13 / 07 / 2020
One year has passed since the deadline for all GP practices to form PCNs. The interface between primary and community care has evolved in different ways across the country, and this is all true of the response to COVID-19. Here we revisit the range of partnerships that community service providers are forming with primary care colleagues, and the support that trusts can offer to PCNs specifically.
- A year since the introduction of primary care networks (PCNs), it is timely to look back on how collaboration between secondary, community and primary care is evolving.
- The Community Network briefing Primary Care Networks: A Quiet Revolution (July 2019) supported NHS community health services to navigate the new PCN landscape, often in conjunction with pre-existing partnerships with primary care. Given the challenges facing the primary and community care sectors, this briefing remains relevant today.
- Although much of the national policy narrative understandably focuses on the creation of PCNs, we know that community service providers operate a number of partnership models with primary care, including partnerships with and support for individual practices and large-scale providers of primary care services, such as super-practices and super-partnerships.
- As a number of our case studies show, the COVID-19 pandemic has accelerated primary and community care collaboration in some areas, as services came together in creative ways to support shielded patients, care homes and more complex care needs in the community.
- However, in other parts of the country, we still hear about the barriers to be overcome, including variable relationships and the levels of support required to establish nascent PCNs in some areas.
- As the health and care sector moves to recover and reset after the first peak of the pandemic, community and primary care services are embedding innovative practice and learning from their recent experiences. This progress needs to be supported by appropriate resourcing and contractual mechanisms that facilitate local flexibilities and collaboration.
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One year has passed since the deadline for all GP practices to form PCNs. Described as the building blocks of integrated care systems by NHS England and NHS Improvement (NHSEI), these geographical networks were formed to work with NHS community health services and other local partners to deliver more joined-up care at neighbourhood level (patient populations of 30,000-50,000) and support the future sustainability of general practice.
But the interface between primary and community care has evolved over time and in different ways across the country. It has developed many forms and functions, of which PCNs are the latest incarnation. The Community Network briefing Primary Care Networks: A Quiet Revolution (July 2019) proposed ways for PCNs and NHS community health services to work effectively together, which remain relevant one year later.
As we come out of the first wave of the pandemic, it is clear that COVID-19 has put a huge strain on all parts of the health and care system. The time will come for an in-depth analysis of the benefits of neighbourhood-level integration during the COVID-19 response, but the emerging picture is one of variation across the country. We thought that this would be a timely moment to revisit the range of partnerships that community service providers are forming with primary care colleagues, and the support that trusts can offer to PCNs specifically.
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PCNs began life in the NHS Long Term Plan (LTP) in January 2019. NHSEI recognised that community and primary care had insufficient resources to meet rising patient need. All GP practices were expected to form geographical networks covering populations of approximately 30,000-50,000 patients by 1 July 2019, if they were to take advantage of additional funding attached to the new GP contract.
This direction to work at scale aimed to address sustainability issues in general practice – both funding and workforce shortages – and to support more integration through collaboration with secondary care, social care and the voluntary sector. It represents the biggest reform to general practice in decades and led to the creation of 1,250 PCNs, which now range from mature partnerships based on pre-existing collaboration to embryonic relationships across new geographic footprints. This was supported by a ringfenced uplift of £4.5 billion (3.8 per cent per year) for primary and community services by the end of the LTP period (2023/24), meaning that funding for these sectors will grow faster than the overall NHS budget. While the new GP contract specified some detail, it remains unclear how this uplift will be allocated between GPs and community providers.
This was an important policy and operational development for trusts and not-for-profit organisations providing NHS community health services, as there was a clear onus on wide-reaching partnerships with PCNs including primary care, community services, community pharmacy, optometrists, dental providers, ambulance trusts, social care providers, voluntary sector organisations and local government.
In July 2019, the Community Network published a briefing which explored the implications of the PCN roll out for NHS community health services and suggested ways for trusts and community service providers to engage effectively with PCNs. Much of this briefing remains relevant today, given the challenges facing both sectors and variation in how effectively PCNs are operating.
In summary, NHS community health services supported the PCN objectives of better integration and population health outcomes at neighbourhood level, as well as more flexible workforce models. They were particularly excited by the possibility of offering staff passport arrangements across primary and community care to help create innovative career paths that would attract people to join and stay in the wider community workforce. They also saw an opportunity to support PCNs as strategic partners in helping to drive neighbourhood integration. Many felt they could offer practical support, including for governance arrangements, employment and back office functions. In the briefing, we highlighted case studies of trusts’ support offers to PCNs, including infrastructure resource and strategic development from Sussex Community NHS Foundation Trust.
However, community service providers were also concerned about several risks and challenges of PCN development:
- As the PCN map was drawn on particular geographies, existing collaboration between primary and community care was disrupted. In some areas, this meant that pre-existing partnerships between locality teams and GP practices took a step backwards. In other areas where there had been little engagement between primary and community care, it took time to reconfigure locality teams and develop relationships with new PCN clinical directors.
