By Dr Jane Halpin and Dr Arvind Madan
Since July 2019, as part of the NHS Long Term Plans (LTPs) ambition to develop integrated health and care, all general practices in England have come together to form one of 1,250 or so Primary Care Networks (PCNs). While this isn’t the first attempt to encourage greater cooperation between practices, it is the first time in NHS history that real terms funding for primary and community health services is guaranteed to grow at a faster rate than that of the overall NHS budget, including £1.8 billion to support the establishment of PCNs.
However, this additional funding comes with significant expectations: an increase in workforce numbers across five staff groups; seven new services specifications aimed at integrating primary and secondary care; forming multi-disciplinary teams with community services; sorting out primary care access; and delivering a more preventative, anticipatory model of care. To realise these expectations requires PCNs to focus on key enablers such as internal and external relationships, technology and analytics and agreed governance and accountability arrangements.
In our latest Integrated Care Systems (ICS) blog, Dr Jane Halpin, Deloitte’s Clinical Lead and Dr Arvind Madan, our Primary Care lead, consider the key challenges facing ICSs as they seek to establish mature PCNs and deliver population based primary care at scale.
The benefits of establishing PCNs
A key ambition for PCNs is to stabilise the GP partnership model and ensure it remains sustainable.1 The delivery requirements of PCNs will be funded by new payments of £1.8 billion by 2023-24. Access to additional funding for general practices in 2019-20 was contingent on becoming part of a PCN by July 2019, unsurprisingly almost all practices formed a PCNs by this date. However, the publication of the PCN draft service requirements, in December 2019, caused almost universal concern among practices about the risk of placing additional and unmanageable strain on the workforce. At the end of January, NHS England and the BMA were seeking a mutually acceptable compromise.2
While the detailed expectations are under debate, the benefits of PCNs are widely acknowledged, albeit there is recognition that the general practices forming PCNs have widely varied histories. We have seen first-hand that while some are already experiencing the benefits of working differently, others have struggled to overcome their past and the strained relationships created by the social and economic environment in which they operate. Where the local context is one of confidence, there is clarity about how the additional funding can best drive improvements, especially in deploying a wider primary care workforce and increasing the resilience of primary and community services (one such example is the primary care led integrated paramedic home visiting model in Wokingham).3 Where the starting position is less secure, we see a risk that health inequity and inequality could increase, exacerbated by the fact the PCN funding is not linked to population demography.
However, there are steps that can be taken to improve the chances of success. Our discussions with primary care leaders have highlighted three main themes: getting the culture and governance right, using data and insights to inform plans, and using the opportunity PCNs offer to transform the care model across the wider ICS. Success will require an open mind-set and a willingness to trial new approaches and learn from both successes and failures.
Culture and Governance
PCNs do not have a statutory footing, but have legally binding Network Agreements that set out the collective rights and obligations of general practices in the network, as well as how the network should collaborate with primary, community and voluntary care stakeholders.4 From April 2020, collaboration with other local care organisations will be a formal requirement of Network Agreements, however the purpose and functions of PCNs are still evolving.5
Meanwhile, PCNs are expected to maintain universal population coverage using a multi-disciplinary staffing model, with practices incentivised to participate through a shared income stream. PCNs are expected to connect primary and community care and give general practices a bigger voice in the ICS with ICSs reliant on PCNs to be the delivery units for their strategies. A key requirement is establishing clear lines of accountability given formal accountability remains with individual organisations and ICS’s have no statutory foundation. However, these accountabilities blur as ICSs bring together provider and commissioning responsibilities in line with the LTP. Establishing the right working environment and shaping the culture of the PCN will depend on having the right leadership and a shared vision and clarity about behaviours expected of staff working in the PCN. This will require new ’compacts’, with local partners and with regulators.
Data and insight
Data and analytics are a priority for most PCNs and establishing a population health management (PHM) approach is likely to be easier at a PCN level than across a whole ICS due, for example, to there being fewer stakeholders to align around priorities and less cumbersome governance around data sharing. However, getting access to good quality analytical support, is likely to require PCNs to share resource within an Integrated Care Partnership (ICP).
A challenge will be maintaining sufficient co-ordination across the ICP or ICS to allow ‘bottom up’ and ‘top down’ priorities to meet in the middle and prioritise common big-ticket items. The chances of sustained success will be greater where services are grounded in a deep understanding of local needs, local infrastructure and achievable outcomes; in part through the application of PHM approaches (covered in a previous blog in our ICS series).6
An early requirement for PCNs is to increase numbers and types of staff, such as pharmacists and social prescribing link-workers, however finding the right staff is proving quite challenging. In the longer term, expectations include improving access to primary care, including establishing a ‘digital first’ approach. Indeed, we will be publishing a research report on ‘Realising a digital first primary care system’ on 10th February.
Meanwhile, PCNs need to help drive the integration agenda by becoming the ‘provider delivery units’ of personalised, preventive, population-focused primary care. Achieving the required changes will require flexibility, to find ways that work best for all local stakeholders. One example is a local community trust that is employing physios on behalf of the PCN to address local workforce supply issues.
What is needed to start to deliver this in practice?
While there may be a short ‘honeymoon’ period before PCNs will be expected to deliver change, the extent of change needed may cause tensions between members and risk taking easy rather than optimal decisions. Mitigating this will require an investment in operational and leadership development. Establishing clear governance, roles and accountabilities should reduce the risk of straining existing relationships, alongside developing a practical and measured approach to developing PHM capabilities. Moreover, the fact that PCNs are developing at the same time as ICPs and ICSs can be seen as a positive, allowing iteration, evolution and co-development to take place. Having clear frameworks and deploying tools as highlighted in our PHM blog, should help PCNs navigate the complexity successfully.7
The realignment of care towards communities will require a coherent and co-ordinated approach between individual PCNs and across the wider ICP or ICS footprint, with the aim of strengthening primary care and helping reduce the demand on hospitals and other services. Done well, it will achieve better patient experiences, outcomes and value; as well as mitigating current service pressures. An opportunity we can’t afford to lose. As a first step we have identified a number of key questions that PCNs need to ask themselves:
- how will your development differ from previous approaches to encouraging co-operation between practices and what lessons can you learn from past attempts?
- what is your role in the wider integrated care system?
- what outcomes do you want to achieve, by when, and how will you measure these outcomes?
1 GP Partnership review, Department of Health and Social Care, January 2019. See also: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf