https://www.pcnacademy.org.uk/topics daily 0.75 2020-02-21 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1580997865844-V53PCFFBZHIH1XI563T4/Large+JPG-20140228_Trade+151_0046.jpg Old home page By clarifying the classification of complex needs, we help practices and primary care networks develop a radically simplified response to meeting need based on acuity, an approach that does not overwhelm primary care. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1580997877286-9GHPRTTM5T8O62TS4M67/Artboard+4%402x.png Old home page This is taking an asset-based approach to meet the needs of people who are struggling to live well. This goes beyond social prescribing to help practices and PCNs provide a stepping-stone, connecting people and collaborating with your community. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1580997891849-X207XU397SK36DD9XQN5/Large+JPG-Aro+Ha_0428.jpg Old home page Primary Care Networks work where there is shared passion and focus. We help PCNs unlock genuine innovations in meeting the needs of the local population. As your critical friend, we help you use your scale and combined expertise to move from managing activity to meeting needs. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1580997856261-1IE5TVLWCTKDC9C1YQ82/20140301_Trade-151_0124-copy.jpg Old home page - creating As the cornerstone of the NHS, General Practice needs to be the best it can be; to provide quality care locally for all, and at the same time reduce workplace stress; generate thinking and learning time and adapt to changing demands. Here we will share our experiences of doing this. https://www.pcnacademy.org.uk/topics/luxurious-ease-899c6 monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1579190658473-6NSG73OIS1Y3LTOA7O5D/Screen+Shot+2020-01-16+at+16.03.51.png Old home page - Where to Start in Primary Care Networks https://www.pcnacademy.org.uk/topics/quiet-reflection-gy6e6 monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1581416218712-VBQ3VRUDA6C7RWA4U49H/pcna+%284%29.jpg Old home page - Frequent Attendance - the work of practices and PCNs https://www.pcnacademy.org.uk/topics/top-bags-of-2019-3yrc3 monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566236932320-M1LY2DRANX03BPMTQ2KZ/image-asset.jpeg Old home page - Where To Start – dilemmas of a PCN CD https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566236950148-ZZWPI816IUWGY9KBEAV2/image-asset.jpeg Old home page - Where To Start – dilemmas of a PCN CD https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566236920255-9FTIVYWUB7W3PXSI4FCZ/image-asset.jpeg Old home page - Where To Start – dilemmas of a PCN CD https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566236907482-IDU13MFC70HRG6UH2SVD/Large%2BJPG-29034478096_3ccaf5fbc1_o.jpg Old home page - Where To Start – dilemmas of a PCN CD https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1581424083728-KQL7GMWL9JZ7EIABR8ZR/pcna+%289%29.jpeg Old home page - Where To Start – dilemmas of a PCN CD https://www.pcnacademy.org.uk/topics/everyday-beauty-5kfhh monthly 0.5 2019-08-23 https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566570067097-LIIOMEIZHAR6P4JAJY6Y/image-asset.jpeg Old home page - Everyday Beauty https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566570467360-6BSRHVAX6O3UEAGGUELC/image-asset.jpeg Old home page - Everyday Beauty https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1565029644232-8TTA8RTTZZE0QPUVVBVO/image-asset.jpeg Old home page - Everyday Beauty https://www.pcnacademy.org.uk/topics/city-of-apples-43dey monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566570143061-47T52DRGFI5HUHUHPGN8/image-asset.jpeg Old home page - City of Apples https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566570243641-2BRGRTCJXH6AHBYCIVRU/image-asset.jpeg Old home page - City of Apples https://www.pcnacademy.org.uk/topics/silver-gold-tl9x7 monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1566236628995-HS9348D4UK3XWDT69ZZ4/20150720-032A9634-Edit-color.jpg Old home page - Silver & Gold https://images.squarespace-cdn.com/content/v1/5d39e06a927f2800017b71e7/1565030109809-M1FR4Y6NNIUOXQOF6VJ2/image-asset.jpeg Old home page - Silver & Gold https://www.pcnacademy.org.uk/topics/category/PCNA+test+category monthly 0.5 https://www.pcnacademy.org.uk/topics/tag/tag+example monthly 0.5 https://www.pcnacademy.org.uk/topics/tag/network monthly 0.5 https://www.pcnacademy.org.uk/blogs daily 0.75 2025-06-02 https://www.pcnacademy.org.uk/blogs/int-insights-2-positioning-ints monthly 0.5 2025-06-02 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/953d1c91-107b-4802-8111-6a935a5a0b48/Screenshot+2025-05-30+at+16.44.33.png All Blogs - DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 2: Understanding Neighbourhood Working & Positioning INTs - Make it stand out Neighbourhood Working Bubble Diagram - Downham, Jansen and Malby https://www.pcnacademy.org.uk/blogs/int-insights-1 monthly 0.5 2025-05-30 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/2aac650d-d6a6-4f71-9c33-31b65bbf8a6e/Screenshot+2025-03-27+at+21.50.54.png All Blogs - DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 1: Learning from the Humber and North Yorkshire Heath and Care