Primary care: network solution

General practice is not flying high. GPs are pivotal to the NHS, acting as gatekeepers to secondary care, and primary care accounts for most patient contacts with the NHS, but the recent British Attitudes Survey found satisfaction with general practice is at an all-time low – fuelled, perhaps, by difficulty in booking an appointment. Recruitment is tough and there remains a large group of GPs aged 50 or more who could retire soon.

It may seem a doom-laden picture, but general practice is changing. For several years, practices have been responding to demand and workforce pressures by working together, usually by creating federations to cover extended hours or by merging into super practices with huge patient lists. The NHS long-term plan aims to take these partnerships a step further by organising practices into primary care networks (PCNs).

The networks will include practices covering populations of 30,000-50,000 people and, to reinforce their place-based credentials, must be geographically contiguous – meaning a practice in one PCN area could not join a different PCN.

PCNs will be vital to the long-term plan’s aims of moving more care out of hospital and into the community and placing a greater focus on preventative care. NHS England has said PCNs are the building blocks of the new integrated care systems (ICSs).

Coming together

Primary care collaboratives are not new. The British Medical Association says 88% of GP practices in England are already involved in a network of some kind – either coming together to discuss the best way to care for local patients in neighbourhoods and localities, or agreeing more formal arrangements in federations or super practices. In the 2018/19 planning guidance, clinical commissioning groups were urged to encourage all local practices to be part of a PCN, but the long-term plan goes further, saying all practices should be part of a PCN by 1 July this year.

In Wales there are 64 GP clusters or primary care networks, which work with their local health boards and community-based health professionals to shape community services. Set up in 2014, they are around the same size in population terms as those proposed in England and offer a range of services, including pharmacy and physiotherapy.

In a report in October 2017, the Welsh Assembly health committee voiced frustration at the lack of pace in cluster development. However, the Welsh government recommitted to developing clusters in its long-term health and social care plan, A healthier Wales, last year. This said GPs and other healthcare professionals would develop their collaboration, focusing on prevention and early intervention.

In England, funding will be provided to kick-start PCNs from the £4.5bn announced in the long-term plan to boost community-based care. Practices will be funded to take part in PCNs via a reformed and extended GP contract (whether GPs are on the general medical services, personal medical services or alternative provider medical services contracts). Most GPs also have a directed enhanced services contract – to provide additional opening hours, for example – and this will now be added to the primary care network extension to the core contract. Additional funding and staff – shared across the local network – will come with the enhanced contract.

Initially each network will include GPs, existing practice staff, a pharmacist and a social prescribing lead. But from 2020 they will also employ first contact physiotherapists and physician associates. In 2021, there will be funding for increased numbers of these staff plus community paramedics. And from 2022 a typical network should have five clinical pharmacists; three social prescribers; three physiotherapists; two physician associates; and a community paramedic. By 2024 there should be an additional 22,000 staff in primary care.

‘The difference patients will see is in the new types of staff coming in,’ says King’s Fund senior fellow Beccy Baird. ‘We are not going to have lots of new GPs any time soon, so the government has focused on professions where there is a surplus of staff and is trying to get them into general practice. They are starting with pharmacy and physiotherapists and will then move on to other groups. If you go to your practice with back pain, you will go straight to the physiotherapist. Pharmacists are really good at managing people with complex, long-term problems, helping to manage their medicines, and also with minor illnesses. Paramedics are good at triage and emergency home visits.’

Ms Baird says that, in principle, bringing GP practices together is a good idea. It can mean practices can offer a wider range of services and it makes sense for community services to be reconfigured around the networks. But she adds: ‘We have some concerns about them coming together – this takes a lot of time and trust to develop. Good collaborations have taken years to develop, but they are being asked to do this quickly. They need to do it right because GPs are really busy.’

In 2019/20, NHS England will fund 70% of the clinical pharmacists’ salaries – 30% will have to be provided by each network – and all of the social prescribers’ salaries, including on-costs. Each PCN will have a lead clinician or clinical director selected from the member practices and funding will be provided for them to spend an average of one day a week on PCN work (based on a population of 40,000).

During 2017/18 and 2018/19, CCGs were asked to invest £3 per head of population in primary care transformation. This was discretionary, but from 2019/20, NHS England will require them to commit £1.50 per head recurrently to develop and administer primary care networks. The financial support should be provided in cash, not in kind, and should ensure 100% coverage by the beginning of July at the latest, it says. Practices will also receive a payment for engaging with their PCN.

Following the transfer of the directed enhanced service for extended hours, networks will receive the associated funding (about £1.45 per patient). New access arrangements are to be implemented in 2020, which will lead to the transfer of another £6 per head to the networks. This funding is currently routed through the GP forward view scheme to improve access.

