This winter has brought an additional challenge for general practice. It appeared in the form of the draft outline of the Network Contract Direct Enhanced Service (the DES, for short).
The DES was published in December 2019, ahead of rollout from April 2020, and has caused plenty of concern. And yet it could be a step closer to the holy grail: making everyone who works in general practice less busy, eventually, or at least containing rising workloads.
The DES aims for real change through the introduction of Primary Care Networks (PCNs). A PCN is a group of general practices banding together with other local community services to provide care collaboratively. PCNs will receive additional funding to hire new roles. They will also, however, be expected to deliver seven new service specifications:
Structured Medication Reviews and Optimisation
Enhanced Health in Care Homes (jointly with community services providers)
Anticipatory Care (jointly with community services providers)
Supporting Early Cancer Diagnosis
Cardiovascular disease case-finding
Locally agreed action to tackle inequalities
Many people are, understandably, worried about this. The DES states that ‘there has been an enthusiastic response to PCNs across the country: over 99% of practices have signed up to participating’. This is true, but with so much funding tied into the new arrangements, they would be difficult to turn down. We hear during our work with clients and partners that some GPs have concerns about the level of clinical and financial responsibility they are adopting as the new leaders of large organisations, rather than of just their own practices. They also worry about the amount of time it will take to set up yet another organisational structure, when they do not have enough to do their day jobs as it is. They feel that, as part of a larger network, they will lose the autonomy they currently value in their roles. And some patients are worried they will lose their personal connection with their local GP practice, and will no longer be able to see their preferred doctor.
PCNs are designed to be centred around a local population of 30,000 – 50,000, so the local connection should remain strong. Arguably, PCNs should also give general practice a stronger voice in the health and care system than any individual practice could have alone. At a time when many small practices are closing, working in PCNs may also allow GPs to preserve their autonomy as individual practices, whereas alternative models of primary care at scale might require GPs to join providers as salaried employees.
Practitioners and patients are nevertheless right to be worried about finding the time to actually do all this. The Kings Fund has warned that ‘the scale and complexity of the implementation and leadership challenge should not be underestimated’. Although GP practices in many areas have experience of collaboration through working in networks or federations, and in ICS development, delivering all primary care services as one integrated system will be a step change. And all the other ongoing challenges – recruitment, retention, workload, rising incidence of complex long-term conditions – will need continual attention, of course, while change is implemented at the same time.
With additional resource (as promised in the DES), and real commitment on the ground, however, implementation successes are possible. We can see this by looking at the most pertinent precursor to the PCN rollout, the Primary Care Home model (PCH). Some areas have seen real improvements since integrating, such as St Austell in Cornwall. In St Austell, one of the four practices in the town was struggling financially and had to hand back its contract. To deal with the resulting influx of patients, the other three merged into a PCH. Collaborating allowed the PCH to address old challenges in new ways, such as tackling inactivity through social prescribing. The PCH’s social prescribing was popular and expanded. It now includes a community matron, a social prescribing navigator, and services ranging from horticulture to art to employment support. GPs in the practices report that forming the PCH has been ‘an overwhelmingly positive experience’.
Given the level of pressure in the system at present, we feel that it is more important than ever to realise the opportunities contained the next phase of the integration agenda. We will be working closely with our clients in the run up to April 2020 and beyond to support them to make the best of becoming PCNs. And we recommend reading the DES yourself in the meantime, if you get a minute, whatever your role in the system is. Because it will take everyone – doctors, practice managers, nurses, pharmacists and more – to make PCNs a success.