A two-way street: primary care networks and integrated care systems

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The deadline for GP practices to agree their primary care network (PCN) boundaries with local commissioners has now passed and the first money is due to flow to the new networks from July. As the dust begins to settle on decisions over membership, boundaries and leadership of networks, attention will now turn to delivery.

Much is expected of the new networks. They will be required to deliver a set of seven national service specifications (the first five of which are due to start by April 2020), provide a wider range of services in primary care, use the skills of a greater range of professionals and work closely with other services in the community through multidisciplinary teams.

Primary care networks are also intended to form an important part of the future NHS architecture. NHS England have described them as the ‘building blocks’ of integrated care systems (ICSs). According to the NHS long-term plan, every ICS must have full engagement with primary care through the named accountable clinical director of each network, and primary care networks must be represented on the partnership boards of all ICSs.

The formation of networks is an opportunity to bring greater balance to local systems by strengthening the voice of primary and community care

It remains to be seen how the relationship between primary care networks and ICSs will develop. Both are nascent structures, and their internal priorities and ways of working are still emerging. So how might they evolve together?

The first consideration is how the voice of primary care networks can most effectively be brought into ICSs (or sustainability and transformation partnerships (STPs) in other areas). The formation of networks is an opportunity to bring greater balance to local systems by strengthening the voice of primary and community care. Traditionally, the acute sector has had a louder voice, reflecting their scale and the national focus on hospitals, but there is increasing recognition of the need to tip the balance towards care delivered in community settings. It is also hoped that practices being grouped together in networks will help to address the complexity of engaging with many separate practices across an area. In addition, networks will bring detailed knowledge of their populations, supporting system-wide decisions to be sensitive to distinctive local contexts and needs.

But bringing the voice of primary and community care to the fore will not be as straightforward as giving all network accountable clinical directors a place on their ICS partnership board. Some larger ICSs will have more than 60 networks – and therefore more than 60 accountable clinical directors – and that’s before taking account of others who need a voice at the table, including local authorities, NHS commissioners, acute, community and mental health trusts, patients and citizens, and voluntary and community sector partners. Networks will need to work together to organise and represent the voice of primary and community care. The pressing workload and staffing issues facing general practice and the long list of requirements on the new networks will mean that, for at least some primary care leaders, finding the time and space to engage with their ICS will be challenging.

The relationship between ICSs and primary care networks must reflect a commitment to a two-way conversation

Another consideration in embedding the new NHS architecture is what will sit between the primary care networks and ICSs. There is wide variation in the size of the first ICSs, but going forward most are expected to cover a population of over a million and some are much larger. There is a big gap between the scale of these systems and the typical 30-50,000 population size of a primary care network. Much of the work to improve and join up local services will be done at an intermediate level, often referred to as the level of ‘place’. Networks might come together with other local providers to shape and deliver some services across a place.

This is already well established in some areas, where provider partnerships have been created to join up services across the NHS, local government, voluntary and community sector and independent provision. In West Yorkshire and Harrogate (an ICS covering a population of 2.6 million) around 50 neighbourhoods sit within six ‘places’, established around meaningful geographies such as Bradford, Leeds and Wakefield. In Greater Manchester (a devolved health system covering a population of 2.8 million) 67 neighbourhoods sit within 10 ‘local care organisations’, established around the 10 boroughs in the region. But many areas do not yet have these building blocks in place, and the long-term plan did not set clear expectations or organising principles around this.

Finally, and most importantly, the relationship between ICSs and primary care networks must reflect a commitment to a two-way conversation. Networks should not be seen as a route for systems to issue rigid directives to primary care – variation in the way primary care networks operate is inevitable and appropriate to reflect local population needs and resources. Instead, the ICS can bring partners together to set a clear strategic vision for a local health and care economy so that all parts of the system – including primary care networks – are pulling in the same direction. ICSs also have an important role in supporting networks to address challenges that require action on bigger scale. Training and retaining enough staff with the right skills to work in community settings, and developing shared care records to support information-sharing are two obvious examples – both are prerequisites for primary care networks to succeed.

Now that primary care networks have formed, the first question ICSs and STPs should be asking is not ‘what can our PCNs do for us’ but ‘what can we do for our PCNs to support them to improve the health and wellbeing of our local population’.

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