Primary care networks: a marathon not a sprint

Primary care networks (PCNs) are the latest in a long line of attempts by NHS policy makers in England to incentivise collective working between fiercely independent general practices. It is hoped that PCNs will harness the energy and entrepreneurship of general practice, draw on prior experience of collaborative working across primary care, and form vital local hubs for population improvement. 

By Professor Judith Smith (Director, Health Services Management Centre, University of Birmingham) and Amelia Harshfield (Analyst, RAND Europe, Cambridge)

NB: This article first appeared on the Health Service Journal (HSJ) website

BRACE

To date, there are some 1,300 PCNs in place, covering populations from 20,000 (i.e. fewer than the suggested minimum of 30,000) to well over the 50,000 suggested maximum.  New funding is being made available to PCNs via a contract held across practices in the network to develop shared services such as social prescribing, practice-based community pharmacy support, enhanced health services for care homes, digital forms of access to general practice, and more effective early cancer diagnosis.  These priorities for PCNs flow from the NHS Long Term Plan, and place primary care firmly at the centre of the policy intention to have better integrated and preventative care, based outside hospitals wherever possible.

Those with long memories will recall the launch of general practice fundholding, locality commissioning, primary care groups, personal medical services schemes, and total purchasing pilots, to name a few.  Whilst some of these initiatives were focused on getting general practice to collaborate and undertake health commissioning or planning work, in almost all cases they ended up concentrating mainly on developing and extending the provision of primary and community health care services for local populations, and, unsurprisingly, solving those problems of most concern to GPs and their teams.

More recently, collaborative working within general practice has tended to emerge more at the instigation of primary care itself, rather than via policy directives from NHS England or the Department of Health and Social Care. For example, super-partnerships, general practice federations and regional primary care organisations have been developed by local practices and their leaders, and research has revealed that 81% of respondent practices in England consider themselves to be part of a general practice collaboration.

Extensive body of research evidence

In the NHS, we often bemoan the lack of research evidence underpinning health policy initiatives. In the case of PCNs however, there is an extensive body of UK and international research evidence stretching back over 30 years. 

In our National Institute of Health Research funded Birmingham, RAND And Cambridge (BRACE) Rapid Evaluation Centre, we are undertaking an evaluation of general practice collaborations to inform the development of PCNs, investigating what can be learnt from research evidence from prior experience, and examining what is helping and hindering this type of working. We are particularly keen to explore the experience of rural as well as urban collaborations, and those places where collaborative working in primary care has struggled to become established. The findings from our study will offer important early learning about the implementation of PCNs and how they are working on the ground.

Four important lessons

A rapid evidence review on collaborative working in general practice undertaken to inform our research reveals four important lessons for PCNs and those holding them to account.

The management support, time and funding required by PCNs will be higher than initially anticipated, and issues such as information governance, financial management, and inter-professional working will prove challenging.  UK and international evidence reveals that sophisticated and specialist management support will be needed for those leading PCNs, for example to bring about significant and lasting changes to how services are delivered within and across practices, to enable appropriate governance of new funding and contracts, and to put in place new and sustainable professional roles (e.g. social prescribers, practice-based pharmacists, PCN clinical directors).

Progress will vary significantly across PCNs, with much of this reflecting the local experience of collaborative working across practices, the presence (or not) of effective primary care management support infrastructure via general practice federations, super-partnerships, or clinical commissioning groups, and the nature of underlying pressures facing general practice such as workforce, demand, access and the use of digital technology. This varying progress will likely prove frustrating to NHS England-Improvement, and there may be pressure exerted for PCNs to merge on the basis of assumed economies of scale, to enable more rapid progress.  But if such mergers start to happen, and there is the slightest sense of this being mandated by ‘the centre’, PCNs will quickly lose much of the support of local practices, being seen as belonging to ‘them’ (NHS England-Improvement and clinical commissioning groups) rather than ‘us’ (local primary care teams).

Clarity and consensus about the remit and expectations of PCNs is vital, for our evidence review revealed that this is often lacking with developments of this nature, with policy makers typically expecting much more than can realistically be achieved within overly ambitious timescales.  Nationally mandated performance metrics will likely be used to try to demonstrate progress and compare PCNs and this can lead to pressure for ‘hard’ evidence of system outcomes, and in particular reductions in use of hospital services, even where it is highly unlikely that the work of primary care teams is able to have such an effect.   Indeed, there is however an almost complete dearth of quantitative research evidence on the ability of primary care collaborations to make changes to services beyond primary care itself, and hence assertions about their role in enabling local service efficiencies are premature. 

Ultimately, relationships and culture are the most important enablers of collaborative working in primary care.  This finding has been confirmed in countless studies, but too often the ‘soft’ issues of organisational and team development, coaching and support for clinical and managerial leaders, and funded time away from the day job to plan, monitor and implement significant service changes, are lacking.  Particularly for primary care, with its often fragile and dispersed management and organisational arrangements, this is a pressing concern.  A further vulnerability for primary care collaborations can be a reliance on a core of enthusiastic clinical leaders, with insufficient attention being given to how to involve, incentivise and support the wider clinical community in getting involved in the work of an entity such as a PCN. Addressing this will be crucial to PCNs being able to change how care is delivered within and across practices.

A bold policy initiative

PCNs represent a bold policy initiative, placing significant new and funded responsibility into the hands of local general practices and their leaders, imploring them to work collectively to deliver a wider range of health services to improve the health of their population.  The use of a collective PCN contract is a significant development, albeit there is much to learn here from the prior experience and research evidence from the implementation Personal Medical Services contracts, and Total Purchasing Pilots.  

Our review of the evidence of general practice collaborations points to a simple and yet critical message for PCNs. They must seek to under-promise, and over-deliver, something that is counter to prevailing NHS management culture which typically gets impatient and unforgiving when its aims for initiatives are slow to be met.  This pacing of progress and expectations will enable PCNs carefully to garner and sustain the support of their constituent staff and practices, put in place much-needed new services for local people, and build an important and powerful evidence base for the future.  PCNs are embarked on a marathon, and not a sprint, and must be trained, supported and assessed accordingly.

For more information on the BRACE Rapid Evaluation Centre please visit the BRACE website.