Even though we are approaching the three-year anniversary of PCNs, the job of being a clinical director is probably now even more difficult now than it was at the outset. Here are the main issues clinical directors are having to contend with right now.
1. Keeping practices signed up to the PCN DES
There is a simmering discontent within general practice at the imposition of this year´s contract. There is a frustration with the lack of acknowledgement of the role general practice has played throughout the pandemic and of the pressures it is currently under. Practices want to retaliate, and the prime target is the PCN.
The PCN is widely regarded as adding to the pressures facing general practice, and despite the benefits of the PCN DES many are considering withdrawing from it. It is often left to the clinical director to make the case for sticking with it.
2. Keeping practices engaged
Even when practices remain signed up to the DES, keeping them engaged is never easy. In larger PCNs there are always those politicking for breakaway groups and smaller PCNs, and everywhere has the ‘what has the PCN ever done for us?’ brigade to contend with. Creating unity, a common purpose, and a shared desire to work together remains one of the biggest challenges facing clinical directors right now.
3. Supporting the additional roles staff
By now most PCNs have been through round after round of recruitment and, eventually, have employed a team of staff using the additional roles reimbursement scheme (ARRS) funds. But this in turn has created a new set of problems: looking after these new staff and keeping them happy.
Many of those taking on the new roles in PCNs have found the transition difficult and they require a significant amount of support. This has led to frustration from the practices, as well as turnover in these roles. The clinical director now has to develop and nurture this new team, cajole the practices into supporting and helping them, and work our how to get the most out of these new staff coming in to general practice.
4. Establishing a support team
Three years’ ago, clinical directors were expected to carry out the entire PCN leadership function on their own. The role has grown exponentially since then, and even NHS England has caved on this point and provided extra funding for PCN leadership.
The challenge for clinical directors now is to find a PCN manager who can work with the practices and their managers (without poaching any of the practice managers!), and to build a leadership support structure to distribute the responsibilities more widely across the PCN clinicians.
5. Keeping on top of PCN requirements
The expectations on PCNs continues to grow. All of a sudden there are the PCN DES specifications, the Investment and Impact Fund and the enhanced access requirements, all on top of the ongoing staffing and other responsibilities within the PCN.
Clinical directors have to find a way of using the limited time the PCN has available to establish and agree a plan, monitor performance and prepare for whatever is next. The logistics (never mind the politics) are a nightmare for any clinical director.
6. Recruiting new staff
The ARRS pot goes up again this year, and the number of ARRS staff within each PCN is expected to double in the next two years. Clinical directors have to attract staff who are becoming increasingly savvy at both choosing their PCN and negotiating their terms, on top of keeping the existing ARRS staff happy.
Some of these new staff have conditions attached, not least of which are the mental health workers who have to be employed via the local mental health provider. Getting these in post is proving more than a challenge in many places.
7. Finding room for new staff
The challenge is not just recruiting the new staff. Once they are in post clinical directors have to find some space for them. This was a challenge when the first ARRS staff were employed over two years’ ago, but now any ‘spare’ space has been filled, and the estates challenge is quickly rising to the top of every clinical director’s agenda.
8. To incorporate, or not incorporate
As the PCN liabilities stack up with the ever-increasing number of staff employed, the initial agreement that the PCN would all be hosted by one of the practices is looking increasingly flimsy. On top of the operational, staffing and practice challenges, there are now also some serious governance questions that need to be answered, and the clinical director has to decide whether incorporating the PCN is the right way forward.
9. Working with other clinical directors
No PCN is an island. However hard the clinical director tries to keep their focus on their own practices and their own population, they will inevitably be dragged into a myriad of system meetings and discussions about the new integrated care system and will have to work with the other local clinical directors to agree how this will happen.
There are often historic rivalries and disputes to contend with, and the clinical director has to navigate their way round these to find a way of creating a unified voice for general practice in the new system.
10. Creating a succession plan and establishing a way out
The all-consuming nature of the challenge of being a clinical director means that no one can continue in the role indefinitely. When the time comes to pass the baton on, no one wants their legacy to be an implosion at the point of departure. All clinical directors need to think about what next, to plan for the future, and to nurture a successor who will be able to slip seamlessly into their shoes when they finally depart. But persuading someone to take on the mantle is easier said than done.
So it’s clear that being a clinical director is a big challenge. Despite all of this, there are huge opportunities for those in the role to make a difference both to the member practices and the populations they serve.
For anyone brave enough to take on the role we are running a course to support PCN CDs to be able to meet these challenges and thrive in the role. You can find all the details here. For everyone undertaking this journey, we wish you the best of luck!
- Ben Gowland, is director, Ockham Healthcare; Dr Hussain Gandhi is a GP partner, clinical director of Nottingham East PCN and owner of eGP Learning; Tara Humphrey is PCN manager and host of the Business of Healthcare podcast
