Primary care networks and the deprivation challenge: Are we about to widen the gap?  

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The newly emerging primary care networks provide an opportunity to tackle health inequalities in England but, as Rebecca Fisher and Beccy Baird explain, they will have to be careful to avoid perpetuating the problem.

In the face of a growing health gap between rich and poor in England, the NHS long-term plan explicitly commits to a focus on ‘health inequality reduction’. The roots of socio-economic inequalities lie deep within communities, and general practice – itself rooted in communities – is key to addressing the problem. As practices scrabble to organise themselves into primary care networks, making meaningful progress towards reducing health inequalities requires these networks to be part of the solution. But unless a combination of quirks, oversights and loopholes in their design and contracting are addressed, there is a risk that they could perpetuate the problem.  

Funding

The Carr–Hill formula – used to weight funding for GP practices – has frequently been criticised for not sufficiently taking the impacts of deprivation into account.1 Despite promises from NHS England and the British Medical Association to address this, the new GP contract fails to do so. As a result, the weighted component of per-capita funding for primary care networks is based on a formula which systematically under-funds practices in areas with the most need. Some of the other sources of income for primary care networks (an annual uplift of £1.50 per patient from clinical commissioning groups (CCGs), and funding for extended hours and extended access) aren’t weighted at all – meaning that networks servicing populations with the greatest needs will continue to do so with disproportionately less resource.

There is a commitment that down the line primary care networks will be able to unlock extra funding from an ‘investment and impact fund’ – essentially a savings scheme accessible to them if they are able to achieve specific targets. Examples given include reductions in accident and emergency attendances and delayed discharges, but these are likely to be easier to achieve in some areas than others. A variety of mechanisms could be used to mitigate this – offering higher payments in deprived areas being one example. Policy makers must specifically consider the impact of deprivation on ability to unlock funding if there is to be equality of access to funds for those with the greatest need, let alone access in proportion to need.

Outside the contract, there are potentially other sources of funding available – NHS England is clear that it expects CCGs to use some of their additional funding for inequalities to boost primary care capacity and access. However, we have heard reports of CCGs withdrawing locally incentivised services tackling health inequalities, citing the need to free funds to make the £1.50 per head ‘core funding’ payment for primary care networks.

Workforce

It’s already clear that the workforce crisis in general practice is disproportionately affecting deprived areas. Between 2008 and 2017, the number of GPs working in the most deprived 20 per cent of areas fell by 511, in contrast to the wealthiest 20 per cent, where 134 additional GPs were recruited. The opportunity to expand teams, deliver care in different ways, and reduce GP workload by drawing on the army of physiotherapists, pharmacists and paramedics announced alongside the contract is exciting, but must be equally available to all primary care networks.

Even on the optimistic assumption that the promised 20,000 additional staff will be available to primary care networks, there aren’t yet mechanisms to try to level the playing field for recruitment. Although some of them will decide to work in areas of greater need (and often greater workload), opening an early discussion about other levers – financial or otherwise – to attract more seems sensible. Otherwise there’s a risk that the PCNs serving the most deprived populations will be least able to recruit, perpetuating the current problem of under-doctoring in these areas.

Danger dominoes

The number of practices closing has risen rapidly in recent years, and the most affected areas have strikingly similar profiles. Areas with older, poorer populations and older GPs (often rural and coastal locations where attracting new staff has been particularly difficult) have borne the brunt of practice closures, with knock-on increases in pressure for the practices still standing. Geographically grouping practices might allow primary care networks to offer more attractive and diverse job roles and to reduce workload by streamlining back office functions. But where the entire geography of a primary care network is an area of high deprivation, increasing inter-dependence between neighbouring practices that are already vulnerable risks a domino effect – where the failure of a single practice drags others with it.

In networks with only small pockets of deprivation within more affluent areas, or where a very small area has a particular defined need (such as a practice specifically providing care to homeless people), a single practice serving that group may find itself and its specific needs isolated within a larger network of practices. How primary care networks address these very specific and local needs will be important, taking care to ensure that the priorities of the majority do not mean the needs of minorities are not met.