From 2020, seven new services – and associated funding – could be delivered by PCNs. These are:

• Medication review and optimisation
• Enhanced health in care home services
• Anticipatory care
• Personalised care
• Supporting early cancer diagnosis
• Cardiovascular disease prevention and diagnosis
• Tackling inequalities.

QoF changes

There will also be changes to the quality and outcomes framework (QoF), including the introduction of a Quality Improvement (QI) element, being developed jointly by the Royal College of GPs, the National Institute for Health and Care Excellence and the Health Foundation.

NHS England says the least effective indicators will be retired, and the revised QoF will also support more personalised care. A fundamental review of GP vaccinations and immunisation standards, funding and procurement will take place this year to support the goal of improving immunisation coverage, targeting variation and groups and areas with low vaccines uptake.

Sustainability and Transformation Partnerships or ICSs must ensure that networks are given primary care data analytics for population segmentation and risk stratification, together with local data. This will allow PCNs to understand in depth their populations’ needs for symptomatic and prevention programmes, including screening and immunisation services.

Though details are scant, NHS England says it will offer PCNs an incentive scheme, offering them a share of savings from reduced avoidable A&E attendances, admissions and delayed discharges, as well as reductions in avoidable outpatient visits and overmedication.

The King’s Fund’s Ms Baird (pictured) says the funding flows will change under the new arrangements for PCNs. In the past, practices have been asked to bid for pots of funding from their CCG or NHS England – to employ clinical pharmacists, for example. However, under the new arrangements funding will be paid directly to the networks. ‘It’s a way of channelling new money directly to general practice,’ she says.

CCGs around the country are pulling together PCNs, with some more advanced than others, building on investment in 2018/19. Bristol, North Somerset and South Gloucestershire CCG, for example, allocated £473,000 to support the development of local PCNs. A recent CCG primary care commissioning committee paper said most localities had laid good foundations for the development of PCNs, dealing with issues such as scale, integrated working and managing resources.

The committee identified areas for accelerated support and additional funding. These included improving organisational and leadership development to help practices work more collaboratively; introducing a new frailty model of care across the area, taking account of local needs; and the development of population health management in primary care.

Nationwide, CCGs have encountered technical challenges in setting up these new bodies. One of these relates to uncertainties around the treatment of VAT. The crux of the issue lies in the organisation hosting the PCN. If this is an NHS organisation, such as a community trust, there is no problem as they sit within the NHS divisional VAT registration. But VAT complexities arise where CCGs are commissioning directly from organisations established as limited companies (as in some early PCNs). There are good reasons to form such an organisation – it could provide strong local leadership drawn from the practices that will be providing PCN services. And in some areas, community trusts do not have the capacity and knowledge to lead PCNs and transform primary care services. But it may be challenging to demonstrate that these limited companies are providing the frontline patient services directly and/or have the direct clinical responsibility for delivery of frontline healthcare services, thus calling into doubt the healthcare provision VAT exemption status. The result is a risk that a further 20% cost could be added into the system for some of this expenditure. 

This has forced some CCGs well advanced with their preparations for PCNs to take specialist VAT and legal advice, which has confirmed the risk and led to CCGs making provisions to mitigate the associated financial impact.

In a statement, NHS England says: ‘We will shortly publish information alongside the forthcoming specification for the primary care network contract directed enhanced service, which we hope will provide reassurance and help general practices and commissioners consider whether and how any VAT costs might arise.’

While NHS England is aiming for 100% coverage of patients by July, GPs will not be forced to join PCNs. However, if they do not, they stand to lose out on current and potential future funding. The BMA backs the creation of PCNs, saying they offer new support and safeguards and handing collaboration control back to practices.

However, not all GPs are supportive. ‘Good news for the prawn sandwich industry,’ quipped one GP in response to the announcement. A joke perhaps, but one that shows a fear of being diverted away from frontline care into endless meetings. But NHS England believes PCNs will free up GPs’ time to allow them and their multidisciplinary teams to not only deliver more care, but also more effective care. Another GP believes the new staff will hit practices in the pocket – not only will PCNs have to find 30% of clinical pharmacists’ salaries, but also NHS England has set pharmacists’ pay below the going rate. There could be a further cost pressure for PCNs as the clinical director funding – which is based on an average of all GPs’ income – is lower than that of a GP partner.

GPs might grumble, but it seems unlikely that they will stand in the way of PCNs because they will want to access network funding. It will take time to get them up and running fully, but if the programme is successful, the NHS could create a responsive local service that manages demand before it reaches hospital.