Primary Care Networks: benefits and challenges

The "Investment and Evolution: five-year framework for GP contract reform to implement the NHS Long Term Plan" determined that general practice should take the leading role in every Primary Care Network (PCN) under the Network Contract Direct Enhanced Service (DES), underpinned by a Network Agreement between the many practices all across the country.

Practices with an in-hours (essential) primary medical care contract will be eligible to sign-up to the DES as part of their network however Federations cannot hold the Network Contract DES. The requirements and provisions under the Network Contract DES will begin on the 1 July 2019 and you should know that the DES has three elements:

  • National Service Specifications: the first of these will not commence until April 2020, and these must be nationally negotiated
  • Supplementary Network Services: developed locally by CCGs and PCNs
  • Network Financial Entitlements (NFEs), these being: the Additional Roles Reimbursement Scheme (ARRS), funding towards the role of Clinical Director (£4.37, Contract), £1.50 per head recurrent funding from CCG allocation, £1.76 Network Participation Payment (which is paid directly to the practice, and not to the Network).  

The debate by stakeholders and various parties concerned has been ongoing for quite some time and still there seems to be no consensus on the (perceived) benefits and challenges of joining a PCN. NHS England says it is important that whilst PCN's should develop in a way that meets their specific local needs but they must also provide a consistent level of support and integration with the wider health and care system. These should include community pharmacies, optometrists, dentists, social care providers, voluntary sector organisations, community services providers or local government according to new NHS contract documents and will be expected to have wide-reaching membership to offer more personalised, coordinated health and social care to their local populations.

In reality, the concept of PCN's has long existed in some form or another (through Out of Hours GP Co-Op's in the 90's, Primary Care Homes, Collaboratives, Federations, super-partnerships, etc.) but NHS England is now pushing for its formal and more organised implementation via inclusion in this DES contract. All practices will be expected to join a network, the network population (as proposed) will be at least 30000 but no more than 50000, should typically include 6 to 10 practices whose level of integration and participation within the network will be determined locally. The various levels of collaboration should encompass areas such as workforce, business model development, digital innovation, clinical governance, estates solutions and other common projects to improve care outcomes.

PCN's are obviously expected to develop at different rates, depending on the level of joint working already happening, the financial strength and support from the local commissioning groups and also the demographic variants of the areas they belong to. Threats to existing large groups may also arise, particularly those whose member practices are widely dispersed 

across several networks. The general practice landscape is usually uncertain and it is up to wise practice managers and GP partners to determine how their businesses remain viable, profitable and innovative in this new NHS universe whilst ensuring at the same time that patients are provided with the best healthcare possible.

Whilst the benefits to practices when joining a network may seem obvious (it is expected that PCN's will ease workload pressures on GP's and GPN's by practices being in a PCN with a wide range of health and social care professionals) it is also important that these benefit the patients (through a better coordination of service providers which will enable patients to access the care they need from the right services and by allowing patient flow to wider primary, community, mental and social services).

However, not all that shines is gold and there have been rumours that CCG's in some areas of England are set to manipulate new PCN's to ensure they align with their own plans (e.g. allegedly a number of CCG's have been trying to influence how networks are set-up, including telling practices which GP should become their clinical director and how they should form geographically in order to align with local community teams). This is clearly contrary to what NHS England suggested when announcing the new five-year GP contract (NHS England and the BMA said formation of the new PCN's should be GP-led, with CCG's becoming involved to make adjustments to membership and boundaries where necessary, for example where a practice falls between two networks).

 

And caution is advised for the extremely optimistic and over ambitious in regards to fast gains with PCN's...

Based on research made on the experience and performance of previously created PCN's, some conclusions can be made:

  • The length of time to form a successful network might span years and exceed the initial optimistic expectations and many collaborations will find it difficult to define and achieve their aims.
  • Over time, smaller providers might feel distraught that their voice is not heard and that none of their suggestions is implemented (or even discussed in meetings) as they will have little bargaining power in a partnership with bigger and more influential providers.
  • Mandating membership of PCN's can provide clear accountability chains and ensure coverage across the country; but it can also lead to GP disengagement and could disturb the ambition and goodwill of existing collaborations that are based on like-mindedness and trusting relationships. Evidence from the development of integrated care systems shows that key factors for successful collaborations include developing trusting relationships, a shared vision, common values, and good leadership. If PCN membership is geographically mandated, it would be wise to allow networks to democratically define their own aims and activities, and for practices to opt-in to shared network activities.
  • It is important that PCN's are not set up to fail by taking on too many tasks / projects too quickly.
  • Careful planning and investment in the recruitment, training and integration of staff working within general practice - including clinical pharmacists, physiotherapists, social prescribing link workers, physician associates and paramedics. This formal commitment to a multidisciplinary team approach in core general practice will be a significant shift from the current modus operandi for many providers and just as contract changes in the 1960s and 1990s led to practice nurses becoming commonplace, this new GP contract signals a fundamental change in how patients will experience general practice, expanding the GP offer to become much more of a 'team sport'.

IT: the current IT infrastructures across the NHS are not fit for purpose and will let down even the most basic of users. Therefore, it is one of the key areas which will require looking at (and proper investment) as the current systems in place constantly run slowly, freeze and/or completely break down even with moderate use and if they are not adequate for a single practice, surely will not be able to accommodate a vast network on a daily basis with health apps, video consultations, websites and data sharing analysis tools all thrown in the mix. If these systems are not looked at, one will expect a lot of complaints and dissatisfaction from both service users and patients!

 

Did you know...

Tree View Designs are releasing an update soon which will make it much easier for practices joining at-scale models to manage their network and/or federation websites: GCM (GROUP CENTRAL MANAGEMENT) - it will allow practices that are part of a group to manage all their websites centrally from one location. This means that each time a group needs information added to all their websites, rather than log into each and every website, a super admin only needs to log into one website and can update all websites within that group instantly.

 

Jorge Goncalves (NHS Practice Manager) 

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