Partnership (HNYHCP) Integrated Neighbourhood Teams Leadership & Development Programme - Make it stand out Needs > Function > Form https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/007b0626-5f90-486d-92f8-f073eebe4506/INT+wOrk+2.png All Blogs - DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 1: Learning from the Humber and North Yorkshire Heath and Care Partnership (HNYHCP) Integrated Neighbourhood Teams Leadership & Development Programme - Make it stand out PCNA INT Development https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/8d97da04-df84-4c5d-a579-3a8cd9797650/Screenshot+2024-08-08+at+18.41.02.png All Blogs - DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 1: Learning from the Humber and North Yorkshire Heath and Care Partnership (HNYHCP) Integrated Neighbourhood Teams Leadership & Development Programme - Make it stand out What is MDT working? https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/a487bd76-5042-4928-9ceb-3337e8546e4d/INT+WOrk+3.jpg All Blogs - DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 1: Learning from the Humber and North Yorkshire Heath and Care Partnership (HNYHCP) Integrated Neighbourhood Teams Leadership & Development Programme - Make it stand out Making sense of the INT challenge https://www.pcnacademy.org.uk/blogs/blog-1 monthly 0.5 2024-12-20 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/ee48a0a6-3fa0-42f5-8b3b-5447b3e1c643/Screenshot+2024-12-20+at+16.06.18.png All Blogs - INT Development Programmes - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.pcnacademy.org.uk/blogs/blog monthly 0.5 2024-12-20 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/87883425-a487-47b8-871f-9a639058827c/Need+Function+Form+INTs.png All Blogs - INTs: Needs - Function - Form - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.pcnacademy.org.uk/blogs/beyond-the-mdt-meet monthly 0.5 2025-03-27 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/8d97da04-df84-4c5d-a579-3a8cd9797650/Screenshot+2024-08-08+at+18.41.02.png All Blogs - BEYOND THE MDT MEET: Realising the Potential of Integrated Neighbourhood Teams (INTs) - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/90b4647d-7244-47f6-8681-e9ad6253d0c6/unsplash-image-bwki71ap-y8.jpg All Blogs - BEYOND THE MDT MEET: Realising the Potential of Integrated Neighbourhood Teams (INTs) - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.pcnacademy.org.uk/blogs/do-we-control-outcomes monthly 0.5 2024-12-20 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/bb0f86e8-4a91-4ac1-9914-c5282b132207/Screenshot+2024-09-17+at+20.02.01.png All Blogs - Do we control outcomes? - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.pcnacademy.org.uk/blogs/how-to-start monthly 0.5 2024-12-20 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1637277303096-D8RWP1F0E5OQX24NOFAC/34624-start-startover-startingline.1200w.tn.jpg All Blogs - 4 things your practice can do RIGHT NOW to improve things - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.pcnacademy.org.uk/blogs/pcn-work monthly 0.5 2020-10-28 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367072443-ZB0LK8PGN1USFUVLOWDE/pcn.png All Blogs - The Work of Primary Care Networks https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367206237-84MV0OATNI12U9FDRPVI/screenshot-2020-01-22-at-20.41.16.png All Blogs - The Work of Primary Care Networks https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367452056-GZ24GW4OJ1NCNY0J8VSI/screenshot-2020-01-22-at-22.02.44.png All Blogs - The Work of Primary Care Networks https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367330562-UPA2XIUYZ7A2ZTGAZYZC/screenshot-2020-01-22-at-20.41.31.png All Blogs - The Work of Primary Care Networks https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367291545-PZZ63TADUN7G6UO977TI/complex.png All Blogs - The Work of Primary Care Networks https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367360260-VV70SNGBCKMD1TGIEVE5/screenshot-2020-01-22-at-20.41.41.png All Blogs - The Work of Primary Care Networks https://www.pcnacademy.org.uk/blogs/acuity monthly 0.5 2020-10-28 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602853453307-WN1PYFPA7UWOTU3U05EC/Acuity+2.png All Blogs - Meeting Complex Needs – Acuity https://www.pcnacademy.org.uk/blogs/pcns-segmentation monthly 0.5 2021-08-11 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1603550202351-4CTX6W7Y5O95T4EXGNU6/Social+and+Medical+Segmentation+Annotated+PCN+Acad.001.jpeg All Blogs - What work should we tackle as a PCN? https://www.pcnacademy.org.uk/blogs/overview-generalpractice monthly 0.5 2021-11-17 https://www.pcnacademy.org.uk/blogs/reducingdemand-step1 monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583155774959-TAXVCW202FOF2RK9ZAE4/screen-shot-2017-07-25-at-12-12-16.png All Blogs - Reducing demand. Step 1- Understand who comes to the practice. - The webforms are: A one page web form for GPs and reception Completed after each appointment or reception contact Tracked for one week The GP / nurse form includes: first estimate of the size of “moveable” demand at the practice The reception form includes: Flow and nature of appointment requests – by hour of day, by day of the week Distribution of requests (days ahead requested) Proportion of named(continuity) requests that we manage to satisfy https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583155906280-KA6K9XBOTMZB406B5PU9/screen-shot-2017-07-23-at-20-33-41.jpg All Blogs - Reducing demand. Step 1- Understand who comes to the practice. