Primary care networks: getting into their stride?
By Prof Judith Smith, Sarah Parkinson, Dr Manbinder Sidhu
Professor Judith Smith, Sarah Parkinson and Dr Manbinder Sidhu discuss in their evaluation, concerns pertaining to PCNs, its increasing progress and, its collective working with various practices.
Primary care networks were established in the NHS in England in July 2019 and typically cover a population of 30,000 to 50,000. They have new nationally-specified contractual duties, focused on better integration of health and social care, strengthening primary care, and improving health outcomes.
PCNs are distinctive in bringing traditionally independent local general practices together to hold a collective contract, through which they can access significant new funding for primary care services. This major change within general practice took place only a few months prior to the emergence of the covid-19 pandemic, which has caused an acceleration of the move to phone and on-line primary care, and all this in a system with significant workforce shortages.
How are they shaping up?
Our newly published rapid evaluation of the first year of PCNs, funded by the National Institute for Health Research, provides a cautiously positive assessment. The research highlights that PCNs are: up and running with governance and management arrangements in place; developing new services such as practice-based pharmacy and social prescribing as required by the national PCN service specification; and have, in lots of cases, used the network as the basis for local planning of the covid-19 response, working closely with NHS trusts, clinical commissioning groups, NHS111 and others.
We flag some concerns however, including: the need for PCNs to enable more local GPs and practices feel fully part of the networks; ensuring sufficient management and leadership capacity that protects the PCN clinical director and team from becoming overwhelmed; and clarifying further the role of PCNs in the local and wider NHS, especially as integrated care systems are formed.
Have we been here before?
PCNs are the most recent in a long line of attempts to form collaborations in primary care. Looking back, it is not unusual for first year reports of new primary care organisations to be encouraging. Early evaluations frequently point to quick establishment, early mobilisation of new services in general practice, the need for more management capacity, and a lack of focus beyond primary care.
Indeed, the NHS is good at new initiatives, setting up structures and governance arrangements, and responding quickly to central policy direction. What it is much less good at is letting new organisations focus on priorities that make sense in the local as well as national context, identifying sufficiently sensitive performance measures, tolerating differential rates of progress, and avoiding the temptation to merge and reorganise, when impatient for quick wins.
This policy impatience risks losing the buy-in and support of GPs and their teams, who may be afraid to commit fully to new organisations that they suspect will disappear within a few years.
What is different this time?
Our evaluation suggests that things may be different this time. PCNs’ progress in their first year appears to have been more rapid than before, in part due to the availability of significant new funding for general practice if practices join a network.
This clear financial incentive to join PCNs has meant that few practices have wanted to be left out. PCNs have been quick to use this funding to put in place a range of new roles, and have also in many cases worked together effectively in developing new services to enable safe and rapid assessment and treatment of people with covid-19 symptoms, alongside sustaining usual general practice care via phone, on-line and in-person methods.
Equally important is the fact that PCNs build on 30 years of increasingly collective working within general practice, defying the received wisdom of primary care as being fiercely independent and sometimes fragmented. Our evaluation revealed that GP super-partnerships, federations and other GP-led collaborations are playing a key role in providing management and other support to new PCNs.
If PCNs encounter too much central performance monitoring and direction, this could threaten the sense of local ownership of PCNs, risking them feeling “taken over”
Crucially, these prior collaborations were formed organically from within general practice, not mandated by government policy. This means that some PCNs have had stronger roots on which to build, having members who are used to working in collaboration, but our evaluation did reveal some risks in this relationship.
There may be clashes between the priorities and approach of the prior collaboration, and between its leaders and those heading up new PCNs. Furthermore, practices within the same PCN who are not part of wider collaborations such as super-partnerships or federations may feel marginalised within some PCNs.
PCNs are offering leadership opportunities to a new generation of GPs who seem more comfortable with collective cross-practice working, having experienced this as the norm during their training in general practice, now seeing this as a route to tackling the increasingly difficult issues of scarce workforce and rising demand in primary care.
The clinical director role is clearly significant, and a key driver of progress. Our evaluation highlighted the importance of ensuring that the right person is recruited as clinical director, and then properly supported by others in the wider primary care team, avoiding an overly “heroic” and individual model of leadership that could lead to burnout for the individual, whilst missing the opportunity of drawing on the management expertise of the wider primary care team.
NHS England and Improvement have been prepared to be flexible in respect of the early development of PCNs, something which was acknowledged by our evaluation case studies to be an encouraging sign. For example, the readiness of NHS E/I to respond to national consultation on the PCN service specifications by rowing back on some elements, then suggesting further shifts in emphasis for PCNs when working within the pandemic context.
Despite this flexibility, there is still a sense that there may be too much central guidance, rather than allowing PCNs to adapt to local contexts. If PCNs encounter too much central performance monitoring and direction, this could threaten the sense of local ownership of PCNs, risking them feeling “taken over”.
So where next?
Primary care networks have faced challenges familiar to their predecessors from across the decades, albeit they have benefited from the increasingly collaborative nature of general practice working, and having access to significant new resources for the development of primary care. They are operating in unprecedented and rapidly changing times, seeking to help lead local practices and teams in response to the covid-19 pandemic.
For example, PCNs have supported new models of care such as covid-19 “hot hubs”, a shift to virtual and phone consultations, a push to restore and sustain services that were paused during the first wave of the pandemic, and supporting practices as they face the second surge of infections happening across the country.
Our evaluation reveals that PCNs have got off to a good start in a very difficult and ever-changing context. They have shown their potential to be effective networks to develop and extend primary care, bound together by contracts, governance, and clinical leadership.
They now need support in building further their management and leadership capacity, securing clarity about their role and remit within the local health and care system, and assurance that they will be allowed to focus on a mix of locally-important and nationally-required priorities. In an article for the HSJ in 2019, we described the development of primary care networks as “a marathon not a sprint”. PCNs are getting into their stride, but whether they have the fitness and endurance to go the full distance remains to be seen.
This article was first published on (10th November 2020 ) on the HSJ website.