What are primary care networks?
Primary care networks (PCNs) form a key building block of the NHS long-term plan. Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system.
While GP practices have been finding different ways of working together over many years – for example in super-partnerships, federations, clusters and networks – the NHS long-term plan and the new five-year framework for the GP contract, published in January 2019, put a more formal structure around this way of working, but without creating new statutory bodies.
As of the latest PCN sign-up in May 2020, all except a handful of GP practices in England have come together in around 1,250 geographical networks covering populations of approximately 30–50,000 patients. This size is consistent with the size of primary care homes, which exist in many places in the country, but is much smaller than most GP federations.
How are they formed?
Most networks are geographically based and, between them, cover all practices within a clinical commissioning group (CCG) boundary. There are some exceptions where there were already well-functioning networks that are not entirely geographically based. Some networks cross CCG boundaries.
While practices are not mandated to join a network, they will be losing out on significant extra funding if they do not, and their neighbouring networks will be funded to provide services to those patients whose practice is not covered by a network. In some cases, where a single practice has met the size requirements of a network, they are also able to function as a network.
What will primary care networks do?
NHS England has significant ambitions for primary care networks, with the expectation that they will be a key vehicle for delivering many of the commitments in the long-term plan and providing a wider range of services to patients.
Primary care networks (PCNs) will eventually be required to deliver a set of seven national service specifications. Three started in 2020/21: structured medication reviews, enhanced health in care homes, and supporting early cancer diagnosis. A further four are also set to follow- anticipatory care (with community services), personalised care, cardiovascular disease case-finding, and locally agreed action to tackle inequalities.
To do this they will be expected to provide a wider range of primary care services to patients, involving a wider set of staff roles than might be feasible in individual practices, for example, first contact physiotherapy, extended access and social prescribing.
Networks will also be the footprint around which integrated community-based teams will develop, and community and mental health services will be expected to configure their services around PCN boundaries. These teams will provide services to people with more complex needs, providing proactive and anticipatory care.
Primary care networks will also be expected to think about the wider health of their population, taking a proactive approach to managing population health and assessing the needs of their local population to identify people who would benefit from targeted, proactive support.
Primary care networks will be focused on service delivery, rather than on the planning and funding of services, responsibility for which will remain with commissioners, and are expected to be the building blocks around which integrated care systems are built. The ambition is that primary care networks will be the mechanism by which primary care representation is made stronger in integrated care systems, with the accountable clinical directors from each network being the link between general practice and the wider system.
How will the funding for primary care networks work?
Much of the new money for the NHS announced in June 2018 is directed at primary and community services, and a large proportion of this will be channelled through networks.
The main funding for networks comes in the form of large directed enhanced services payment (DES), which is an extension of the core GP contract and must be offered to all practices. This will be worth up to £1.8 billion by 2023/24. It includes money to support the operation of the network and up to £891 million to help fund additional staff, through an additional roles reimbursement scheme.
The contract is between the commissioner and individual practices, but receiving the money for the directed enhanced services payment is contingent on being part of the network and the money will be channelled through a single bank account directed by the network.
Funding and responsibility for providing the extended-hours access services, which pays GPs to give patients access to consultations outside core hours, will transfer to the network directed enhanced services payment by April 2021. Networks also receive payments from the Investment and Impact Fund, a financial incentive scheme similar to the Quality and Outcomes Framework that rewards networks for performance in delivering high quality care.
The key funding streams that PCNs receive in 2020/21 are given below . Payments are on a total per annum basis unless otherwise stated.
- Core PCN funding: payments of around £1.50 per registered patient to support the PCN as an organisation.
- Clinical director contribution: payment for approximately a quarter of a GP’s full-time hours to act as the PCN clinical director.
- Additional Roles Reimbursement Scheme payments: reimbursement of the salary for the new roles being recruited into general practice (eg, clinical pharmacists, physiotherapists) along with certain other costs such as employer pension and national insurance contributions.
