With the single neighbourhood and multi-neighbourhood provider (SNP and MNP) consultation underway primary care networks (PCNs) will need to work through their next steps as they consider the SNP contract. Complexity will be added by multiple organisations needing to work together across a footprint, including at scale MNPs. As the consultation document outlines scale should be used to design and co-ordinate neighbourhood health services in their footprint, including delivering services directly if needed. With signs of greater responsibility, and an opportunity to shape the future, as well as responding to the consultation, neighbourhoods may wish to ensure they take steps now to prepare. This joint article by PCC and GGi outlines areas PCNs/neighbourhoods may wish to consider.
In a second joint article, GGi’s Simon Hall and Helen Northall, CEO of PCC, offer more food for thought for primary care organisations about neighbourhood health.
The emerging single neighbourhood and multi-neighbourhood provider (SNP and MNP) arrangements may look primarily like a contracting change. In practice, they raise some fundamental questions about how primary care collaborates, makes decisions and exercises accountability across organisational boundaries.
In a previous article from GGi and PCC, we suggested five questions every neighbourhood lead should consider before new organisations or governance structures are created. These focused on purpose, leadership and accountability.
The first consultation regarding SNPs and MNPs has been launched, with a more detailed consultation to follow once initial responses have been considered. It is now more important than ever that governance and decision-making processes are considered so that organisations are prepared when these contracting routes are confirmed.
The consultation sets out the background. The intention is to provide the building blocks for organisations operating at scale, enabling them to work closely with general practice to co-ordinate the delivery of services. For MNPs, this will mean co-ordinating services across multiple neighbourhoods (or SNPs). The SNP offer is presented as an evolution of the primary care network (PCN) directed enhanced service (DES), with safeguards intended to ensure that practices do not lose income in moving to an SNP contract.
The intention is to enable local commissioning based on local population needs, developing end to end neighbourhood pathways with stronger accountability for outcomes while having greater local flexibility to serve local communities.
Accountability requires governance
With stronger accountability comes a need for good governance. Complexity will be added by multiple organisations needing to work together across a footprint – at MNP level, and some areas may need multiple MNPs for different pathways.
MNPs, according to the consultation document, should use scale to design and co-ordinate neighbourhood health services across their footprint, including delivering services directly if needed. It suggests the MNP contract holder to be a legal entity, for example an incorporated primary care organisation, community interest company or an NHS Trust.
Against that background, we suggest seven practical questions that neighbourhood leaders should be asking now.
1) How should decision making work?
Many collaborations – neighbourhoods, federations or alliances – operate with good intent but limited authority. They can coordinate and influence but, in some cases, feel unable to decide without going back to members. As MNPs develop, it is important to be clear about where decisions are made and who has the authority to make them.
2) Do you need to review or update current arrangements?
Review existing processes and documentation at PCN, SNP and federation level. Are agreements with practices up to date? Who within each practice has the authority to agree what the collaboration can decide? Are those arrangements still fit for purpose?
3) How will other partners affect how decisions are made?
MNPs are likely to include multiple providers – for example SNPs, NHS trusts, and voluntary sector organisations. How will decision making work when other parties are included? Could one organisation veto a decision? This will need to be worked through as MNPs form, but thought should be given now to the red lines that individual collaborations may not wish to cross.
4) What sort of contracting model could be used?
Different MNP footprints may be needed for different pathways, so thought needs to be given to how these building blocks will work together. Each MNP will need a strong sense of direction and purpose, underpinned by trust between the parties and a culture of working together for the good of the population – even where this may not always benefit every individual organisation.
It is worth considering now whether lead provider models, alliances or more formal collaborations might be appropriate, while retaining flexibility, good governance and clear accountability. At this stage, the important thing is to understand the different contracting mechanisms that could be used rather than prematurely settling on a particular model.
5) Have you stress-tested your ideas?
To understand whether the mechanisms you are considering will be fit for the future, test them against realistic scenarios. What happens when things go wrong? Testing governance, decision making and accountability before they are relied upon in real-life situations can save time – and potentially legal costs – later.
Throughout this, function before form remains critical. More mature neighbourhoods have a strong sense of direction and purpose, with clear priorities aligned to population need and a connection between those priorities and work at practice, neighbourhood and wider system level.
The conversation should therefore start not with organisational models, but with what needs to happen differently for the population. What should sit at practice level? What is best organised at neighbourhood level? What requires greater scale? And how will risk be identified, discussed and acted upon in a way that reflects the reality of integrated delivery rather than organisational silos?
6) Do you have the leadership skills you will need?
Working across organisational boundaries requires leaders who can influence peers without formal authority, gain agreement across diverse organisations and earn the trust to represent colleagues. That requires emotional intelligence, the ability to lead cultural change and the skills to manage change sensitively and actively.
This cannot be left to chance. It requires explicit thought about leadership roles, responsibilities, behaviours and support – and dedicated time for leaders both to do the day job and to manage the relationships and politics around it.
This becomes increasingly important as neighbourhoods take on more complex responsibilities, from proactive care for high-risk populations through to urgent access, prevention and community-based pathways, including deciding when to work at a greater scale to achieve the changes required to make the NHS fit for the future.
7) How will you connect to patients and communities?
Neighbourhood health carries with it an implicit promise: that services will be organised around the needs of people and communities. This requires deliberate effort to understand communities, to engage with them meaningfully and to incorporate their perspectives into decision-making. What are the respective roles and responsibilities of the collaboration and its individual organisations for patient and community involvement? What can you build on? Primary care contractors can draw on their existing experience of patient engagement, including patient participation groups. Practices and PCNs can also build on what has already been achieved through social prescribing, going further to identify community assets and build on the strengths of local communities as partners in care.
Use data actively and work with patients, voluntary sector organisations and community groups to understand what matters to local people and how services can best respond, drawing on asset-based community development approaches where appropriate.
Complementary expertise
PCC and GGi bring complementary expertise to support that journey. PCC contributes extensive practical experience of supporting practices, PCNs, federations and provider organisations, and the teams within them, to develop services and strengthen collaboration. GGi brings expertise in governance, organisational development, leadership , board effectiveness and neighbourhood health.
Together, we can support organisations from their earliest conversations about collaboration through to becoming confident provider organisations, bringing together leadership and organisational development with practical expertise in governance, business planning, contracting, quality and delivery.
Neighbourhood health should not be viewed simply as another organisational reform. It is an opportunity for primary care to shape how care is delivered for the next generation. Those organisations that invest now in relationships, leadership, governance and organisational capability will not simply be ready for whatever structures emerge. They will help create them.
Contact enquiries@pcc-cic.org.uk or contact@good-governance.org.uk to discuss how we can support you.
Authors: GGi Principal Consultant Simon Hall and Helen Northall, Chief Executive, PCC.
