Look Who’s Talking: Dr Neil Paul

Article by Dr Neil Paul, GP Partner in Sandbach

Primary care networks (PCNs) are the current hottest game in town, but not everyone knows about these huge changes to healthcare delivery. This week I was stunned to meet a GP who actually hadn’t heard of them at all, as most should have!

However, it turns out he was from Scotland where for once they are not the ‘guinea pigs’ so I will forgive him. Although most GPs should know what they are, I suspect a lot of people in primary care and the wider world are not yet aware of them.

In case you don’t know what a PCN is, let me explain. Every GP practice in the country has been offered the opportunity through a DES (direct enhanced service – extra money for doing something) to form a PCN.

The idea is based on the National Association of Primary Care (NAPC) primary care home model, which states that health services should be delivered to populations of around 30,000–50,000 people. This is the ideal size for having enough of most conditions to make doing something worthwhile, without being so big as to make it difficult to manage.

Ideally, PCNs should be geographically co-located and form natural populations. This enables place-based care, which is the other buzz term we are hearing a lot. This is the basis for forming integrated care partnerships (ICPs), which are the bodies that need to think in these delivery units. An ICP is another reorganisation in which all the providers in an area – including acute, community and primary care – are put in a room, given a set amount of money and told to get on with it.

The idea is that they will do a better job of it than the old commissioner/provider split. It’s all based on the accountable care model made popular in the States, and there are lots of publications from organisations like the King’s Fund that provide information about it.

In my opinion ICPs are a good idea; it seems to work in the States. However, once formed, they seem to take two to three years to really start delivering results. This is partly because at first they concentrate too much on secondary care and not enough on primary care and the screening, public health agenda.

So far, more than a thousand PCNs have been set up, which goes to show you can do anything if you incentivise it with money, and fewer than ten practices have refused. How happy the PCNs are about forming, and whether they are delivering anything significant, other than the bare minimum that is in the DES contract, remains to be seen.

The PCN DES itself appears to have been written by committee, with various ideas in mind. There is no doubt that practice resilience is one of them. Practices have been saying for ages that they are falling over, and they are struggling to recruit. Perhaps forcing practices to work together breaks down the barriers and encourages them to help each other and be open about their problems, especially if they are being asked to reach collective targets. Of course, some old rivalries are hard to break, and I’m sure it’s not all plain sailing.

Another idea is to promote new staff and new staff types in practice, and the DES certainly brings a lot of money into primary care to do this. It’s actually done in quite a clever way. By only paying for 70%, it encourages practices to have skin in the game. Simply being given staff might not get them to engage; do you engage more with something you pay for?

By limiting the spend to new types of staff, the DES encourages practices to skill-mix, to evolve and to experiment. Many practices are change-resistant, and this perhaps breaks that resistance. The pharmacist in practice scheme certainly helped to do that with pharmacists. It also achieves this by taking a baseline of staff, which minimises potential gaming, making sure practices don’t just pocket the money and that it is genuinely spent on new staff.

Some might say another idea behind the DES is to force mergers, and some mergers are happening. Locally, whole towns are forming one super-practice. From a resilience point of view, perhaps bigger is better. Some say this is to make it easy for practices to be privatised. I’m not convinced, as all the evidence shows that private organisations aren’t interested in getting into the NHS. However, other NHS bodies, such as trusts, might be keen; and, indeed, some are taking over practices. This doesn’t always go smoothly, and a couple of trusts I’ve spoken to have told me it’s a lot of hard work for little gain.

Many practices don’t want to merge, though some are happy to start thinking about sharing back office and outsourcing services. This ‘working at scale’ agenda seems to be one of the big drivers behind the DES, and the reason behind it is an attempt to level up primary care delivery, service levels and quality.

In an ICP world, all providers sit around the table and share out the money. From people who have done this, we know you should invest in primary care and not secondary care. It is oversimplistic to say that this is because prevention is better than cure. If primary care is disparate, not joined up and (even worse) variable in quality, why would you give it any funding or contracts?

Joining up practices by giving them collective targets to achieve is definitely part of the game. This makes them self-regulate performance due to peer pressure and drives a levelling up. Practices merging clearly need to join up everything, as you can’t have different parts of one practice working in different ways. Practices that aren’t merging but are trying to work clinically in a more uniform way are (or should be) concentrating on pathways, protocols, formularies and common training. They need to spend a lot of time putting clinicians in a room to discuss topics and their different ways of dealing with them.

Joining up the front end is hard; often, people come from different backgrounds and like the way they do things, and without the impetus of a merger they may resist change. However, there is a feeling that joining up the back end could be easier, and there seems to be less resistance to outsourcing or collectivising the back office, perhaps off-site. Again, working on common protocols and procedures is the answer.

There is a huge role for training companies to deliver standard training and assessments across a PCN to help this levelling up and to drive standardisation and harmonisation. There is also a role for them to help evaluate the differences and perhaps to project-manage the implementation: sometimes, just having a training package isn’t enough.

Hopefully, now you know a bit more about PCNs and why practices are forming them. Some want to merge, and others want to work together – either front of house or back office. Some are doing it to be part of an ICP and represent their areas, and some are doing it for the money and the new staff (that is, to survive). Next time, I plan to talk more about some of the things a PCN might be up to.

Dr Neil Paul

Dr Neil Paul is a GP partner in Sandbach where he delivers 5 clinical sessions and runs a clinical research team.

He is a PCN clinical director, a GP Federation Executive, and a board member of CCICP (a community services provider), as well as a shadow board member on the Cheshire East ICP.

He runs a company supporting other PCNs and GP Federations called Howbeck Healthcare and also runs CheshireGPed which puts on evening educational meetings for GPs in the area.