- Care home premium: payments of £120 per care home bed to help cover the additional cost of providing services to patients in care homes.
- PCN support payment: small additional weighted payments to further support the PCN in 2020/21.
- Extended hours access payments: payments of £1.45 per registered patient for providing extended hours services.
- Investment and Impact Fund: financial incentive scheme with payments to the PCN based on performance.
Additionally, individual practices within the PCN also receive a Network Participation Payment: a payment of £1.76 per weighted patient made to recognise an individual practice’s commitment to being part of a PCN.
What are the additional types of staff that will be funded?
The Additional Roles Reimbursement Scheme, part of the directed enhanced services payment contract, will fund much of the cost of the specific new clinical roles, with the different roles coming in over the period of the contract. Networks can currently receive full reimbursement of salary and on-costs for 12 different additional roles including clinical pharmacists, social prescribing link workers, nursing associates and physiotherapists as of October 2020. The scheme is continuing to expand the number of roles it covers with community paramedic and mental health practitioner roles due to be added to the scheme in 2021/22.
Funding under the scheme is intended to cover only new staff rather than existing roles. Networks will have the flexibility to decide how many of each of the types of staff they wish to employ.
Who are primary care networks accountable to?
Practices are accountable to their commissioner for the delivery of network services. Practices will sign a network agreement, a legally binding agreement between the practices setting out how they will discharge the responsibilities of the network. Primary care networks can also use this agreement to set out the network's wider objectives and record the involvement of other partners, for example community health providers and pharmacies, though these partners will not be part of the core network, as that can only be entities who hold a GP contract.
It would be possible to remove a practice's entitlement to the directed enhanced services payment if the commissioner felt it was not delivering these services, in the same way a commissioner could remove a general medical services contract, though this is extremely rare. Each network has an identified accountable clinical director who is appointed by network members. The role of the clinical director is complex – its stated purpose is to provide a voice upwards to the wider integrated care system, and to be a single point of contact for the wider system, rather than to be accountable for the performance of the network or its constituent practices. Some networks are also investing in network manager roles to provide additional support.
What does the evidence show makes for successful collaboration in general practice?
Previous research by The King’s Fund found that collaboration in general practice was most successful when it had been generated organically by general practices over a number of years, underpinned by trust, relationships and support, and where there was a clear focus and agreement on the role of the collaboration (for example, whether it was to share back-office functions, provide community services or for quality improvement). Collaborations were less successful where there was a lack of clarity of purpose or engagement or over-optimistic expectations. There are also some technical issues including high costs of shared information systems or complexities around financial liabilities and premises which might need to be addressed.
Wales, Scotland and Northern Ireland have already implemented similar models which England can learn from. In Scotland, a key feature of the new GP contract has been the obligation to become part of a geographical quality cluster. These have been seen as variably successful, working well when they worked on similar quality improvement initiatives and less well when they covered a mix of urban and rural practices that faced different issues and had difficulties coming together to agree priorities. The Welsh health boards have also established clusters of practices: a Welsh assembly inquiry into their operation found evidence of good work but highlighted a concern that the cluster model may be over-reliant on key individuals and that professionals are not being included in cluster work as much as they should be.
Primary care networks in England will need support to build the trust and relationships needed for successful collaboration, resisting attempts to be over-optimistic in what can be achieved in the short term. The scale and complexity of the implementation and leadership challenge should not be underestimated, and those leading primary care networks will need significant support if they are to deliver the ambitions set out for them.
What difference will primary care networks make for patients?
Primary care networks have the potential to benefit patients by offering improved access and extending the range of services available to them, and by helping to integrate primary care with wider health and community services.
Previous research on the impact of larger scale general practice on patient experience found mixed views. While some patients prioritise access above all else and are interested in the potential of larger collaborations to improve that access, others are more concerned about continuity and trusting relationships and are concerned these may be lost. Practices will need to work with their patient participation groups and the wider local community if they are going to address the needs of their local population.
