Where To Start – dilemmas of a PCN CD

I’ve been lurking on Whats App groups and meeting with PCNs during their rushed and short meetings. I can see the intent of PCNs getting lost in the bureaucracy of how to be paid for pharmacists, how to manage VAT….. the idea that PCNs will be real networks of collaboration with the ability to solve problems that need them to work together is getting saturated by ‘stuff’ as the old world bite back. It’s getting to the point where the start up noise is drowning out the real long term point of PCNs. In June after we had interviewed a number of PCN Clinical Directors and leaders I put together a blog on Purpose which set out the challenge of doing the transactional stuff in order to be able to do the real work of PCNs – meeting needs that cant be met by a general practice on its own.

It is now August and time to move onto the real work of PCNs before everyone forgets what that is. If PCNs carry on getting bogged down with the transactional, contractual ‘stuff’ they will have nothing left for the real work, and nobody to do that work with.

There is no doubt that some of the architects of PCNs totally get it – their intent is about changing the model of care – the way we meet needs together. So here are some top tips for CD leaders for the coming months:

  1. Prioritise Purpose. Do the things that really matter to your community, you and your collaborating practices.
  2. That means – Discover Needs. Work with your partner practices to find out whose needs are not being met by the current system of delivery. Your practice nurses, receptionists and GPs will have a good hunch, so follow you noses and see what you can find out.
  3. Meet those Needs – work together to solve these complex people’s problems.
  4. Create a legitimate space. Do enough of the ‘stuff’ to make sure you have the air cover to do the real work, and get help for the ‘stuff’ from those that do it well. There are plenty of people working in local NHS organisations who know how to project manage the life out of the NHS, use them for the transactional work.
  5. Make your own luck – involve anyone in the creation of your network that could help, and who is committed to your purpose. Local councillors, community leaders, other services.
  6. That reminds me – you do need to be clear about your purpose in a way that your community can understand it, and will back it because it’s clearly adding value….
  7. Work out who you are accountable too. You are using and spending public money, who do you think can say yes or no to how you do that? Who do you want to be your ‘owners’. There is real power in making that your community rather than the NHS hierarchy.
  8. Develop a membership model that ensures you can have all the benefits of a network – creative solutions, diverse views, peer based collaboration, real impact; that means equality, and a clear view about what being a member means in terms of obligations (joining in ) and expectations (clarity of purpose ), and how you will handle those that don’t pull their weight and those that are over enthusiasts! Predicating a core group of ‘doers and enthusiasts’ also predicts network failure (Malby and Anderson Wallace 2018) its all together or not at all….

There are two key and neglected purposes of PCNs:

  1. Meeting the needs of people who are too complex for a general practice to handle on its own, but not so complex that they are primarily the business of secondary care
  2. Getting upstream into prevention and supporting people who don’t access health

Focus Your Time on the Main Purpose of PCNS: Meeting Complex Needs

In the meetings I’ve been too there is real energy about understanding their communities needs and finding better ways of meeting these. All PCN meetings should have the majority of their time spent on this work. My suggestion is that participating practices bring a ‘deep dive’ notes review of a few of their complex patients – the ones they know are bouncing round the system – mapping all the dates in a year or two where that patient has ‘touched’ the health system (hospital, outpatients, district nurse, GP etc). Here is one set out as a list and a ppt

Which of the patients notes you have reviewed together do you think you can solve at PCN level? Put a couple of hours aside at a PCN meeting and talk this through. It will really help you both clarify what the PCN is for but also what you think you can do better together. If you don’t think you can – who can? ICS? For the ones who you think you could do better for, with the help of others in the system, work out who else you need and bring them to the table. Start designing solutions together with other partners. Collaboration is at the heart of the PCN.

An example of a solution that lies just within the collaborating practices

One group of practices recognises the skills in helping people with tricky leg ulcers and they have a great nurse in one of the practices – what if she supervised all those patients in the PCN, passing her knowledge onto the practice staff and offering skilled review? Here we are in danger of getting into the transactional stuff – the process for this could be bogged down by payments etc, but what if each practice gifted some expertise into the network for a number of sessions? This is the joy of real networks – then no transactional stuff needs to happen.

This is the real work of PCNs. To do it you need to know who is attending frequently and why. We know that about half of people who attend frequently have really complex needs; and about half their problems dissipate over time and another cohort replaces them. The second group are probably the work of general practice, the first group could provide the patients/ people and families who need a more joined up approach.

This is meaningful work, it will engage your practices and generate energy and resources.

Getting upstream into prevention and supporting people who don’t access health

We have found that a lot of people (particularly young people) don’t access services at all – they are storing up problems for later life that could be nipped in the bud.

The red shows how few people are accessing this practice from ages 7 to 28!

Not only that but general practice is there for the whole population, and some people are just not being served.

What do you know about this across all your participating practices? If you had a look at this data you might want to collaborate to reach the younger people who need, and deserve your services.

The next blog will tackle social prescribing, but for now if you look at the time you spend in meetings and you align it so that the majority of the time is to meet the real purpose of your PCN, you will be stopping the old world biting back and have the chance of making a real difference to and with local people.

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