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583155925991-R3Q8LLS9OTR7OTDQJY5Z/screen-shot-2017-07-23-at-20-34-51.png All Blogs - Reducing demand. Step 1- Understand who comes to the practice. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583156372083-DS0FGEYFM0F0UJ39NEJC/recep+patterns.png All Blogs - Reducing demand. Step 1- Understand who comes to the practice. https://www.pcnacademy.org.uk/blogs/reducingdemand-step2 monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583157485413-LP0SLGJGS4DCQFZBNBUW/histo.png All Blogs - Reducing demand. Step 2 - Match supply to demand https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583157060231-UHEKWYONF2FWIS6XNKMS/screen-shot-2017-07-23-at-20-51-49.png All Blogs - Reducing demand. Step 2 - Match supply to demand https://www.pcnacademy.org.uk/blogs/proactive-on-fas monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367818599-97J05IP3OFSX37R0ZT32/screenshot-2019-09-11-at-09.52.29.png All Blogs - Proactively Managing People Who Turn Up Frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367798912-UJC8W26DCUHOP9K0POXQ/distribution-of-appointment-fa-sept-2019.jpg All Blogs - Proactively Managing People Who Turn Up Frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367925399-EE278HZCRFGK90H8W288/screenshot-2019-08-19-at-15.43.40.png All Blogs - Proactively Managing People Who Turn Up Frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583367739144-URAUIAKXFPVTYZKS45M0/screenshot-2019-09-11-at-09.49.57.png All Blogs - Proactively Managing People Who Turn Up Frequently https://www.pcnacademy.org.uk/blogs/collaborating-communities monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602855399610-J6MEGA0UEZJFARISJUKQ/SP.png All Blogs - Reducing demand by collaborating with people and communities https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583364822113-L87YGB0OTTBU0KM8RMUV/screen-shot-2017-11-20-at-09-48-10.png All Blogs - Reducing demand by collaborating with people and communities https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602856025357-06Z2JC61Y1XBXPDQJOSH/Screenshot%2B2020-10-16%2Bat%2B14.41.16.jpg All Blogs - Reducing demand by collaborating with people and communities https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583364846851-2CKFWEM4FTBMWAEIDTR7/screen-shot-2017-11-20-at-18-33-32.png All Blogs - Reducing demand by collaborating with people and communities https://www.pcnacademy.org.uk/blogs/variation monthly 0.5 2020-10-28 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1603658210244-USRSTTLH3N9M6HC626BP/Variation+Iceberg+V2.jpg All Blogs - Variation and General Practice Where and why does variation exist in general practice? The classic Iceberg model applies here. When thinking about variation we tend to concentrate on what is above the waterline, but it is what is beneath that underpins and holds the key to the causes of it. Above the surface Clinical variation What general practice tends to concentrate on is a simplified subset of clinical variation which is driven by QOF[1]. QOF details the basic standards for practice process, interventions, patient assessments, care planning and outcomes for many high volume conditions and patient groups. Without getting into the discussion about where these clinical standards come from, the intention is that QOF incentivises all practices to do these basic things. My experience is that this has quickly lost meaning. GPs often separate the work of QOF, from actual doctoring. They see very little link between QOF and their practice, other than it being a bureaucratic burden. All that said, clinical variation is still very important. GPs vary in their prescribing choices, in their diagnostic choices, in their consultation approaches and in their knowledge around different conditions. Patients get different things from different GPs. This potentially impacts quality and safety; but it also impacts efficiency, it impacts cost and also it means that patients get conflicting responses. Data on implications of all of this is available although either difficult to capture or in some cases dated. Despite this, the data is hard hitting. The comprehensive NHS Atlas of Variation paints a stark picture of variation. For example it suggests that variation in the number of people on a dementia register as a percentage of estimated prevalence varies between 26% and 58.8% across practices within NHS England. On the subject of prescribing there are countless examples. For example this scientific summary from the NIHR journal details variation of prescribing of nonsteriodal anti-inflammatory drugs between GPs and between practices. The Society for Academic General Practice found that rates of prescribing for sore throats varied significantly. It found that there some practices can be 2.5 times more likely to prescribe for patients presenting with a sore throat than others (when