Before Christmas, NHS England launched a consultation about five specifications for services it wants primary care networks (PCNs) to provide. Enhanced care for care home residents and structured medication reviews are being considered from April this year, while anticipatory care planning, improved cancer detection and population health initiatives are proposed for subsequent years.
From NHS England’s perspective, the specifications can be seen as an attempt to roll out successful initiatives from its ‘vanguard’ sites, and to implement interventions with the potential to reduce hospital admissions, enable earlier diagnosis, improve clinical outcomes, and support patient-centred care.
But a flood of social media and trade press responses to the consultation demonstrate that, for many PCNs, the specifications are asking too much, too soon from newly formed organisations still finding their feet. Feelings have also run high about the extra work required to deliver the new services, supported only by funding for a small number of additional non-medical posts. One group of PCNs estimated that a typical practice would need to invest over £100,000 on people and resources per year to deliver the five services.
It seems likely that the specifications will be significantly revised, but their release and the subsequent consultation process have highlighted some critical issues about PCNs that need to be clarified.
First, they focus attention on different perceptions about the role of PCNs between GPs and policy-makers. From the start, there have been mixed views about what PCNs are meant to be doing. Our own ‘pre-mortem’ of PCNs summarised the range of clinical tasks and system functions they are expected to undertake, but also highlighted that a lack of guidance on how to do this might cause confusion.
The specifications suggest policy-makers are more focused on PCNs being at the heart of community teams and multi-professional services that help to reduce demand for hospital care. Responses to the specifications suggest that GPs see the first task of PCNs as stabilising practices and supporting the delivery of core clinical services. Meanwhile integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) also have big ambitions for the part PCNs will play in delivering out-of-hospital care.
Second is the extent of strain that still exists in general practice. After several years of falling funding and rising demand, a 2016 Lancet paper estimated that GP workload had increased by 16%. This increase in productivity went beyond the virtues of improved efficiency, and has been associated with burnout and driving GPs out of the workforce.
A recent workforce survey reported that, while things are starting to improve for GPs and overall satisfaction has risen slightly, multiple pressures still exist. The absence of additional funding for the service specification, and NHS England’s proposal that staff in newly created network clinical roles should be used to deliver the enhanced services, supporting the wider system rather than core general practice, has gone down badly. The continuing workload pressures and lack of extra resources are preventing GPs from looking positively on service specifications for which there is some evidence of benefits to patients and the wider system.
The other issue is the time needed to form effective PCNs. They came against a backdrop of workload pressures, rising demand, growing regulatory burden and workforce shortages. With unprecedented speed, almost every practice in England had joined a network within six months of the policy announcement.
However, the time and effort required to join and participate in PCNs (meeting attendance and reading papers, communicating with colleagues) should not be underestimated. PCNs that emerged from existing collaborations between practices might have already invested the time and effort needed to build trust between member practices, but GPs in newly formed networks must address this important issue too. The additional discretionary time and effort required to make a PCN ‘motor’ – redesigning pathways, building relationships with clinicians in other services, recruiting, inducting and overseeing new workers – may seem overwhelming alongside the continued increase in demand for access and clinical care.
Each of the new service specifications requires time and resources for implementation, and the collaboration and high-trust relationships needed for this to be done successfully cannot be forced into existence. So the timeline for delivering the new service specifications is critical. The consultation document includes reassurances from NHS England that it won’t expect too much, too quickly – only two specifications have to be implemented immediately. But many PCNs are still trying to implement this year’s specification and may lack the capacity to take on more.
In responding to the consultation, NHS England will have to manage various tensions. Between the relative priorities of stabilising general practice and transforming the wider system. Between honest acknowledgement of the time needed to establish effective PCNs and their natural desire for system change at pace. Between the ambitions of the People Plan to ‘make the NHS the best place to work’ and acting on evidence that work pressure – which, in the short term at least, will be increased by forming PCNs and implementing new service specifications – causes burnout.
The additional funding promised to the NHS by the government will help to take the edge off pressures on the NHS. But STPs and ICSs across the country have developed ambitious plans for service transformation and financial recovery in which PCNs play a central role. Meanwhile the government will want to see concrete improvements in NHS performance and access to justify the investment. A perception that the NHS is unable to drive forward progress on delivering its own plan will not be viewed favourably within certain sections of the new government.
If NHS England ignores feedback it receives during the consultation and presses ahead with its current plans, many GPs have declared their intention of pulling out of enhanced services agreements – creating significant risks for wider system transformation plans. Responding to the feedback and changing the timeline and expectations of enhanced services is likely to slow the pace of system transformation, but may help to keep GPs engaged with the plans.
Difficult choices. But nobody thought that implementing the Long Term Plan would be easy.
Rosen R (2020) “Crunch time for PCNs”, Nuffield Trust comment.