- The national approach to channel additional funding for care in the community through PCNs has raised concerns around their capacity to deliver the new service specifications, as well as stabilise general practice within the funding envelope available. Community providers feel that the focus in recent months on contractual negotiations has shifted the conversation away from finding the right model of care to drive effective neighbourhood integration. Primary and community care providers should be supported to develop the right model of care, collaborative culture and behaviours, which should then be supported by the funding and contract.
- There are also risks around the requirements on PCNs to expand their workforce to populate multidisciplinary teams, including clinical pharmacists, first-contact physiotherapists and community paramedics. Well intentioned recruitment by primary care colleagues could destabilise the local labour market and existing recruitment strategies, as they would be competing for the same limited local talent pool as secondary care providers. For example, ambulance trusts are grappling with shortages of paramedics, which could be exacerbated when recruitment for community paramedics for PCNs begins in 2021. PCNs are not bound by Agenda for Change remuneration requirements, so could pay staff higher wages and disadvantage other services. It is therefore crucial that recruitment of healthcare professionals is done in collaboration with system partners, with system-wide strategic intent, and based on a shared local vision.
Commitments within the ambitious agenda set out for PCNs in the LTP included an expectation they will deliver seven national service specifications. Five of the seven were intended to start by April 2020: structured medication reviews; enhanced health in care homes (with community services); anticipatory care (with community services); personalised care, and early cancer diagnosis. The other two - cardiovascular disease case-finding and locally agreed action to tackle inequalities - were intended to start by April 2021.
Initial excitement at the scale of ambition gave way to controversy at the high delivery expectations included in the draft Network Contract Direct Enhanced Service (DES) (December 2019) and concerns about insufficient resources allocated. Following negotiations between NHS England and the British Medical Association’s general practice committee, the updated DES contract (February 2020) included delivery of three, rather than five, pared back service specifications from April 2020 and more funding for additional roles to support the government’s new commitment of delivering 50 million more GP appointments by 2024. On 12 June 2020, 98 per cent of practices signed the PCN contract for next year.
In response to COVID-19, NHSEI postponed the structured medication review and medicines optimisation elements of the DES contract until October 2020. But, PCNs were expected to begin work on the early cancer diagnosis specification as planned and, from 1 May, deliver elements of the enhanced health in care homes specification. However, community service providers had reservations about the way the enhanced health in care homes framework was brought forward in May. While the PCN service specifications were fit for purpose at the time of writing, COVID-19 has accelerated different models of support to care homes from community and acute providers, and some community providers feel that defaulting back to the PCN delivery model risks failing to sustain care home support most effectively. The emphasis should instead be on developing the right system-wide support model, underpinned by the contract and funding mechanism.
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Embracing different partnership models
It is important to remember that there are many different forms and functions of primary and community care collaboration that pre-date and co-exist with PCNs, ranging from informal collaborative relationships to shared pathways, collaboration at scale and structural integration. The drivers behind this collaboration also vary, including the financial unsustainability of the local primary care system and implementation of population health management approaches.
Structural integration of primary and secondary care
Some trusts, such as Northumbria Healthcare NHS Foundation Trust, have set up wholly owned subsidiaries and now run several GP practices alongside their acute and community health services. This approach is often taken in partnership between primary and secondary care to prevent financially unsustainable GP practices handing back contracts. Trusts have the scale required to absorb the financial risk, standardise workforce models to tackle recruitment and retention issues, and use technology to support back office functions. While this fully integrated model of delivery is sometimes unhelpfully framed as a ‘takeover,’ trust leaders are clear that their drivers are support and sustainability.
Integrated patient pathways
In other areas, primary care providers now deliver parts of acute and community care pathways. For example, in Birmingham, the at-scale primary care provider Modality has been subcontracted to deliver parts of speciality pathways in secondary care. Modality has successfully reduced costs to the system and decreased waiting times - for example, from over nine months to less than two weeks in cardiology. This model also aids recruitment as placements can be offered across general practice and secondary care specialties, which has proven essential given the serious shortages of GPs.
Collaborative working relationships and joint projects
Where relationships between primary and community care are less mature, joint projects and enablers can foster collaboration on a more informal basis. Developing shared patient records, such as the Hampshire Care and Health Information Exchange, and collaborating on digital care pathways can improve mutual understanding and facilitate further collaboration. Enablers include good analytics, financial sustainability, simplified pathways and workforce collaboration. The case study of primary and community care collaboration in Bexley shows how digital technology can enable joined-up working across different services.
Primary care at scale
Prior to PCNs, many GP practices were already operating at scale within GP federations, super-partnerships or the primary care home model developed by the National Association of Primary Care. These arrangements are also at varying levels of maturity and some still harbour elements of local competition. PCNs were not designed to replace these pre-existing models and NHSEI has confirmed that PCNs and GP federations can co-exist to deliver a broader set of integrated out-of-hospital services for their local communities. Our case studies in Leeds and Bexley show how this coexistence works in practice.
