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Primary care networks – the key to a more co-operative NHS?

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Networks The future of primary care is in joined up working, and PCNs provide a formal structure to achieve this

Primary care networks (PCNs) form a key building block of the NHS long-term plan and bring general practices together to work at scale.

Many people are living with long term conditions such as heart disease and diabetes or have mental health issues that mean they need to access health services more frequently. To meet these needs, practices have begun working together and with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in PCNs.

The impetus behind PCNs dates back to the 1990s, when single handed practices were working in isolation. Carol Webley-Brown, a nurse at One Health Lewisham, GP Extended Access, and a member of the Queen’s Nursing Institute (QNI), says that this approach was ‘not fit for purpose’.

She says that not only were their issues with cover for single-handed GPs who were sick, or had long term health problems, but that their premises, often houses converted into practices, were not geared to the mobility needs of older patients, such as lacking lifts or ramps.

To address these issues, in 1999 primary care groups were established, emphasising partnership and collective responsibility for patients’ care and welfare. Following the move, some single-handed GPs retired while others joined health centres and became part of a group of practices.

While GP practices have been finding different ways of working together over many years – for example in super-partnerships, federations, clusters and networks – the NHS long-term plan and the new five-year framework for the GP contract, published in January 2019, put together a more formal structure around this way of working, but without creating new statutory bodies, the King’s Fund says.

According to the think tank, since 1 July 2019, all but a handful of GP practices in England have come together in around 1 300 geographical networks covering populations of approximately 30–50 000 patients. ‘This size is consistent with the size of primary care homes, which exist in many places in the country, but much smaller than most GP federations. Around 50 networks, usually in very rural areas, will cover a population of less than 30 000, but most are bigger than 50 000,’ the King’s Fund says.

PCN structure

Most networks are geographically based and, between them, cover all practices within a clinical commissioning group (CCG) boundary. There are some exceptions where there were already well-functioning networks that are not entirely geographically based, and some networks cross CCG boundaries.

Every PCN has a clinical director and administrative support from practice managers, but it is typically down to individual practices how they structure PCNs.

PCNs are closely linked to the ambitions of the NHS Long Term Plan, which focuses on the expansion of services and funding within a community, says Dr Richard Vautrey, chair of the British Medical Association’s (BMA) General Practitioners Committee.

‘These include trying to improve early diagnosis of cancer, improving care of nursing home patients, identifying hypertension. All of those areas are identified as part of the Long Term Plan and will increasingly be linked to PCNs,’ he says.

Benefits of PCNs

Where emerging primary care networks are in place in parts of the country, there are clear benefits for patients and clinicians. PCNs are ‘a good thing’, says Dr Vautrey. ‘They provide greater support for practices because there are an expanding number of people working in and around them to take on some of the workload burden of individual practitioners,’ he says.

He hopes PCNs ‘will help to reduce the practice workload as there will be other healthcare professionals working alongside GPs’. Those additions include pharmacists, physiotherapists, physician associates and paramedics, who as well as taking on some of the GP workload may be sharing their knowledge within the wider team, and also increasingly networking with colleagues, ‘learning about their experiences, and hopefully finding that a helpful process’, Dr Vautrey says.

Ms Webley-Brown, who works in Lewisham, says the area has six PCNs, which were established last year. ‘We’re trying to work together to take the pressure off GPs and still meet the needs of patients.’

One of the advantages of PCNs, she says, is that clusters of practices know the challenges they face and the patient group they are managing, and so can share their knowledge and experiences. She cites the example of when a cluster of GPs that are part of a PCN are managing an elderly, frail population. Another cluster trying to deal with this population ‘can learn from that PCN, which can share good practice’, she says.

PCNs are also an opportunity to make the most of ‘social prescribing’ – sometimes referred to as community referral – where GPs, nurses and other primary care professionals refer patients to a range of local, non-clinical services. Ms Webley-Brown says social prescribing is ‘a fascinating area and a brilliant way forward to help groups whose needs are not met’.