presented with the same patient). With my collaborators Becky Malby and Tony Hufflett at London South Bank University we have created new analysis to explore variation from an angle not possible through nationally collected data. Through GP led data collection we have found that within practices there is variation in next steps decision making by GPs. For example, within one large practice the recall rate (‘I would like to see you again’) varied between GPs from 6% of patients to 33% of patients seen. More anecdotally, I have recently been having discussions with practices on outstanding medication reviews (the volumes of outstanding med reviews can be substantial). While the problem is to a great extent a product of patient behavior and practice capacity, in unpicking the problem, it is clear that there is variation in what priority different GPs give to medication reviews. It is unsurprising that knowledge plays a great role in variation in clinical decision making. It is important to consider that this is not just a product of training and experience, but it is a product of systems to aid decision making. From example in his acclaimed BBC Reith Lectures Atul Gawande states that the volume of medical knowledge has now exceeded an individual clinician’s capacity to retain it. So the extent that systems of support are in place causes variation in decision making. This variation of knowledge is not just about deep clinical knowledge, it can be around the knowledge of the broader determinants of health. For example views and knowledge that the non healthcare determinants of health dwarf the healthcare determinants of health. Again, this is not about a good or bad judgment and of course the causes are multifactorial. What is clear is that there is variation, it does have a profound impact and the best people to unpick all of this are the clinicians themselves. A simple way I begin to explore this is by asking GPs what kind of practice they work in. Are you working in a practice that is essentially a roof over four or five autonomous clinician’s heads? With the practice essentially providing payroll and back office support and the clinicians go about their work independently of each other? OR Are you a family of practitioners, with a consistent and co-developed approach to practice? Beneath the surface So what drives all of this? I have identified four drivers of variation that underpin the visible variation as detailed above. Model and process Internal process Practices vary in terms of internal process. From how correspondence is managed, to how test results are communicated. Despite practices sharing the same craft, there is massive variation in how internal process has evolved. What cements this is variation in how internal processes are used. For example, it is typical for one GP to trigger another appointment for a patient by asking the patient to contact reception again in a few weeks, while another in the same practice may book that appointment direct for the patient there and then. Model (or design) Practices vary by model. Some have triage systems, some have a wide skill mix, some are big, some are small, some offer a wider range of services, some have great links with other services, some run community groups and some actively engage in developing their communities. Again, not a right or wrong judgment, but this all has an impact on the services offered. Ultimately the model of the practice influences its capability to respond to patient demand (see Purpose below) – and what type of demand it can respond to, such as health and also social. Perception and management of risk Risk drives much of the variation in practice. The views that different clinicians take around risk, driven from a medical legal standpoint can divide clinicians. It impacts next steps decision making with patients, and it determines how defensive different clinicians’ practice is. This results in overseeing and over treating – the levels of which vary by clinician and by practice. It is not just risk of litigation or of harming a patient. Risk around triggering complaints is also a source of variation. It is common statement that more experienced clinicians manage risk more effectively and thus practice less defensively. I don’t believe it is as simple as this. A clinician’s perception of risk is also driven by previous incidents, by complaints and by training. The role of the professions Professional ideology drives variation in practice from two main perspectives. The first is the power / relational dynamic between the professional and the patient. The approach from a GP who takes a traditional medical professional ideology may take the view that they the professional has the role of identifying what is wrong and telling the patient what to do about it. It could be described as a paternalistic relationship with the patient. On the other hand, another GP may take a different starting point with a shared power dynamic. Helping the patient take some of the responsibility. An example of this is patient centred care. https://gpview.co.uk/how-do-we-reclaim-gps-core-role-in-long-term-condition-management/ The second source of variation driven by professional