Neighbourhood integration: the building blocks of system working
As PCNs embed their new multidisciplinary teams and develop population health management approaches, sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) are connecting innovative work at neighbourhood level up to provider partnerships at place level (defined by NHSEI as a patient population of 250,000-500,000, although this varies between systems). Neighbourhood integration between primary, community and local partners provides the building blocks of meeting local health and care needs and addressing the wider determinants of health. The scale of this transformation at neighbourhood level will be highlighted in the Community Network’s upcoming Neighbourhood Integration Project.
Overcoming barriers to primary and community care collaboration
There are several challenges that providers of primary and community care often need to overcome to work together collaboratively:
- A history of poor relationships, different cultures and lack of mutual understanding between secondary and primary care providers.
- Procurement processes, contract structures and commissioning are still tailored to the GP partnership model rather than facilitating collaboration.
- PCNs are still embryonic in some areas. Even with PCNs, navigating the primary care landscape within an STP/ICS footprint can be challenging for secondary care providers given the sheer numbers of GP practices in their patch.
- Primary and secondary care clinicians need to be brought along with the integration agenda, often by workforce or technological incentives rather than financial ones.
- The lack of tangible deliverables for integrated health and care services can also be a barrier to collaboration, although increasingly systems are taking the initiative to do this locally.
Despite these challenges, community providers have adapted and reconfigured their existing multidisciplinary structures and workforce arrangements within the new PCN footprints. Given it takes time to develop relationships and an aligned vision for health and care services for the local population, there is a mixed picture of engagement and progress across the country. The case study of integration between primary and community care in Derbyshire shows how investing time and energy in building good working relationships is essential.
The impact of COVID-19 on primary and community care collaboration
Both primary and community services have played an essential role in the NHS response to COVID-19. Community providers used their years of experience and expertise to rapidly adapt services, including redeploying staff to new discharge to assess teams and priority services. This ensured the community sector was able to safely discharge thousands of medically fit patients to free up hospital beds for the initial peak of COVID-19, as well as support patients with more complex needs in the community - both COVID-19 and otherwise.
Many community providers also played a key role in supporting care homes during the pandemic. They built on existing relationships developed during flu outbreaks and winter pressures, to provide similar support with staffing and resilience issues, training on good infection prevention and control practices, and early identification of deterioration.
Primary care services have been similarly essential, continuing to support patients via remote consultations and using virtual triage to ensure people received the care they needed. Innovative super-partnerships like Modality report that productivity and staff morale remained high, as the increased use of digital technology and drop in referrals meant that clinical time could be redeployed for care planning and proactive case management.
Community providers’ experiences of collaborating with primary care colleagues during the pandemic are variable. In some areas, COVID-19 has accelerated PCNs’ development and cemented nascent integrated care initiatives at neighbourhood level. Shielded patient lists have given renewed impetus for primary, community and social care colleagues to support the most vulnerable. Community providers have also been able to support PCNs with their expertise in infection prevention and control, such as advising how to operationalise red and green GP sites for COVID and non-COVID patients.
The case study of primary and community care collaboration in Leeds shows how the foundations of neighbourhood-level partnership working facilitated an effective response to COVID-19.
In other areas, community services report gaps in primary care capacity, which they have sought to support. For example, some providers saw an increase in referrals into community nursing because general practices were not able to offer home visiting services. This is demonstrated by referrals to take blood for shielded patients or develop care plans for people not previously on community services’ caseloads. Where PCNs were embryonic prior to COVID-19, it has been more challenging to collaborate a coherent primary care service offer.
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While COVID-19 has accelerated collaboration between primary and community care in some parts of the country, other areas will need more support to recover from the impacts of the pandemic and time to work through competing pressures. The marked expansion in the use of digital technology, remote monitoring and virtual consultations during the pandemic will need to be embedded into ‘normal’ service delivery where it continues to work best for patients and staff. PCNs will soon need to turn their attention to the DES service specifications due for implementation in October 2020.
As NHSEI re-establishes its operating model of system by default, neighbourhood-level integration will likely play a key role in addressing health inequalities exacerbated by COVID-19 and accelerating population health management. Primary and community care will need to be well represented in strategic decision-making on the restoration of services at system level. The system architecture needs to facilitate the right behaviours and good relationships, supported by resources moving around the system in the right way and contractual mechanisms that do not hold back transformation nor restrict different models of care.
NHS community health services have a clear vision of high-quality joined-up care in the community, supported by ‘home first’ discharge pathways, increased investment and flexible workforce models with their partners including primary care. To achieve this vision of more care delivered in the community, national prioritisation and funding – both capital and revenue – are essential to ensure that the NHS resets to a new and improved normal.
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