What does your PCN look like? Does it look the way you want it to?
Primary Care Networks (PCN) are now in their third year. Many PCNs are emerging from the COVID vaccine programme into a business as usual footing. Perhaps it is time to step back and take a look at what the rest of 2022 might look like for PCNs?
There appear to be multiple manifestations of “PCN” mode of working. These range from the mostly inactive: described as the “forgotten 500” (F500) in some quarters, to the networks performing highly against various spend or activity metrics, the definition is not precise. The “500” may actually be over half of the 1250 PCNs in England. The number across GM is unclear. Models of working are a spectrum from PCNs banding together under degrees of local federation leadership, to wholly autonomous PCNs working at “place” to meet the needs of their population/neighbourhoods. Some have a hybrid of engaging with federations in some elements, out-sourcing to other providers in others and directly employing and delivering in others.
This picture of multiple models may seem chaotic and rife with uncertainty – what is the “right way”? Frankly, there is no right way, and navigating uncertainty is indeed the ask of PCN leadership. Perhaps rather than uncertainty, this variability is simply a reflection of the diversity of the practices’ modus operandi? PCNs so often feel the tension between system-led and place-led working. The NHS has many elements that are “top-down”. Anyone who has worked on the vaccine programme will be able to relate to this. “Place”/neighbourhood is the reverse – population informed configuration of services. This tension is probably felt at multiple levels, and there is no doubt that it is felt at PCN level with subsequent impact on decision making. Each PCN must navigate this tension in a way that meets the needs of both system and place.
One way of assessing a PCNs’ activity is whether, how and what ARRS (Additional Roles Reimbursement Scheme) roles are being employed. ARRS is list size-scaled funding of staff from less traditional, to primary care, workforce sources.
Nationally there has been – and continues to be a – significant ARRS underspend in its first two years. In a number of CCG localities, the spend remains below fifty percent. There are some PCNs who are not using any ARRS funds at all. This seems counter intuitive – why not get more staff in, the money cannot be used for anything else?
In the latest episode of the Primary Care Knowledge Boost Podcast Doctors Lisa and Sara speak to Judith Dawson to about supervising new members of the primary care team employed under the ARRS scheme.
There are a number of factors for ARRS underspend. Primary amongst these will be uncertainty regarding this workforce for many PCN leaders. Accessing alternate parts of the health and social care workforce is one thing, but how much corporate knowledge is there about who to integrate pharmacists, paramedics and mental health practitioners into general practice? For many, this lack of knowledge leads to uncertainty. Developing sufficient expertise to have the confidence to resolve this uncertainty and move to recruitment seems an unreasonable ask in the face of overwhelming demand for our time dealing with existing work streams. Taking on new staff from novel professions will inevitably create governance and management overhead beyond the act of recruiting and inducting. How much supervision should a paramedic or pharmacist receive? How can the First Contact Practitioner pathway be funded? Does our existing indemnity insurance even cover these professions? Who is doing this work in your PCN? In the face of uncertainty and workload, criticising the PCN teams that default to inertia seems unreasonable. What is the solution to this multi PCN issue? What is the solution in your PCN? Here in GM we are lucky enough to have a HR advisor courtesy for the GM Primary Care Team. If you want to know more about this offer you can email gm.gpexcellence@nhs.net.
PCNs present – what may be – a once in a generation opportunity to embark on an innovative, maybe even entrepreneurial approach to improving the health and wellbeing of our populations and staff for general practice. PCNs are an opportunity for new ways of working rather than just more (capacity) of the same. They are an opportunity to apply new capabilities to the demand driven challenges in primary care. Is this how you PCN looks and feels?
The new roles appearing in primary care can present a challenge to our patients, many of whom will be accustomed to the more traditional model of general practitioners, nursing and HCAs but less accustomed to pharmacists and paramedics in their primary care journey. There remains the implied task of communicating with our registered patients. Often this falls upon the new practitioner to “break the ice”, though perhaps there is benefit in a broader, network level approach.
For those PCNs who seek to innovate, embracing the concept and reality of change management will be key. Change requires leadership – creating a vision, forging momentum, delivering change and then iterating improvements. This is a demanding ask for leadership, so who in the PCNs will take up the mantle? The obvious answer is the Clinical Director (CD) – the one formally funded leadership role in the PCN model. CDs must juggle the demands of this role with pre-existing demands on their time such as clinical work, practice level leadership and possibly a portfolio of other roles. Leading change will require more time than many CDs have at their disposal. Many PCNs fund business managers or similar from their PCN core funding. Are these the lynchpins in the leadership of the PCN – are they able to create the vision, momentum, results and iterations of change? Let’s identify, encourage and develop the knowledge, skills and behaviours needed by these new leaders to lead in a complex system and through uncertainty.
Leadership might be viewed on the nature vs nurture spectrum. It is possible that some characteristics and leadership behaviours are more innately manifest in some individuals than others. A greater truth is that the knowledge, skills and behaviours of successful leaders can be nurtured through intentional development. Is that intent for development present in your PCN leadership? Is there awareness of the demands of leadership as a parallel set of competencies across knowledge, skills and behaviours dimensions in your PCN? There are opportunities to gain support from the NHS NW Leadership Academy as well as GM Primary Care Delivery Team. If you want more information on leadership development offers, then email gm.gpexcellence@nhs.net.
PCN leadership is a new – and subtly demanding – piece of the success puzzle for primary care. To optimise success, a PCN must be aware of the need for leadership development, be undertaking active development as well as conducting reviews and iterations – the classic Kolb cyclical model of learning. This process facilitates the journey (Benner’s) of novice to expert for leaders. If your PCN is not progressing as you would like, take a look at your leadership function. Time and resource spent developing this is usually time well-spent.
About the blogger
Drew Carroll is a Primary Care Network Clinical Director, Advanced Clinical Practitioner and Managing Director of a leadership consultancy. He has a background in healthcare, the British military and industry. Claiming to have learnt most leadership lessons “the hard way”, he works to have impact at system level and is passionate about looking after staff first. He can be contacted via admin@an-turas.co.uk.
