learning together about change, innovation, best practice and challenging each other on how they are developing new solutions locally – as part of a learning network.
Alongside the PCN delivery network, PCNs need to collaborate in a learning network – not as a board within a PCN but as a community of practice. You can find out more about types of networks here http://www.source4networks.org.uk/learning-space/engagement-participation-and-collaboration-in-networks. This could be a role for Federations or AHSNs.
There are four key areas for organising practice in networks (Malby and Anderson-Wallace 2016)
- Power & Leadership – How is power used and leadership enacted? How do decisions get made?
- Purpose and Direction – How are the joint and several purposes of the network surfaced, how are these purposes developed and how is direction set and adjusted? How expectations of action are set, maintained and measured / evaluated?
- Communication – How do you ensure that communication is supported as a primary organising process, which constitutes and reconstitutes the network moment by moment?
- Knowledge & Learning – How do you ensure that knowledge is developed as a shared asset and that social learning opportunities are maximised?
Little in the literature I have read has addressed these core ‘practices’ in networks. Neither does the job description for the clinical director or the advice on governance take the core learning on Leading Networks
Network leadership is:
- Democratic and inclusive
Whilst making the most of difference for creative ends. Networks need to be managed but in collaborative, non-hierarchical ways. (Malby & Anderson Wallace 2016).
You can read a brief summary here (and watch the webex on the same page)
It seems to me that PCNs have two functions:
- Economies of scale to meet the purpose of the crisis in general practice – supporting general practice by providing services / staff that cant be afforded within a practice. This requires coordination and is delivered though a hierarchical management form (it could be a lead provider)
- Working at scale to meet demand – developing collaborative integrated services for people with complex needs that requires coproduction – through a network delivery form.
Do see our book on this (Malby and Anderson Wallace 2016) and our website Source 4 Networks
Malby B, Anderson Wallace M (2016) Networks in Healthcare. Managing complex relationships. Emerald.
Reiss-Brennan, B., Brunisholz, K.D., Dredge, C., Briot, P., Grazier, K., Wilcox, A., Savitz, L. and James, B., (2016). Association of integrated team-based care with health care quality, utilization, and cost. Jama, 316(8), pp.826-834.