In July 2019, NHS England hoped to see every patient in England covered by a new Primary Care Network (PCN). A year, one global pandemic and approximately 1,259 PCNs later, fledgling PCNs have stepped up to the plate to meet the current crisis.
However, while the localised and collaborative decision making exemplified 5by PCNs in dealing with the COVID-19 outbreak is a cause for celebration, PCNs are not universally applauded. As a countryside dweller turned urbanite myself, I was happy to dig a little deeper and reflect on what this nationally proscribed change to service delivery could mean for those general practices on the margins i.e very rural surgeries, and those operating in urban areas of high deprivation.
In this two-part blog post I will explore the effect of PCNs on two key areas for rural and urban general practices: funding and the workforce.
In this post, part one, I will focus on the opportunities and challenges commissioners and STP leads may encounter establishing and operating PCNs in very rural areas.
Part one: PCNs in the sticks
Primary care is struggling. This is particularly true for rural GP practices operating in remote areas with scarcely distributed and aging patient populations. In fact, remoteness not only increases costs but also negatively affects the funding provided to meet demand.
For example, while it is generally agreed that rural care delivery incurs additional costs, a rapid review of the impact of rurality on the costs of delivering health care found that current adjustments to the funding levels received by hospital trusts actually result in urban areas receiving more than rural areas for providing the same service.
The upshot is that on account of their remoteness, rural healthcare systems must do more with less. How will PCNs alleviate or exacerbate these difficulties?
Beyond geography, securing staff is a major challenge for rural practices. Amongst others, key factors contributing to the recruitment challenge include:
- the disproportionate out-migration of young adults
- high rates of employment
- centralisation of specialist services.
PCNs may provide an opportunity to address some of these recruitment challenges by offering attractive employment. In 2018 the National Centre for Rural Health and Care identified large employers, varied job roles and opportunities for career development as opportunities to leverage to maximise the rural workforce.
In PCNs, primary care healthcare professionals will work in multidisciplinary teams at multiple locations as part of a larger partnership. Furthermore, PCNs create opportunities for primary care staff to have a say in how care should be delivered, with GP practices playing a central role. This creates more opportunities for leadership and career progression.
However, while the job offer may be better, recruitment initiatives still take time. Unfortunately, some rural practices stretched to breaking-point may struggle to dedicate the resource needed to capitalise on their improved prospects.
Workforce pressures are not the only challenge for fledgling PCNs finding their feet in rural areas. According to the BMA handbook, funding for PCNs, including reimbursement for new job roles, will depend on the patient population size.
It stands to reason then that rural PCNs with smaller patient populations will receive less funding despite the increased costs associated with operating in a rural area. This increase to their financial pressures could increase the risk of practice closures, or even have knock-on effects for patients. Of particular concern is the effect individual practice closures could have on their wider network.
To mitigate this, rural PCNs will need to think carefully about how they adopt PCN specifications to distribute the burden e.g. job sharing the clinical directorate and partnering with other health and social care providers.
Fortunately, PCNs may provide the means for rural practices to champion their cause in a regional forum. By combining their voices and speaking loudly about their unique challenges, they may stand a better chance of attracting the attention of national policymakers.
Source: British Medical Association
PCNs have the potential to greatly benefit the rural healthcare community by helping them to tackle historic workforce challenges. That said, it is a shame that the opportunity to address the trend of underfunding rural services was not taken in the design of this new national way of working. Rural PCNs will need to continue to speak up about funding inequalities and take full advantage of PCNs as a forum to amplify their voices.
Unfortunately, potential is not always realised. There is a risk that hasty planning and implementation could have severe consequences for practices already on the edge of closure. Commissioners and STPs will need to think carefully about the support they can provide these practices in the short-term to ensure all practices benefit from greater integration.