Forget the days of GP practices competing against one another. Collective working is the way forward for the NHS. And now it has been formalised through the new five-year GP contract in England.
Practices will not be forced to join one of the new ‘primary care networks’ (PCNs) set up through the contract. But in reality, they’ll have little choice. Just joining a network will unlock funding worth £1.70 per patient – an annual average of £14,000 per practice – through the ‘practice participation’ additional service.
But more than this, they are being tempted by untold riches set aside for these new formations. A new ‘network DES’ will incorporate all the funding from the current extended hours DES – which will no longer be available to individual practices.
It will provide 70% of the ongoing costs of employing pharmacists, physios, physician associates and paramedics, and 100% of those for a social prescriber. And it will give the networks 59p per patient to appoint new leaders.
The great cash giveaway doesn’t end there. CCGs will be directed to provide £1.50 per patient to the networks, which will be ringfenced. This is the result of successful negotiations by the BMA and NHS England. It seems everyone thinks PCNs are the way to go.
And yet concerns are growing about these networks. Critics say there is little evidence collective working improves patient care or GPs’ working lives. Indeed, some collectives have collapsed under financial and recruitment pressures.
Above all, there is a worry that the new networks are being implemented with undue speed, and that they could end up with some top-down coercion.
We know they will comprise groupings of practices covering 30,000 to 50,000 patients and will be based on location. Every practice will have the right to join one. Beyond this, we don’t know what the requirements will be.
GP practices working in groups is nothing new. The RCGP first advocated federations in 2007, when it drew together its roadmap for the profession, on the basis they would improve patient access and provide an extended range of services.¹ Since then, practices across the UK have increasingly begun to club together locally.
In England, federations – typically serving around 100,000 patients – have been growing in number.
And NHS England former head of primary care Dr Arvin Madan made it clear last summer that large-scale general practice was the direction of travel, when he suggested in comments published by Pulse that GPs should be ‘pleased’ to see small practices closing.
This is not just happening in England. In Northern Ireland, there are 17 incorporated GP federations, with almost all practices taking part, while Scotland and Wales have 147 and 67 GP ‘clusters’ respectively (see box).
By establishing PCNs as a formal model, NHS England says it wants to implement a model of general practice that ensures resilience.
But there appears to be little evidence so far that it can solve the problems facing general practice – heavy workload, long hours, staff shortages, increased patient demand.
How practices are working together in different UK nations
All practices in Scotland are part of a GP cluster. There are approximately 147 GP clusters of different sizes, depending on local circumstances and geography. A typical cluster includes four to eight practices covering 20,000 to 40,000 patients. Unlike federations in England, which are for service delivery, clusters involve ‘peer-led quality improvement discussions’.
Wales has had primary care clusters since 2014, when a new GP contract was agreed between the BMA’s Welsh GP Committee and the Government. Each of the 64 clusters serves a population of 30,000 to 50,000 people, with health boards responsible for determining the geographical area they cover.
The local health board, Welsh Ambulance Services NHS Trust, local authority and local third-sector organisations are all members of the cluster alongside the LMC. The role of the cluster is to co-ordinate services on the basis of localities.
There are currently 17 fully incorporated GP federations covering 1.8 million patients, with virtually 100% participation from practices. On average, a federation comprises 17 practices, each serving around 100,000 patients. According to the Health and Social Care Board, Northern Ireland is the only UK nation with a ‘unified model of federations governed by a unified members agreement covering its entire population’. GP federations aim to support practices and help deliver the Health and Social Care Board’s transformation agenda.
NHS England has relied on case studies detailing how primary care networks work in different regions to make the argument for PCNs.
But in terms of evaluation, a review led by the London School of Hygiene & Tropical Medicine in 2018 looked at existing studies assessing the impact of collaboration between GP practices² It found ‘good quality evidence of the impacts of scaling up general practice provider organisations in England is very scarce’.
An ongoing piece of work by the University of Manchester that began in 2016 is investigating federations in England – but the results will not be published for several months.
The most fundamental review was published in 2017 by the Nuffield Trust.³ It looked at the ‘primary care home’ model – based on 50,000 patients – concluding that, while there were benefits to creating networks, there were also challenges.
The review, commissioned by the National Association of Primary Care – which is behind the model – said new working relationships between GPs and other staff take time to establish, with ‘significant’ investment in time, money and support required.
The timescale is ambitious to say the least
Dr Brian Balmer
But this is something practices don’t have. NHS England is not due to release its specifications for what constitutes a network until the end of March.
NHS England originally said CCGs had reported 88% of practices in England were already working as part of a network. Yet its acting director of primary care Dr Nikita Kanani admits the real number is ‘probably a bit lower, because people account for networks in slightly different ways’.
The BMA has clarified to Pulse that federations are unlikely to meet the requirements for networks. This means many practices will only have two months from release of the specifications this month to the mid-May deadline to register what are likely to be completely new organisations responsible for a huge chunk of future funding. Then they will have just over a month to launch the networks by the start of July.
GP and Essex LMC chief executive Dr Brian Balmer says: ‘The timescale is ambitious to say the least – I would be astonished if the entire country can get this together. Some will do it probably more than we realise because GPs are good at grabbing new opportunities, but to say everyone will would be optimistic.’
