‘We’ve missed a real opportunity with PCNs’: top London GP leaves clinical director role

Top-down management, endless meetings, and restrictive recruitment rules have led east London GP Dr Farzana Hussain to walk away from her PCN leadership role.

Dr Farzana Hussain

‘I feel we're putting our emphasis in the wrong place,’ Dr Hussain tells GPonline as she reflects on her decision. ‘I haven't changed my aim in wanting to improve care for patients, but I’m going to do that medically now - it’s a big step down for me in a sense.’

Dr Hussain, who practises in Newham and was photographed as one of the faces of the NHS for its 72nd anniversary at the height of the COVID-19 pandemic, has been a PCN clinical director since the scheme’s inception in July 2019.

She recalls being ‘very excited’ when networks launched, but has recently quit the role after becoming ‘disillusioned’ and frustrated with the approach failing to deliver on its central promises.

It comes as some clinical directors warned GPonline last week that they could walk away from leading networks due heavy workloads and uncertainty around management funding and the future of the COVID vaccination programme.

Dr Hussain says: ‘When the NHS Long Term Plan came out in 2019 with PCNs, it was supposed to be an opportunity for practices to collaborate with their community, hospitals, and mental health trusts to improve population health. But these last three years I have not seen that happen at all.

Primary care networks

‘The Investment and Impact Fund (IIF) for me is just a super QOF - it doesn’t feel any different and I don’t think there’s been anything transformational about it. Work that PCNs have been asked to do, such as flu jabs, was already being done at practice level anyway. So I’m not sure that we needed to group practices to do that.

‘We have missed a real opportunity with PCNs which were heavily influenced by primary care homes (PCHs) - that is what I wanted to do, where providers were collaborating and working together. But none of that is coming through in the asks that we have at all,’ she adds.

Speaking to GPonline back in 2019, former president of the NAPC Dr Johnny Marshall warned NHS England needed to avoid a top-down approach to the development of PCNs if it wanted to replicate the best of its PCH model - which PCNs are broadly based on - and improve care.

The NHS Confederation also stressed in a 2020 report of the progress of networks that clinical directors ‘need to be given the freedom to fully use and maximise their competences’. However, Dr Hussain says the structures have become hierarchical and too target focused.

Clinical director role

‘There doesn't seem to be a lot of wriggle room for clinical directors. There's lots of talk of PCNs being able to do what they want, but there are lots of things that are already decided for you and it feels very top down instead of allowing us to be free to make decisions.

‘There is a narrative from the top that we need to reduce variability, I absolutely agree…but we don't need to do that with financial sticks. It feels like we are tying practices up against each other and asking them why they didn't perform. I don't feel that is a clinical director's job, I think it's about supporting people and getting people to share learning. I certainly don't see my role as a clinical director to bully other practices.'

Excessive time spent in meetings is another reason why the London GP says she is leaving her role as a co-clinical director. With GP teams in England delivering an unprecedented 367m appointments in 2021, she says health leaders need to carefully consider how they want their staff to be deployed.

‘It feels like we're taking clinical directors out to go to meetings left, right and centre, but we haven't got anybody in the practice to see people with complex conditions. People are really sick and there's a lot of complex clinical care, and we are asking clinical directors to sit for hours in endless meetings where they don't actually have much of a voice.

Complex clinical care

‘My personal view is that I am much better placed, looking after my patients providing clinical care because my whole point of wanting to be a clinical director was to improve care for the community and I don't think the current PCN module and the current ask of clinical diretors is allowing us to improve local community care at all.’

Senior fellow at health think tank the King's Fund Beccy Baird warned last month that general practice and PCNs need more support to integrate staff recruited through the additional roles reimbursement scheme (ARRS) - adding that the roles may need to change to boost recruitment.

This view is backed by Dr Hussain who expresses concerns around the lack of funding available to embed new starters. She says: ‘There's no built in support time for that, leaving clinical directors and PCNs being run ragged trying to do this, sometimes at the cost of their practices…We can't just bring the new role in and expect them to fit in and hope it happens without the supervision and embedding.

‘These roles are in effect free, we're not paying for them, but practices still can't get them. So we have to ask ourselves the question about whether it’s working. It wasn't just about throwing money at it, we need to throw money at the right places.’

How PCNs need to change

Dr Hussain says she still believes in the potential of PCNs, even though her time as a clinical director has come to an end. But she inists a major rethink of the model, in addition to the clinical director role, is needed if networks are to be successful.

She says: ‘I personally think the way PCNs are going, I don't think it's going to help the NHS. But I think we could still pull it back by a very different funding model and a very different ask of PCNs.

'Firstly, I think we need to evaluate after three years whether the ARRS funding model is working. I don't know many people who have got dieticians or occupational therapists, for example. So do we stick with these roles or do we want to use that money to employ GPs?

‘I also think surplus funding from the ARRS should go into core, or should have greater practice involvement in how it is spent because at the moment we’re not even sure that we’re going to see that surplus and if we do we have to make loads of plans for it which I think is wrong.

‘We also have to consider the clinical director role and resolve what it is we’re asking of them…are they accountable officers, or are they there to bring in new services to the PCN or to improve policy within the PCN? And I think there should also be a DES or something where every PCN is given full flexibility to run its own programme on health inequalities to address local needs.’

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