Getting to the purpose of PCNs. Holding true to purpose whilst the old world bites back.
“If you don’t like the way that people are behaving, they are likely to be organising around a purpose that you don’t support.” Julian Pratt
In May 2019 we conducted a set of interviews with PCN leaders and held an open workshop with Nikki Kanani. This blog focuses on the ‘So What’ of Primary Care Networks – their Purpose. You can also see what Nikki has to say in the next blog to be posted.
Emerging Purpose of PCNs
I’ve been watching a trail of conversations on various Whats App groups as GP leaders try to make sense of the size (and voting rights) payments (for people and hours), governance (read payments and what that means for VAT) and partnerships (and conflicts of interest).
This came after excitement at the additional payments for primary care and the focus on collaboration that seemed to build on the emergent trajectory arising from developments such as Primary Care Homes and other collaborations that meet the needs of people with complex needs and work upstream to secure health and wellness.
The two dialogues are not sitting comfortably together. Whilst the nature of organising is never neat and tidy, there seems to be extraordinary confusion over Working at Scale and Economies of Scale, over partnerships and networks, over self-managed emergent change and top down dictat, over CCG determined or Primary Care determined sizing and memberships.
This confusion is sat alongside the pressing immediate issues – the need for a new workforce that may exceed supply, and a growing mental health crisis with little sight of a plan to invest in services. One GP told me that the wait for CBT for someone that was too seriously ill for online support was 11 months.
The lack of clarity about what PCNs are for – what problem they are there to solve – could generate significant beurocracy and ‘meetings’ as a burden that stifles the very innovation they need, and the ‘top down’ requirements are pulling PCN leaders that way.
It reminds me of this power dynamic (Heimans and Timms).
Dynamic, innovative primary care leaders are trying get PCNs off the ground at incredibly short notice, whilst also trying not to get bogged down in the ‘old world’ to the detriment of the need for relational collaboration. The late night weekend Whats Apps are a testament to their focus on doing the right thing and keeping the end point in mind.
Starting Points Matter
As we know from Complex Systems theory (Malby and Fischer 2006) starting points really matter. If the founding conversations for a network are all about power, that is what will play out in the ensuing development. The scrabble to secure the ‘governance’ frameworks for PCNs and the range of invested interest perspectives on what PCNs are really for could drag PCNs back into the very structures they are there to overcome – the world of transactional contracts. Governance becomes how to handle the money rather than its true meaning which is how to make ethical decisions together to secure public value. Governance needs a conversation about ownership (who to give an account too), as yet an absent concept in many of the PCN development discussions as the immediacy of securing the funding ties PCNS into the transactional old power world. Without a clear purpose PCN leaders will struggle to keep sight on the real opportunities of PCNs, or to dismiss overly beurocratic risk adverse interpretations of guidance by CCGs.
All this points different stakeholders holding different purposes, and using power to secure the one they are invested in.
What are PCNs for?
You may well have had a look at my blog on networks where you will see how important it is in any network to be clear about purpose. Without a clear shared purpose how can you collaborate? How can you review how well you are doing; the difference you are making (which needs to be in service to the shared purpose)? How can you be accountable for taxpayers money? Without clear shared purpose you can only measure the ‘things’ that you have been told to do and whether you have done them – there is no higher innovation narrative. Shared Purpose will hold PCNs into a collaborative network space where ideas can emerge and creative solutions can be designed.
We interviewed 10 leaders of PCNs. From these interviews we found a wide range of purposes that PCNs are holding at the moment which seem to fall into 2 camps – Economies of Scale (transactional, which will increase demand) and Working at Scale in Networks (which can meet need and reduce demand).
The Range of Current Purposes Held by PCNs
These purposes were not all held by every PCN, rather a mix is held by each PCN. (See footnote from the list from the Nuffield Trust)
1. Networks Working at Scale
Learning and innovation
Delivering complex care/ integrated care (for some as part of the ICS) together
Support communities to help themselves – increasing community assets
Get upstream into prevention by collaborating with schools/ nurseries/ families
Act as an integrator – connecting and enabling partners
2. Transactional Economies of Scale
Alleviate GP pressures (with new staff), improve workload and therefore improve workforce job satisfaction
To get the income (practices won’t survive without the NCDES) and scalable investment
Deliver extended hours
Sort out failing / struggling practices
This list of purposes also seems to fit into the Old Power (transactional) / New Power (network) values.
However they do not all sit comfortably together. Extending hours is symptom management and doesn’t get to the root of the issue. Collaborating on upstream issues, working with communities on the social determinants really does reach into those causal issues. Taking a needs based population approach has the hope of enabling primary care to make a difference; taking a deficit demand based approach will sink primary care. These two approaches need two different management and leadership approaches. Economies of scale requires partnerships and MOUs. Working at Scale needs collaborative intent and self-organising networks which may over time develop into a new organisational form but as the old adage goes – form follows function, it will take time for new collaborations working on meeting need to develop the relationships required to secure an organisational form that works for the members and their local population.
Moreover is you see my blog on Working at Scale you will also see that not everything happens at the scale of a PCN.
Exploring the potential purposes of PCNs
1. Learning and Innovation
For instance the best scale for Learning and Innovation is borough / Federation – you need a wide enough diversity of tacit knowledge alongside enough members to secure effective knowledge brokering to bring the very best evidence and experience to bear on local problems. A PCN whilst is should be a learning system, needs to collaborate at a bigger scale for Learning and Innovation to be its core purpose.
2. Delivering complex care/ integrated care
This does make sense at a PCN scale where the scale incorporates the natural boundaries of collaborating services (community, MH, third sectors, out of hours). Evidence from other countries demonstrates that you can develop algorithms where the PCN is the next step up from General Practice before the need for secondary care admission.
3. Supporting communities to help themselves and getting upstream into prevention
This entirely depends on the identity of the population you serve. Communities collaborate to support each other where they recognise each other as from the same community. For some places this will be at General Practice Scale, for some at a small group fo General practices serving one community or a PCN. Its not the General Practices that determine the community- its the community that determines the boundary for doing this collaborative work.
4. Acting as an integrator
I wasn’t sure why PCNs are best placed for this and how this differs from doing integrated care work.
5. Transactional
All of the transactional purposes are really drivers for MOUs rather than developmental purposes for a collaboration.
Robust General Practice at the Heart (see our blogs here)
It was heartening to hear Nikki Kanani speaking about the importance of General Practice as the Foundation for PCNs (see video here) which concurs with the evidence from High Performing Health Systems. PCNs will fail if General practice is not robust. This means that not only do PCNs need investment so do general practices. Our work in the London Primary Care Quality Academy demonstrates just that – each practice needs to be optimising its relationships with the assets in its community, managing failure demand, sorting its back office functions and innovating to meet need (not demand). From this bedrock of great work, the PCN agenda will naturally form – the work that cannot be done in general practice but only at a wider scale.
Footnote: Purpose of PCNS from Nuffield Trust Seminar 4th June 2019
Collective provision of Primary Care services especially national service frameworks
Fully integrated community based care
Building block for wider integrated care system
Reduction of avoidable hospital care
References
Malby B and Fischer M (2006) Tools for Change: An Invitation to Dance.