ideology is around the role other professions play. Depending on professional standpoint, different GP partners vary in how open they are to other professions playing a role in their practice. For example this could be around the role of nursing, therapists and the role of receptionists. This is not always overt, like a decision to employ a different professional or not, but often it is more subtle. For example whether a professional group is included in decision making about the shape of new services. Context Context, in this case external context, causes a lot of the variation in different practices’ capability to respond to patient demand and how they are shaped and operate. This context could be seen as the system they work within. Factors that influence this range from: • the financial contracts, • the prominence of GP networks (such as federations and the LMC), • the stand point of the commissioner (do they take a performance management or a developmental stand point), • the population served (this influences not only the demand but also the attraction and retention of staff), • demand • the historic reputation of the practice(s), • history of major safety / safeguarding incidents in the local area, • and demand variation including seasonality. Purpose Finally we have variation around the purpose of a practice. Specifically this is around the role an individual practitioner, and / or a practice chooses to take in meeting the social determinants of health. Through a small-scale study I supported, GPs judged that 49% of patients were likely to be struggling in their context (severe social stressors) and 6% had a chaotic social context. In other words more than half of the patients seen were likely to have a life context that would deeply impact their ability to follow advice or make lifestyle changes. This dramatically limits the effectiveness of a health dominant approach to general practice. What a GP chooses to do about this is a source of variation. Some GPs chose to try and help with the social determinants, some chose not to. This is driven not only by capacity (time), but also by what they see as the purpose. Should the social care system pick these patients up? What are my beliefs around an individual’s responsibility? Should we as a practice devise ways of helping people in this situation? A GPs response is deeply personal in many cases. Driven by preferences, ideology and politics. The net result is very different individual approaches to practice from GPs and also very different practice models. For practices that view social need as part of their purpose, the model can be very different. For example take the acclaimed Bromley by Bow Centre. It was started as a community centre first, and then health services added. The so what? Returning to Deming’s System of Profound Knowledge, for a profound knowledge of process, then we must seek to understand variation. What this discussion highlights, is that variation in general practice is multilayered and should not be oversimplified. It is also not a case that all variation in bad. In fact the ability to vary is key to helping some patients. As a vital first step, seeking to systematically understand variation using the prompts in the Variation Iceberg places you in a much better position to understand why things are as they are, and what the conditions for change need to be. https://www.pcnacademy.org.uk/blogs/reducingdemand-step3 monthly 0.5 2020-10-26 https://www.pcnacademy.org.uk/blogs/blog-3 monthly 0.5 2020-10-28 https://www.pcnacademy.org.uk/blogs/fas-breakingcycle-1 monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602849075161-5QS07DA53LV69E9OV40Q/Data+5.png All Blogs - Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602848831848-OXBWRHN40NBTDL1KEH3X/Data+1.png All Blogs - Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602848905336-JK10IGJWZ4CICL996TJG/Data+2.png All Blogs - Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602849017372-XR52OL2BMYHJ4H9BYS60/Data+4.png All Blogs - Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently Circa 40% are Struggling with life https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602848957661-R6444E93XMF1O9COMUW0/Data3.png All Blogs - Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently https://www.pcnacademy.org.uk/blogs/sp-3things monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583365537804-BKU7T2DJLTM54YWK1CKB/screenshot-2019-10-09-at-16.03.53.png All Blogs - The 3 things you should know about Social Prescribing https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583365518092-QSJN8X29JCZQI1DZS859/picture-4.png All Blogs - The 3 things you should know about Social Prescribing https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583365236059-P35F8VHTFS0RNXDE8M09/picture-3.png All Blogs - The 3 things you should know about Social Prescribing - You can read the report here. The report has four inspiring case studies – The Alvanley Way (Alvanley Family Practice) The Frome Connections (Frome Medical Centre and Health Connections Mendip) Grenfell: After the Fire (you may have seen the fantastic Fatima Elguenuni at NHS TEDx) Wakefield: Dancing Down the Corridors (Creative Minds, West Yorkshire Partnerships Trust). https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583365732092-IEJWNDFLIJLRW1ARXBRY/picture-1.png All Blogs - The 3 things you should know about Social Prescribing - The London South Bank Asset-Based Health Inquiry investigates how best to develop social prescribing.It sets out the imperative to build out from communities not artificially mandate a scale for working with populations that doesn’t recognise existing community identities. