In primary care there is a flurry of activity and excitement, as well as some fear and trepidation, as the government moves forward with its policy to shift the emphasis of healthcare delivery from secondary to primary care. The Five Year Forward View (NHS England, 2014) set out the vision for greater collaboration between GPs and wider community health services, hospitals and social care. More recently, the NHS Long Term Plan (NHS England, 2019) focuses on building an NHS fit for the future by:
- Enabling everyone to get the best start in life
- Helping communities to live well
- Helping people to age well.
The plan aims to improve outcomes for major diseases, including respiratory disease, cancer, stroke, heart disease and dementia. Crucial to this are measures to:
- Improve out-of-hospital care, supporting primary medical and community health services
- Ensure all children get the best start in life by continuing to improve maternity safety, including halving the number of stillbirths, maternal and neonatal deaths and serious brain injury by 2025
- Support older people through more personalised care and stronger community and primary care services
- Make digital health services a mainstream part of the NHS, so that in 5 years, patients in England will be able to access a digital GP offer.
The Long Term Plan (NHS England, 2019) introduced primary care networks (PCNs), which are seen as a vehicle to deliver the outcomes set out in the policy.
What are PCNs?
PCNs should ‘typically’ cover a population of between 30 000 and 50 000 people. PCNs are expected to be geographically contiguous and coterminous with local Clinical Commissioning Groups (CCGs) and Integrated Care Systems (ICS). The NHS long term plan envisages PCNs will be the vehicle for improvements in primary care and wider population health. All patients in England have been covered by a PCN since 1 July 2019.
PCNs will comprise local general practices and will be the vehicle for collaborating and working in partnership, and sharing staff and resources, while maintaining the independence of individual practices. The 2019 GP contract required practices to join PCNs, although this is not mandatory.
Leadership in the PCN
Included in the plans for PCNs is the role of clinical director. All PCNs must appoint a clinical director, ‘from a variety of clinical backgrounds’ which includes general practice nurses, primary care nurses and GPs. Most PCNs have a GP as clinical director, but other clinical staff can bring a different perspective to the role (Scott, 2019). Many nurses will have the requisite knowledge and skills that would allow them to function as clinical directors, and as such would provide the PCN ‘strategic and clinical leadership to help support change across primary and community health services’. This provides nurses with an opportunity to lead and shape the strategic direction of the PCN and promote the primary care nursing workforce as integral to delivering the national aims set out in the Long Term Plan.
However, one of the biggest challenges facing primary care nurses becoming clinical directors in PCNs is the pressures in primary care and on practice nurses themselves. Up to 33.4% of the practice nurse workforce are due to retire by 2020 (Bradbury and McCallum, 2015). Practice nurses already suffer from a challenging employment model, different training and education models and availability, and significant variation in accessing education and training, even when it is locally available (Bradbury and McCallum, 2015; Oldman, 2019).
A Queen's Nursing Institute (QNI), leadership programme set up for clinical directors of primary care networks has been shelved after nurses struggled to get funding to do the training (Stephenson, 2019). Faced with these challenges, it is now more important than ever that nurses in primary care take the reins and lead on how they will work in the future. This is not an easy task; those nurses who have already taken up posts as clinical directors of PCNs recognise the difficulties faced (Hussain-Mills, 2019). The Ten Point Plan (NHS England, 2018) identifies the challenges faced by nurses in primary care, while providing an action plan to address the issues raised. Nevertheless, this is not a panacea to all the challenges faced. Nursing leadership in primary care is crucial, as the structure of primary care across the UK continues to undergo unprecedented changes.
Historically, nurses working in primary care and as practice nurses have undergone many different iterations and developments, often shaped through governmental policy and local contractual requirements (Duncan, 2019a). Therefore, change should not be something to fear. However, nurses need to be empowered and supported to develop their leadership skills so that they are able to rise above the challenges and take on the opportunities to be found in PCNs. Expecting them to take on new roles without support will be doomed from the start.
To enable nurses to positively contribute to integrated primary care, we need to prepare them as leaders through support programmes (Nieuwboer et al, 2019). Nurses across primary care are already preparing themselves for these changes by exploring models of care that are patient-centred and link to neighbourhood, place and system levels (Duncan, 2019b). My view is that now is the time for nurses in primary care to take up the reins themselves and demonstrate their worth to primary care, GPs and PCNs.
‘Faced with these challenges, it is now more important than ever that nurses in primary care take the reins and lead on how they will work in the future’