Walsall LMC medical secretary Dr Uzma Ahmad says she is worried about the lack of detail. ‘We’re part of a federation, which was not geographically set up,’ she says. ‘For a network we have to align ourselves to our patch, which is totally different. Specifications are not out yet but the current information is networks will be different from the federation set-up.’
Yet timing is not the only issue. There are also fears around how practices will work together – especially due to the requirement that PCNs be based on geography. Dr Ahmad says it has taken time for practices in federations to understand each other’s priorities and see eye-to-eye over running the organisation. A key benefit was being able to choose members outside the local area, she says.
‘Now, to be based on geography will be challenging because it’s a new set-up, getting to know different types of neighbourhood and practices and developing a relationship with them is going to be done in quite a short period.’
And these relationships will be vital, because they will have to collaborate in order to receive this funding. To start with, practices will no longer receive extended access DES funding – this will now be funnelled through the networks.
Developing relationships will be a challenge
Dr Uzma Ahmad
In future years, networks will also have to meet seven ‘national service specifications’ to receive the funding for their extra staff. These include: medications reviews; enhanced health in care homes; anticipatory care for high-need patients; ‘personalised care’, to implement the NHS Comprehensive Model; early cancer diagnosis; CVD prevention and diagnosis; and tackling neighbourhood inequalities.
There are fears some of these requirements may lead to overdiagnosis. But there are also concerns they are onerous: for example, the care homes requirement expects residents to get regular clinical pharmacist-led medicine reviews and networks to provide weekly visits and emergency support.
Jamie Green, clinical director of the General Practice Alliance Ltd federation in Northampton, also worries that defining PCNs by regions might pose extra problems for rural practices.
‘One of the big difficulties will be the difference between town-centre based practices and larger geographical areas we see in rural practice,’ he says. ‘Having between 30,000 and 50,000 patients within a rural practice population means dealing with huge areas and distances.’
There a further issue of how to support struggling practices within networks. For example, Pulse has found that 16% of practices rated ‘inadequate’ by the CQC are not part of a federation or network.
The experience of some federations shows collective working can create new problems – and has even led to them being abandoned altogether. In 2016 in Doncaster, a private limited company set up by 23 shareholding practices – Danum Medical Services Ltd – that served 37,000 patients folded after losing contracts and running into financial difficulties.
In the same year, a 54-practice federation in Bedfordshire went into liquidation. Horizon Health Choices Ltd had been in operation for a decade but recruitment problems and internal management issues led to its demise.
No turning back
Dr Bob Gill, an NHS campaigner and GP based in south-east London, says: ‘There’s no evidence mergers or close working offer any advantages to patients.
‘It’s already difficult within practices to function given the pressure they’re under and this will cause even more tensions between surgeries and clinicians.’
But the move to collective working is pretty much set in stone. And it has support from policymakers. Wessex LMCs chief executive Dr Nigel Watson chaired the Government’s review of the GP partnership model. He believes networks will raise poorer-performing practices, not drag the rest down.
‘With the additional funding, I would hope networks can work with CCGs and those practices to try, through peer support, to support [poorer performing practices], and the variation in quality would actually diminish significantly.’
Most importantly, the GPC and NHS England are completely behind the move.
Dr Kanani emphasises we have moved away from the culture of competing for contracts, and networks will lead to better care. She says: ‘I want us to move to a culture of collaboration, support and compassion. It has to be about people getting access to assets in their community and being supported to stay well.’
And, for BMA GP Committee chair Dr Richard Vautrey, it is not only patients who will benefit – it will help the profession as a whole. He says: ‘Support and funding for primary care networks mean practices can work together, led by a single GP, and employ extra staff to provide a range of services locally, giving patients access to the right professional, and helping GP workload pressure.’
GPs will collectively hope that they are correct. Because this might be the last throw of the dice for general practice.
Timeline for primary care networks
• Now to April 2019 – Primary care networks prepare to meet network registration requirements
• By 29 March 2019 – NHS England and GPC England to jointly issue the ‘Network Agreement’ and 2019/20 ‘Network Contract DES’, including specifications
• By 15 May 2019 – All networks must submit registration information to their CCG
• By 31 May 2019 – CCGs must confi rm every patient is covered by a network
• Early June – NHS England and GPC England jointly work with CCGs and LMCs to resolve any issues
• July 2019 – Practices receive £1.70 per patient for joining a network
• 1 Jul 2019 – Network Contract DES goes live across 100% of the country and national entitlements under the 2019/20 Network Contract start:
- Year 1 of the additional workforce reimbursement scheme, including 100% of the salary of a social prescriber and 70% of the salary of a pharmacist
- Funding to cover the network clinical director’s time, worth 59p per patient
- Ongoing £1.50 per head from CCG ringfenced allocation
• Apr 2020 onwards – Seven ‘service specifi cations’ come in to force for networks and funding for physiotherapists and physician associates begins
Source: A five-year framework for GP contract reform to implement the NHS long-term plan
¹ RCGP. Future direction of General Practice: A roadmap. London: RCGP; 2007
² Pettigrew L, et al. The impact of new forms of large-scale general practice provider collaborations on England’s NHS. BJGP; 2018; 68 (668): e168-e177
³ Kumpunen S, et al. Primary Care Home: Evaluating a new model of primary care. London:Nuffield Trust; 2017