The Community Network long-read highlights how primary and community care services are collaborating in different ways around the country, including through PCNs, in which groups of practices covering 30,000-50,000 patients join forces with NHS community services to deliver integrated care. Delivering care at this neighbourhood level means PCNs have the potential to develop meaningful relationships with local partners and bring a more powerful primary care voice to the table in their local health and care system.

In many areas, the common purpose of responding to COVID-19 created an impetus for primary and community services to work ever more closely together. This is reaping benefits for both patients and staff.

The case studies we share here demonstrate how some PCNs and community services are embracing this new opportunity for integration and system working.

1. Joint working between primary care and community services during COVID-19: a case study in Leeds
Overview: This case study describes the joint working between Leeds GP Federation and its constituent PCNs, and Leeds Community Health Service, which has been enabled and supported by Leeds CCG. The strong foundations of partnership working enabled a cohesive response to COVID-19 across the city and demonstrates the agility of partnerships built on trusting relationships. Challenges: The challenge of obtaining a consensus and consistent view from colleagues in General Practice is a common one. Supported by Leeds CCG, a GP Confederation was created in the city to facilitate and enable a more cohesive voice from general practice to engage in system wide working. The CCG provided funding to support the organisation and embedded eighty staff from functions in primary care development and medicines optimisation within the Confederation. What the organisation did: The CEOs of the GP Confederation and Leeds Community Healthcare NHS Trust were fully committed to working collaboratively and building stronger relationships within the community. They agreed to co-locate head office functions and to share joint appointments of some senior leaders including the Medical Director and Director of Workforce. Both partners were involved in an annual programme of development sessions with the Clinical Directors of the newly formed PCNs. The sessions covered topics such as the future vision for community services, leadership models and approaches, and health inequalities. These sessions were important in building relationships between stakeholders and agreeing longer term purpose and strategy. The approach of working with PCNs has been to drive quality and safety improvement collaboratively and within the frameworks set by local and national contracts. Partners have consciously avoided command and control leadership and instead looked to build upon local knowledge and experience. One of the challenges for PCNs has been employing staff using Agenda for Change terms and conditions. Leeds Community Healthcare NHS Trust agreed to employ staff on behalf of the PCNs and deploy them within PCNs. This has enabled the creation of a more flexible, resilient workforce with fewer employment risks for PCNs. Both organisations worked together to improve local services, with one example being the delivery of wound services in the community. In partnership they successfully bid for a £12 million contract to deliver the Leeds Mental Health Well-being Service. Both projects signalled that collaborative working could deliver improved clinical services and a better experience for all staff . Results and outcomes: This partnership between primary and community care in Leeds has resulted in a cohesive and collective voice for general practice at system-level conversations. It has also improved the quality and safety of some community services. The community-based response to COVID-19 in Leeds has been cohesive thanks to the right foundations of partnership working. Examples include: - The director of adult social services co-ordinated the distribution of PPE for the city, which included mature mutual aid for all health and care organisations. - GP practices worked together to manage COVID-19 caseloads and support the most vulnerable patients, facilitated by the GP Confederation. - Community services worked together to support care homes and within twenty-four hours implemented the enhanced health in care homes service specification. Daily multidisciplinary team meetings are taking place in some care homes which has improved communication channels between the organisations going into Care Homes. Similarly, sharing contact details across teams has cut out a lot of time-consuming referral processes and has led to better outcomes for residents. - Some PCNs also created ‘safety huddles’ where primary care and community services jointly reviewed caseloads and supported the ‘shielded patients’ list. - Discharge to assess has been accelerated. Overcoming obstacles: There have always been differences in the culture and operations of providers of NHS community services and General Practice. However, the solutions are driven by neighbourhood and place-based methodologies that build genuine and meaningful dialogue across partners and reflect the local communities that they serve. During COVID-19 the national response has been one of ‘command and control’. However, the places that have responded to the crisis most effectively have been those that had strong relationships in place prior to the pandemic. As part of the reset and recovery phase, primary and community care will continue to work together to evaluate the changes that have taken place and where there have been benefits. The joint working with PCNs and Community will act as a catalyst to go further faster in Leeds. An important factor will be ensuring that resources move around the system in the right way and that contractual mechanisms do not hold back transformation.
2. Using digital to support integration between primary care and community services during COVID-19: a case study in Bexley
About the organisation: Bexley Health Neighbourhood Care (BHNC) is a not-for-profit Community Interest Company and GP Federation supporting 22 GP practices in four PCNs with a patient population of around 446k within South East London. BHNC in its current structure has been in place for just over 12 months and continues to grow and innovate in six areas: - primary care and PCN support - community care - workforce development - infrastructure and IT - governance and quality - business development - training and education. The BHNC Board is comprised of four elected voting directors who are all GPs. All 22 GP practices are members of the GP Federation, which supports practices to secure quality services for patients through the delivery of the following objectives: - Support Bexley GP practices to help secure the best services for patients and meet the challenges of a changing NHS while improving patient outcomes through PCNs. - Improve the morale of general practice in Bexley by sharing expertise, services and resources to support staff. - Make a positive impact on the improvement of medical services and the quality of care in Bexley by working closely with the CCG, local NHS trusts, local providers and patient groups to improve the delivery of healthcare based on the needs of the population. - Lead and improve the education of staff and patients in Bexley by working with the Bexley Training Hub for staff and the GP Federation’s own Training Faculty for patients and staff - Look at local, national and global innovation to transform PCNs and introduce bespoke digital solutions to create efficiencies with the system. Challenges: The two main challenges for BHNC during COVID-19 were and continue to be: 1. How do we track and look after our patients / care home residents? 