Organising for the seven service specifications

Understanding the work of primary care networks - and organising for it.

For the most part, the direction of travel and expectations are heavily set for PCNs. These service specifications are:

• Structured Medicines Review and Optimisation

• Enhanced Health in Care Homes

• Anticipatory Care

• Personalised Care

• Supporting Early Cancer Diagnosis

• Cardiovascular Disease Prevention and Diagnosis

• Tackling Neighbourhood Inequalities

At the time of writing, there are ongoing negotiations about the exact nature of these specifications, and crucially, the funding that will be tied to them. Regardless of the outcome of those negotiations, these specifications will be tied to a major source of practice funding.

Many PCNs, after the initial imposed rush of employing physios, social prescribers and pharmacists, are now thinking about how to begin to work towards these service specifications. This is a key time for PCNs and decisions taken now, will have a lasting and hard to undo impact a PCN’s capability to meet the service specifications.

Many think that these specifications can be met though hierarchies and classic deployment of policy. In fact, the very notion of a ‘specification’ points to this – it the ‘business as usual’ form for the majority of the NHS. Our work with PCNs suggests that for the majority of the service specifications, this is the opposite of what is required and what will be effective.

When planning for the service specifications, the temptation is to dive into the detail, thinking about individual patients. The trick is to stay at a high level in these opening stages. It is your organising form that dictates how effective you are in meeting these specifications. The work of each specification is not the same - thus the required shape of organisation differs.

I recently worked with a group of 16 PCN Clinical Directors and we ran an exercise to begin to plan for these services specification.

We thought about this against two distinct types of work required to help someone:

Linear

A largely process driven bio-medical response. Such as a test in secondary care, drug, an onward referral to a clinical specialist or medical assessment. This can be highly technical in nature but success is generally reliant on process steps coming together (Downham 2019).

Relational

A response that may include, but is largely reliant on factors outside the bio-medical. Such as the person's environment and social circumstances. This features a number of loops of interventions and relationships form the foundation (Downham 2019).

We then thought about the organising form that might be best suited to achieve this for each of the specifications:

Hierarchical

Concentrating on structure and process to deliver and manage control of services against specifications. Based on legitimate authority. This is the typical form a traditional provider model takes.

Network Based

Where the work is innovative (doing better things, rather than making things better), where multiple independent parties need to come together and where needs are complex and interdependent.

LINK TO BECKY BLOG ON THIS

Putting this together produced a very valuable picture for PCN planning around organisational form.

What the matrix above (developed by 16 PCN Clinical Directors) tells us is:

• All but two of the service specifications need a true network based response. Reliant on multiple, independent parties coming together with a common purpose. A simplified, defragmented, response to need is also crucial.

• Our ‘business as usual’ hierarchical structures are not the solution.

• A drive for process improvement is only suited to the more transactional specifications – such as Early Cancer Diagnosis and Medicines Reviews. We cannot rely on a process improvement (sometimes called Quality Improvement) approach. The above suggests we need to challenge our work and our structures more fundamentally.

• The key to the specifications in the bottom right is the context of the patient. Context (social determinants) drive health and we need to acknowledge this fully in our service design (instead of trying to move it to another part of the system).

This practically means

 Commissioners need to:

• Build in funding for time for PCNs to concentrate on true network building.

• Stop inadvertently forcing PCNs into hierarchical (provider) forms by putting deadlines and funding links to short term delivery aims. Help PCN clinical leaders concentrate on forming true network working, rather than driving them to form management and provider hierarchies.

• Simplify the provision of community care through longer term and integrated commissioning. This requires more flexibility on specification and scrutiny, in order for front line staff to be able to do ‘what matters’ and form relationships.

• Understand the end to end costs of care rather than the point (intervention) costs. This radically changes the conversation. The money is there, we just waste it with hugely fragmented responses to helping people with everyone concentrating on their bit.

PCNs need to:

• Consider the work very carefully. This starts with understanding the need. (LINK TO UNDERSTANDING NEED BLOG). This should shape the work.

• Take this understanding and spend time creating a common purpose. No network of individual services and stakeholders can operate without a clear, co-designed, purpose. It is the glue that holds it all together (LINK BECKY BLOG).

• Consider how much of the work is reliant on patient context and thus a relationship with the patient. How effective are your practices at providing continuity of care to those who need it (TONY BLOG).

• Be clear on what work happens should happen at what level (LINK TO BLOG ON NEED):

o   Practice level: Low and medium acuity patients in a stable social context.

o   PCN level: Low and medium acuity patients with under pressure with social context. High acuity patients with stable social context.

o   ICS level: Patients with turbulent social context. High and very high acuity patients.

• Spend time creating your theory of change for each service specification. Driver diagrams are a great way of doing this. You will find common core drivers that are the same across most of the service specifications.