Since their introduction in 2019, general practice has begun to grasp the opportunity presented by PCNs. This has been shown not least through their response to the Covid-19 pandemic.
However, primary care networks continue to face a number of obstacles. Some of the most pressing relate to the introduction of new roles. Recruitment is often an issue for networks, particularly in remote or economically unattractive areas with wider health care workforce problems. New roles may be recruited primarily based on availability rather than planned around the needs of the patient population. Even when new staff are in post, there are challenges around culture, supervision, understanding of new roles and network sharing arrangements that need to be overcome if these staff are to become embedded as effective and valued members of their team.
For primary care networks moving beyond the immediate challenges of Covid-19, there is also a need to maximise the value of their spending and used their income effectively to develop and strengthen the network and ensure their offer matches local patient need.
Some friends living in England have assumed from comments in this report that GP Cluster activity in Wales has been a success. I see no evidence on the ground for that. Indeed the Welsh Assembly enquiry quoted listed as its first recommendation that "The Welsh Government should publish a refreshed model for primary care clusters which restates a clearly defined vision for them from the beginning of the new financial year". In practice little money has been routed via the Clusters and minimal benefits for patients are observable.
Dizzying speed of top down reforms do not allow implementation. We do not know enough about Community Health Trusts. NHSE obstructed our enquiries as 'commercially sensitive' since the PM's November announcement. Coordinating such underfunded transfers of work need trust and goodwill, both are in short supply. Work force issues will also impede. I'm concerned.
An interesting read, complicated, and would appear those who chose not to join the 'Network' could see their patients disadvantaged, many years ago I met the Secretary of State for Health with my MP, the talk was about 'Fully Funded' GPs, the question to me was: what are your thoughts on this? the reply was this was working very well in my area, but others 'outside this system' were disadvantaged. This appears to be an attempt to do exactly the same the same, in a more complicated manner.
The difference being the 'Network' of those choosing to 'join' had to prove they were offering a service required of them to keep this status and 'financial reward'.
The NHS is supposed to be offering Patient choice, Patient centred, and 'Holistic' there is no EVIDENCE of this, and those GPs 'outside' of the NETWORK will be disadvantaged.'
The CQC have absolutely no chance of 'monitoring' an 'unequal' service, if some are 'outside of the NETWORK?
I now return to my 'Pet' subject the Care Act 2014/5 and Mental Health, I know that GPs are 'out of their depth' when we 'speak' Schizophrenia, Bipolar, LTC. Patients are discharged from 'Statutory Care Plans' still subject to Section 117 Free Aftercare, not supported by CMHT, no Personal Budgets. I cannot see how this latest idea, benefits these Patients, particularly if you are not part of the NETWORK?
The 'Fully Funded' GP idea of many years ago was great, it was clear that those NOT part of this scheme were disadvantaged.
The problems with the NHS is it is always trying to re-invent the system instead of identifying good practice and replicating it across the entire NETWORK.
The idea is set to fail for many reasons, too many to list.
This is a promising development with the potential to end the crisis in primary care, which is caused by overprescribing of drugs (only 10% of which are evidence based) and which are doing more harm than good, and making the NHS toxic so that few want to work in it. The solution is do commission, procure and provide a new system of social prescribing in which complementary therapists are licenced to create Community Care Centres as mental A&Es, open for crisis care, and providing a wide range of group interventions, including exercise, music and movement, singing, psycho education courses, including mindfulness based cognitive therapy 8 week courses, which have been NICE recommended since 2004. These therapists should be paid against submission of the used prescription vouchers as pharmacists are paid for drugs. See paper 9.141 of www.reginaldkapp.org.
If Primary Care Networks are to be successful, then there will need to be significant support available for primary care professionals not only as clinicians, but also as members of a network. The NHS will need to think very carefully about how to support PCNs as fledgling organisations in their own right, and not assume that skills in networking, leadership, MDT working, community engagement etc are already there.