With NHS England stating that around 88 per cent of GP practices are already part of some form of wider collaboration with other practices, it might be tempting to think that that the new-found importance of primary care networks (PCN) – groups of GP practices covering populations of 30–50,000 – in the NHS long-term plan is really evolution not revolution (they got 25 mentions in the plan: I counted them).
It might be equally tempting for many to ignore the changes as being all rather parochial to the world of GPs – after all, they are formally part of the GP contract. Don’t fall for either temptation – both represent a misunderstanding of just how important the new primary care networks are meant to be.
To date, where GPs have been working at scale, they have mostly been largely informal arrangements, with local variation in both how big they are, what they do and how they relate to the rest of the NHS. The GP contract turns primary care networks into a more formal programme covering all of England, with a clear and very ambitious set of functions. Our primary care networks explainer provides a longer description, but suffice to say, some existing collaborations must now be disbanded as they do not fit the bill of the new ‘primary care networks’. So what are they supposed to do and why do they matter?
Primary care networks are intended to be the answer to three very different challenges facing the NHS. Firstly, as you have probably noticed, we are deep in a workforce crisis in general practice (covered in our recent publication, Closing the gap). While every effort needs to be made to recruit and retain more GPs, it is just not possible to meet rising demand without looking to other professions and broader team working. This is not a knee-jerk reaction to shortages of GPs: team working, using the skills of a wider group of healthcare professions, makes sense in the short term and long term to improve care and access for patients. Additional money for primary care networks will target specific professions, notably pharmacists and physiotherapists to begin with. This is for good reason: they are large, established professions, there is a high demand for their skills in primary care settings and, critically, the supply of these professions is much more robust than many others. As this is not the result of cunning workforce planning, I think we all need to recognise that, at least in this case, Lady Luck has smiled on the NHS. However, if some of the key ingredients are there to make improvements at pace we need to recognise that they are not all there. Moving towards a new team-based approach with more people and professions taking part will be a significant test of leadership and collaboration, with the estate and IT likely to provide just two of the challenges to implementation.
Secondly, primary care networks are also meant to be the answer to a key gap in NHS architecture. Sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) have sometimes struggled to get the voice of general practice properly built into their governance as there is no formal organisation or structure to represent them and this has hindered the integration of primary care with community and other services. The lead clinical directors of the new primary care networks will now take a seat on the emerging ICSs and it is hoped this will fill this gap. With meaningful geographic footprints at reasonable scale, NHS England also now expect community services to reconfigure themselves in line with these new primary care networks. As with workforce re-design, this is all easier to say than it is to do – whether it’s the implications for already stretched GPs now taking on additional roles in ICSs, or the leadership challenge those individuals will face with (still independent) practices.
Thirdly, primary care networks will also be expected to play a key role in efforts to improve population health. What exactly that means in practice is not at all clear yet, with proposed service specifications covering a whole range of things from preventing coronary heart disease to tackling neighbourhood inequalities. Much of this will underpin the specific commitments in the long-term plan.
Taken together, this is a lot to expect. As primary care networks form and then begin to take on their responsibilities, there is so much that is still unclear and that could go wrong – a lack of development and workforce support, overly onerous performance management and managing relationships in primary care to name a few. It is a long list. After all, primary care networks are, strictly speaking, just contractual agreements built onto the GP contract; they are not organisations.
But rather than feeling a sense of doom, I think there are two reasons we should approach this with a sense of opportunity. Firstly, many of these key success factors are themselves in development – ie, we can still get it right. Secondly, the workforce problems in general practice are deep. The challenges in enabling primary care to play a full part in efforts to integrate services are long standing. The potential to improve health remains great. Taken together, this was no time for half measures or a lack of pace and so, yes, the implementation challenge is daunting, but how could it have been otherwise?