Tue 9th Apr, 2019

Are PCNs the catalyst for finally creating citizen centric care?

In large organisations, change is constant which means that if you are unable to manage change then you should expect the management itself to be changed. The NHS itself has been through many re-organisations with a whole lexicon of its own acronyms. From GP fundholding and SHA’s, to PCTs and CCGs, followed by STPs and now to PCNs.

With so much change, it is no wonder that the vacancy rate in the NHS is 9/100 jobs versus the national average of 2.7/100. We also see newspapers’ headlines, highlighting on a weekly basis the lack of access to care for patients due to the shortage of staff and funds. Then we have a large number of people moving from one internal re-organisation to another re-organisation, with the only visible difference to an outsider being a change to the email signature. When the only resource that can implement change is people, and if there aren’t enough of them ‘inside the tent’ then change will just not happen.

The NHSE itself is about to receive a large increase in funding and is expected to use money this to drive change including creating PCNs across the whole country by 1st July 2019. This money is be used to adopt services to the aging population, address increasing numbers of those with chronic disease and deal with multiple co-morbidities.

With 2019/20 budgets set to rise by £7.2bn up to £121.8bn, much of this additional funding is earmarked for staff and transforming services, however, will PCNs be able to access and use this funding to drive real change especially with such a short time horizon? Draft reference guidance for PCNs only came out 8 months ago and this gives little time to move and align organisations. Moreover, PCN creation will need changes in workforce, citizens attitudes, adapting technology and digital tools, clinical governance and real estate and developing new business models in the future.

One of the main change themes for a PCN to address is around how they can use and implement new technology. The guidance asks for moving more ‘consultations’ from a real-estate based intervention to an online intervention, while recognising that self-monitoring can also benefit the population. The Networks should be able to implement technology to share records and apply work- force planning to ensure the right level of skilled staff is matched to the appropriate human need. One of the goals is to reduce the 27% of current GP appointments that are inappropriate and to move care to being delivered at the right level for the consumer. This will need rapid technology development and adoption.

The challenge emerges as this new digital enabled technology should not and realistically cannot be created inside the NHS. Instead it should be driven by innovators and entrepreneurs working in an agile environment. The NHS didn’t invent MRI scanners, Robotic surgery, coronary stents nor has it built any EPR or Clinical IT system and/ or been able to deploy and drive adoption at any scale. We all remember the staggeringly costly failure of NPFiT, how Choose and Book took nearly 8 years to deliver an acceptable service (complete with rebrand) and how often we see systems fail, lose records or are delayed beyond reasonable levels.

Just as Uber don’t drive taxis, but instead provide the technology to get vehicles to the right place at the right time, Airbnb don’t own rooms or apartments but connect travellers with property owners, and OpenTable don’t own restaurants but allow choice and recommendation, how could we expect those within a system like the NHS to redesign themselves into a digital system and deliver transformation? It would be a bit like expecting taxi drivers to invent and code the Uber app or surgeons to build their own surgical robots.

With the requirement to use technology to deliver the PCN agenda, providers need an open playbook to choose the technology that they need and would matches their agenda. The current NHS/Kainos App, which is being touted as a ‘70th birthday gift from the NHS’ is seen by many as a mere copycat that will enter into an arena where digital entrepreneurs have signed up nearly 14.5m citizens onto online services already. The NHS/Kainos App still can’t connect all practices, all Clinical systems, and/or integrate any online consultation services. The current score user ratings for popular apps range from 4.6 to 4.8 out of 5, while the NHS/Kainos App has a 1.4 out of 5 rating in the last month. This can’t be seen as a user centred design.

The enthusiasm for the NHS/Kainos app is waning, especially with most of the leadership team exiting out of the NHS (many to join UK innovation engines), with realisation of the additional workload that the app will place on practice staff, and with it providing little additional functionality to that which exists in the hands of 14.5m people already. The question needs to be asked, why would we want to spend £100m of tax-payers money on yet another app, when at last count there were over 20 NHS branded apps already on the various app stores. At a time when cancer drugs are not able to be funded, when there aren’t enough MRI machines compared to our European neighbours, and when we can’t hire enough frontline staff, is this a good use of public funds?

The question of whether PCNs will be able drive change will therefore depend on the following drivers:

  1. They should not be forced to use innovation that only works with centrally dictated technology as this will limit their flexibility, competition and ability to transform the citizen’s experience. Choice will ensure competitive pricing and avoid an oligopoly.
  2. They will need to be funded to test and trial multiple services to see what works for their local population and service.
  3. They will need new faces around the leadership table to help, challenge and guide and especially those used to manage change, rather than having another internal shuffle.
  4. Governance will need to be light touch to ensure that the bureaucracy of upwards reporting doesn’t take away all the time for executing the plan. The balanced scorecard type approach is needed more than reports for reports sake.
  5. They will need to engage their workforce and show them how this new model will help them and their citizens and not add to their already heavy workload. People don’t work in the NHS because they are excited about filling in forms, they want to help their fellow citizens.
  6. They need to be given time to plan change before being expected to deliver. Failing to plan is dreaming, while rushing ahead without a fully formed plan is a nightmare.
  7. They need freedom decide what services to perform themselves and what they can get done more efficiently and more effectively from other qualified and quality providers.

The clock is ticking and plans need to be delivered soon, if we are to see benefits in the coming year of this move to local management of health.

Mike Lewis

Photo by Marc-Olivier Jodoin on Unsplash