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602857800608-9SZO8I46T0IW698ZQCC7/Scale.png All Blogs - The 3 things you should know about Social Prescribing https://www.pcnacademy.org.uk/blogs/reducingdemand-step4 monthly 0.5 2020-10-26 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583158316012-J8HXM78SSAB0XKPGFBV8/screen-shot-2017-07-24-at-10-43-00.png All Blogs - Reducing demand. Step 4 - Going Live https://www.pcnacademy.org.uk/blogs/fas-breakingcycle-2 monthly 0.5 2020-10-26 https://www.pcnacademy.org.uk/blogs/blog-post-title-four-6ec83-7dlwl monthly 0.5 2020-10-26 https://www.pcnacademy.org.uk/blogs/blog-2 monthly 0.5 2020-10-28 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1602770050213-HY5CNN7CVBE0GW4A56CG/PCN+CD.png All Blogs - Where To Start – dilemnas of a PCN CD https://www.pcnacademy.org.uk/blogs/carehomes monthly 0.5 2020-10-28 https://www.pcnacademy.org.uk/blogs/resilient-communities-video monthly 0.5 2020-10-28 https://www.pcnacademy.org.uk/blogs/pcn-purpose monthly 0.5 2020-10-28 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583366292837-3H9C7VIVG70HWQTLBQKC/screenshot-2019-06-03-at-16.31.18.png All Blogs - Getting to the purpose of PCNs. Holding true to purpose whilst the old world bites back. https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1583366523326-JYMBMNLIHUBBGB53PZ94/screenshot-2019-06-03-at-16.31.46.png All Blogs - Getting to the purpose of PCNs. Holding true to purpose whilst the old world bites back. https://www.pcnacademy.org.uk/blogs/pcn-organising-for-seven-service-specs monthly 0.5 2020-11-10 https://images.squarespace-cdn.com/content/v1/5e208587b5afaa42c02bc6d6/1603645116342-EJ3ILMHWAQJASHLMZOMY/Linear+Relational.jpg All Blogs - Organising for the seven service specifications What the matrix above (developed by 16 PCN Clinical Directors) tells us is: All but two of the service specifications need a true network based response. Reliant on multiple, independent parties coming together with a common purpose. A simplified, defragmented, response to need is also crucial. Our ‘business as usual’ hierarchical structures are not the solution. A drive for process improvement is only suited to the more transactional specifications – such as Early Cancer Diagnosis and Medicines Reviews. We cannot rely on a process improvement (sometimes called Quality Improvement) approach. The above suggests we need to challenge our work and our structures more fundamentally. The key to the specifications in the bottom right is the context of the patient. Context (social determinants) drive health and we need to acknowledge this fully in our service design (instead of trying to move it to another part of the system). This practically means Commissioners need to: Build in funding for time for PCNs to concentrate on true network building. Stop inadvertently forcing PCNs into hierarchical (provider) forms by putting deadlines and funding links to short term delivery aims. Help PCN clinical leaders concentrate on forming true network working, rather than driving them to form management and provider hierarchies. Simplify the provision of community care through longer term and integrated commissioning. This requires more flexibility on specification and scrutiny, in order for front line staff to be able to do ‘what matters’ and form relationships. Understand the end to end costs of care rather than the point (intervention) costs. This radically changes the conversation. The money is there, we just waste it with hugely fragmented responses to helping people with everyone concentrating on their bit. PCNs need to: Consider the work very carefully. This starts with understanding the need. (LINK TO UNDERSTANDING NEED BLOG). This should shape the work. Take this understanding and spend time creating a common purpose. No network of individual services and stakeholders can operate without a clear, co-designed, purpose. It is the glue that holds it all together (LINK BECKY BLOG). Consider how much of the work is reliant on patient context and thus a relationship with the patient. How effective are your practices at providing continuity of care to those who need it (TONY BLOG). Be clear on what work happens should happen at what level (LINK TO BLOG ON NEED): o Practice level: Low and medium acuity patients in a stable social context. o PCN level: Low and medium acuity patients with under pressure with social context. High acuity patients with stable social context. o ICS level: Patients with turbulent social context. High and very high acuity patients. Spend time creating your theory of change for each service specification. Driver diagrams are a great way of doing this. 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