Problems to recognise, opportunities to grasp

Although the timelines for their development are ambitious, and details of support and evaluation strategies rapidly required, primary care networks are an exciting opportunity for general practice. General practice can and must do more to reduce health inequalities, but the areas with the highest socioeconomic need will often require the most support. The risks outlined above demonstrate some of the ways in which primary care networks could widen an inequality gap, but this is far from inevitable if policy makers recognise the problems and work to find solutions.

  • 1.Kontopantelis E, Mamas MA, van Marwijk H, Ryan AM, Bower P, Guthrie B and Doran T (2018). ‘Chronic morbidity, deprivation and primary medical care spending in England in 2015-16: a cross-sectional spatial analysis’. BMC medicine 16(1), p19.

Comments

Pearl Baker

Position
Carer Independent Mental Health Advocate & Adviser,
Organisation
Independent Mental Health Advocate and Adviser
Comment date
12 May 2019

The difference between Urban and Rural Areas are significant. Patients living in Rural areas are disadvantaged for a number of reasons: Transport, GP and Staff Recruitment, 'integration' with other services are disadvantaged if not part of the 'NETWORK'. The closing down of Libraries, 'day centres' all put the Rural Patient at a disadvantage.

Those living in Urban areas are disadvantaged by the 'sheer' number of Patients: unable to secure an appointment. GP telephone calls to elderly Patient will miss out 'vital' signs that are only visible to the 'naked eye'. Libraries, 'day centres' all closing.

Elderly Patients living in 'isolation' of others will NOT contact anyone, they NEED and Should be on the 'RADAR' of the 'SYSTEM' already, again i refer to the GERMAN system:

'Isolation' for the elderly is a 'huge' problem it requires the GERMAN system to improve the Health & Social Care of these individuals.

The GERMAN system already identifies those above via an 'integrated' system, these individuals are on the RADAR, regular visits, organising activities with the community, 'keep fit' social inclusion, community activities, all paid for by the state. It STOPS the progressive illnesses developing.

I cannot envisage the current system ever improving, if more funding and thought is not given to the difference between the Urban and Rural delivery of Health & Social Care.

Population Health is NOT about the South/North divide, it is more about the Rural/Urban areas of our Country.

Population Health also have other 'players' LG & Social Care Ombudsman CQC and PHSO, all have a 'part' to play in ensuring COMPLAINTS are investigated impartially, and based on EVIDENCE.

The PHSO/CQC will only investigate Regulated Services, many Patients are now being placed in 'Supported Accommodation' NOT Regulated. EVIDENCE has identified many 'vulnerable' once living in Registered Regulated Accommodation are now having their placements 'deregistering', and then claim Housing Benefit. Their funding comes from a different 'pot'. These patients are seriously 'unprotected' and my experience has identified 'Safeguarding' issues are serious.

The LG & Social Care Ombudsman have NOT kept up to 'speed' with the ever changing 'Health & Social Care System' and allow the issues mentioned above to continue.

The CQC have the responsibility to ensure GP Practices apply the LAW, but their own 'Methodology' does NOT allow them to Inspect or Investigate Complaints, that WOULD identify serious problems within the entire 'integration' system.

SUMMARY;

Transport a problem in Rural areas.
Accountability of those within the system via the current COMPLAINTS system CQC/PHSO/LG& Social Care Ombudsman.
Recruitment of GP/Staff in Rural areas.
Urban areas overwhelmed by Patient numbers.
Population Health is for all to see. It is not he divide between the South'North it is about Rural/Urban areas.
'Elderly' more at 'risk' of isolation: Social inclusion, because they often live alone, no 'seamless' Health & Social Care System in place.
Carers are all but forgotten, we are only provided with 'sign posting' when we don't actually have the time! what we need is some 'space' to enjoy something outside our Caring responsibilities.

Elderly Carers receive no financial support 'Carers Allowance' because we receive a STATE Pension' we paid for? Direct Discrimination.

Thirty five years of Caring has identified an absolute 'shambles' of a System that is Supposed to improve our lives. elderly, vulnerable, still at risk of 'NEGLECT' Safeguarding issues still remain.

EXAMPLE: Dementia is on the increase: if you live in a Rural area you have nothing, if you live in an Urban area you are more likely to have something, but this could end up with you have ZERO, because of TRANSPORT.

I know from experience if you care for a Dementia patient they are more likely to enjoy life, less likely to cost the STATE, however Carers require SUPPORT, this is sadly 'missing'.

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