The Fuller Stocktake – what will it take to meet the vision, and are we heading in the wrong direction?

Health Service Journal, 7th June 2022

The ‘Fuller Stocktake’ was published last week. It is a NHSE commissioned report into the future of Primary Care and it presents a vision of Primary Care Networks shifting to neighbourhood level teams, built around communities.

It is a vision that returns to the original ethos and purpose of PCNs, but one that is an uncomfortable clash with the cold reality of the current direction of travel.

We are now in the 4th year of the PCN contract. The first year (2019) was spent setting up and organising, 2020 was dominated by Covid-19, 2021 focused on delivering the Covid vaccine programme (which showed how effective PCNs could be with a clear and simple purpose). The fourth year so far is looking like a grind: delivering targets dictated by the national contract and extending access to Saturdays and evenings.

Many of us who became Clinical Directors did so to improve local health outcomes, narrow inequalities and build up community teams to support older and more complex patients. It can feel like the major purpose of PCNs has been squeezed out. There is only so much time in the week, especially clinical and leadership time. Every new commitment placed on PCNs has an opportunity cost.

The recent contract contains 40+ micro targets. PCN Clinical Directors inevitably are shifting their time and attention away from system work, building community teams, and population health, towards box ticking processes and internal GP practice work.

After a bruising period during the pandemic, General Practice is dusting itself off and thinking what happens next. For many it doesn’t look pretty; burnout, reducing numbers of GPs and increasing workload all contribute to rock bottom morale (although this is not universal which gives some hope). Anything that occupies more GP time, rather than frees it up, will struggle to gain traction and may encounter hostility. 

In addition, the ‘PCN movement’ is looking shaky. What started as an exciting vision and concept seems to have lost its way. This maybe partly down to a lack of focus on organisational development (infant organisations need nurturing), partly in danger of being strangled by the contract, and partly down to confusion and overloading of purpose: PCNs have been at various times expected to; stabilise General Practice; be the building blocks of the new ICSs; develop community teams; recruit and manage a new workforce and now deliver a multitude of new requirements. The truth is that many, if not most PCNs haven’t the resource to do all these things at once. It is understandable to have high expectations, but unless there is a brutal focusing on the highest priority then there is a risk that PCNs will not manage any of the above.

There is still an opportunity to revitalise this concept and vision, but it will take some smart decisions both locally and nationally, including a reverse in tone and strategy.

The Fuller Stocktake centres around three ‘offers’: ‘Streamlining access to care and advice’, essentially building urgent care systems at PCN level. ‘Providing proactive personalised care from a multidisciplinary team of professionals’, for higher need individuals in the community. ‘Helping people stay well for longer’, which is working with communities and local organisations on the prevention agenda.

These feel like the right priorities, but anyone who has worked on this understands that this is all about partnerships, leadership and hard work. Without some time and space to develop these very local projects, they simply will not happen.

The contrast between the themes in the report and the PCN contract is stark; very little of the above is reflected in the contract, and some of it may work against the vision – for example stretching a struggling workforce into evenings and Saturdays thins the teams out, putting at risk daily urgent access and focuses team building elsewhere.

There is now a choice to be made. Primary Care could be built into a place of work that provides high levels of clinical satisfaction and imbeds into local communities (a significant side effect of this would be to seriously enhance retention).

To achieve these aims there needs to be a subtle balance of active system level support for PCN development, and local innovation. There is an opportunity to finally move away from the transactional and confrontational relationship between Primary care and the NHS centrally, and towards a more equal and constructive partnership. It is time to drop the parent-child relationship and shift towards more mature and sophisticated policy levers.

The new leaders in Integrated Care Systems also have a choice. As they are being formed, the main source of clinical system leadership in Primary Care - CCG clinical leaders are being removed. The expectation is the clinical leadership will come from PCN Clinical Directors, but again there is only so much time (around one day a week for everything).

ICS Boards should prioritise filling this potential vacuum and give genuine support to PCN leadership, without this the vision for PCNs and ICSs will not be realised.

Above all, there is a compelling need to focus and prioritise on the most pressing concerns. The Covid-19 response and the vaccine programme showed what Primary Care can do with a clear simple purpose and support to achieve it.