2. How do we track and look after our staff and the operation of GP practice sites? This was an immediate COVID-19 challenge, but crucially while we define an ever changing ‘new normal,’ this is very much also a longer term challenge as the NHS will never go back to pre-COVID ways of working. There is also the challenge of coordinating the wider multidisciplinary team caring for our patients / residents in a very agile way. Staff are increasingly working remotely and this will be the ‘new normal’, thanks to the use of digital technology. What the organisation did: BHNC responded to COVID-19 by rapidly developing a digital solution to the two challenges above, with its digital partners Appian and Convedo UK, as well as wider social and community care partners. This app was designed to track information about patients and care home residents, including workflows for care assessment, planning and delivery. It has the potential to support PCN service delivery in the long-term, including the enhanced health in care homes service specification which was brought forward following the impact of COVID-19 in care homes. BHCN focussed on building the key areas of the enhanced health in care homes service specification into the patient flow process. The app is built according to specific ‘personas’ who have different levels of access to patient information e.g. discharge staff, social care, rapid response, community care GPs etc. The PCN has a ‘helicopter view’ of all patients in the system, so it knows what pathway each patient is on and where further support is required. This can all be tracked live. Results and outcomes: The digital solution has the potential to enable the multidisciplinary team to be very co-ordinated in the way it tracks the care of patients and care home residents. The initial feedback on the digital solution and targeted deployment is very positive. BHCN has been able to collaborate with local partners in the live testing and development of the solution across different boroughs in South East London and across England. These new collaborative partnerships led to a common set of objectives: to beat COVID-19 and digitally innovate to sustain the highest quality of care for patients. The live pilot results will be evaluated in June / July 2020. The new live pilots phase, as part of the PCN service specifications, is with one practice in three care homes in Bexley and a large care home in Lambeth. There is obviously much work still to do. The timetable set out by NHS England and Improvement in the NHS long term plan expects rapid progress on building multidisciplinary teams and digital enablers. By March next year all PCNs and multidisciplinary teams are required to have fully deployed new ways of working, including the digital solutions to meet the challenges. The development and leverage of BHCN’s digital solution is still to be proved at scale but the early signs are positive for staff and patients. Overcoming obstacles: The development of the app was the easiest part. Taking a risk as a small organisation was the biggest challenge. Delivering a large-scale digital change management solution during a pandemic was also a huge challenge as it took time to convince everyone of the longer term benefits of embedding a new system. Successful culture change must be earned, and new digital solutions proven to work for staff and patients. BHCN overcame this by working with individuals who wanted to trial something completely new and continuously improve without being put off by setbacks. BHNC and their partners continue to learn how best to engage with key stakeholder groups. This is essential to the success of the digital support offer, as staff and patients need to benefit from its use.
3. Joint working between primary care and community services during COVID-19: a case study of Derbyshire’s Integration Journey
Overview: Community services and General Practice in Derbyshire are on a journey towards integration, which is heading in a positive direction. Relationships are good, which brings efficiency benefits in itself. However, system leaders agree there is still a long way to go; with every forward step, more obstacles are revealed and must be navigated. What the organisations did: Significant time and energy has been invested into developing positive relationships between General Practices, community services, social care and the voluntary sector. This has involved several initiatives, starting with CCG development, continuing through ‘Place’ and now with PCNs. The organisational development programme ‘Leading across Boundaries’ from the East Midlands Leadership Academy has also played a significant part in starting that cross-organisational conversation. Building open and honest relationships has been a core part in the success of primary and community care collaboration to date, and provided a firm foundation on which to develop truly integrated services. More recently, GP practices in Derbyshire have created an informal “GP Alliance” which enables a unified, constructive GP voice in system conversations. In parallel, Derbyshire Community Health Services (DCHS) NHS Foundation Trust has shown its commitment to integrating with General Practice by appointing a Clinical Director for Integration who is an ex GP with the credibility to lead the integration work, provide honest brokerage and challenge both the community trust and General Practice colleagues to work together in new ways. Results and outcomes: Local leaders across community and primary care have built mutual understanding and empathy across the system. The chief executive of DCHS invited GP Providers to be part of the DCHS Board Development session, and in turn she attended the GP Alliance development session thus building an empathy and understanding of each part of the system. These relationships are now at a point where both community and primary care colleagues can constructively challenge each other without questioning the intentions or motives for doing this, other than to move the integration and transformation journey forwards. During the COVID-19 pandemic these relationships have proven invaluable, allowing mutual aid and rapid resolution of problems and misunderstandings through direct conversations. The availability of PCN Clinical Directors to broker conversations between community teams and their local GP colleagues has been a great facilitator - in previous times, similar issues would have been escalated via the CCG, taking weeks to resolve and damaging relationships. Once again, local leaders role modelled successful partnership working by agreeing a pragmatic way forward to continue weekly multidisciplinary team meetings during the COVID-19 response. There are a number of specific projects where groups of GP practices are working together with DCHS to improve outcomes for patients by removing duplication across primary and community services. Examples include the Erewash and Chesterfield Frailty teams, the Primary Care Plus Acute Frailty Home Visiting Service and the Derby City South PCN care homes project. The system leaders in Derbyshire continue to evolve the partnership model together, recognising that they won’t always get it right first time but will continue to work together to deliver better care for patients and a better working environment for staff.