And being culturally sensitive to people’s needs through networking and working with others involved in community care, and focussing on individual’s specific healthcare needs, is like ‘a bolt of lightning to make people realise if we work together we can achieve much more’, Ms Webley-Brown says.

Jennifer Aston, an advanced nurse practitioner for Granta Medical Practices, and a member of the QNI, also embraces the power of PCNs. ‘The concept is a good one – it goes back to “what does our patient population need?” And the big purpose behind it is right – to try and improve and care for groups of patients who have not been as well served as they might have been when you have lots of small practices. But by working at scale you may be able to give a more joined up holistic service,’ she says.

She gives examples of patients with wounds who may also have social needs, or who might need to have podiatry care for people with diabetes. She stresses the importance of healthcare professionals looking at people’s conditions associated with a specific issue. ‘You might focus on say a foot wound and then look at giving support to the patient about the management of good foot care.’

Another benefit of PCNs is that they offer the opportunity to go back to community-based multi-professional working that typified the shape of healthcare 30 years ago. ‘That was a time when you knew the district nurse, the health visitors, and the school nurses.

‘Teams have been working in isolation. But hopefully PCNs will result in more joined up communication,’ she says.

She believes if PCNs ‘get it right, it will hopefully break down silo working and help find ways to improve individuals’ mental and physical health so they have a better quality of life’.

Looking at workload, Ms Aston says PCNs are an opportunity for identifying ‘the best people with the right skills’ to deliver care’.

And Ms Webley-Brown says PCNs are helping nurses ‘to be more connected with each other, to communicate far better’. But she warns that with ‘so many gaps’ in district nursing and school nursing, and with many nurses of retirement age, ‘there will be recruitment and retention issues’ for PCNs.

Barriers to PCNs

While viewing PCNs as a positive development, Ms Aston says there are barriers to making them work, notably ‘how we access appropriate money’ to make them work.

Changing the culture of people who are used to working in silos but now have to work as part of a team can also be challenging. ‘The problem is organisations have, in some cases, been pushed together unwillingly. Practices asked to be part of a PCN may have been rival practices, with cultural differences,’ she says.

For practice nurses, there is the danger of their value not being acknowledged. Ms Aston says only a few places have given nurses the option to apply for a clinical director post or to have a ‘significant input into the PCN process’.

And the PCN DES fails to specifically identify GPNs.
Dr Crystal Oldman, chief executive, the Queen’s Nursing Institute (QNI), says the charity has highlighted in its response to the PCN DES that there was ‘a potential for much of the work detailed there to be undertaken by appropriately qualified nurses’.

‘For example, in many areas nurse practitioners in general practice are providing care homes with scheduled support for the healthcare of residents,’ Dr Oldman says.

She says the QNI noted that general practice nurses (GPNs) were omitted from being identified specifically in the PCN DES ‘and we have had much feedback from our stakeholder GPNs that they felt that their contribution to the health of the population had been completely ignored. I have heard that this was in fact a deliberate decision, because of the lack of registered nurses available’.

She says it is ‘regrettable as it has left GPNs feeling their value had been overlooked – at a time when there is a need for greater recognition of their considerable skills’.

However she is confident that NHSE ‘have listened to our detailed feedback on all aspects of the PCN DES and will respond accordingly, recognising the current work of the GPNs and working with HEE to support both GPN recruitment to primary care and the education and training needed to meet the needs of the communities served’.

While it is ‘early days’ for nurses to get to grips with how PCNs work ‘we understand its principles’, says Ms Aston.

But she believes while health care professionals are ‘trying to think differently how to deliver care out of hospitals’, those working in the community, including community nurses ‘need the opportunity to be involved in decision making about what we should be doing as a PCN rather than a narrow approach to fixing problems.

‘We’re at a crossroads – but we can’t keep going as we are, and we’ve got to find different ways to provide care.’

Kathy Oxtoby is a healthcare journalist


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