Since being announced as part of the GP contract in England 18 months ago, primary care networks have split opinion. Costanza Pearce asks whether they are helping or hindering GPs
It’s been 18 months since the 2019/20 GP contract in England, perhaps the most radical in 15 years, introduced primary care networks into the general practice landscape. And this month the networks encounter one of their biggest challenges: carrying out weekly ‘care home rounds’ through their multidisciplinary teams.
This is the first of a number of requirements being introduced as part of the Network Contract DES, and there is an anxiety around the looming workload deluge.
An exclusive Pulse survey of 179 PCN clinical directors – covering around 14% of all PCNs – reveals seven out of 10 think the resources PCNs are being given in 2020/21 are inadequate for the requirements set out in the DES.
Around 98% of GP practices are in a PCN, and ultimately it will be grassroots GPs who will have to deliver the new requirements. These practices are saying PCN membership is proving to be hard work for them, and they fear the increasing workload in the coming years.
One reason for this is the flagship additional roles reimbursement scheme (ARRS) – which funds networks to recruit healthcare professionals such as pharmacists and paramedics – has not been effective yet, despite being the main incentive for practices to join networks.
A Pulse investigation reveals that less than half of the available funding was used in 2019/20, with many CCGs failing to reinvest the unused ARRS spending back into networks, as they are supposed to.
All this has led to GPs being worried about whether being part of a PCN will turn out to be a help or a hindrance.
‘No benefits yet’
Kent LMC medical secretary Dr John Allingham says many practices are not yet feeling the benefit.
‘In Kent, we’ve got 42 PCNs. One or two are flying [but] a lot of the grassroots practices are not noticing any difference.
‘As an LMC, we have put a phenomenal amount of work into PCNs and I don’t think we’re seeing that much back. We’re certainly not getting the benefits that we wanted.’
Yet despite the angst surrounding the service, only 2% of practices decided against taking part in the DES in 2020/21 – although only 1% opted out in 2019/20. There seems little sign of more practices doing so in future years – the vast majority of PCN clinical directors are positive about the project as a whole.
But this may change after having to contend with the care home service, which is at the forefront of everyone’s minds and for many GPs epitomises the problems of networks.
Wokingham North PCN joint clinical director Dr Rupa Joshi says: ‘I don’t think we’re fully prepared for how much work the care homes service is actually going to be. That’s going to hit us come 1 October.’
It is one of three services being introduced this year, but it is definitely the most controversial. One in 10 PCN clinical directors feel they will be unable to fulfil the care homes DES requirements from this month, with a further quarter saying they are unsure.
PCN service specifications – in summary
Enhanced health in care homes service
From 1 October, all PCNs must deliver a weekly ‘home round’ for care home patients, provided by members of a multidisciplinary team. This must include prioritising which patients require a review. The weekly round must include ‘appropriate and consistent medical input from a GP or geriatrician’ but the ‘frequency and form’ of this input should be decided according to clinical judgement. Digital technology can be used to ‘facilitate’ the medical input. Personalised care plans for care home residents must be developed by the MDT within seven working days of admission to a home, or readmission following time in hospital. There is now flexibility within the contract for the service’s clinical lead to be a non-GP clinician, to allow Covid-19 arrangements to continue.
Structured medication reviews
From 1 October, each PCN must identify patients who would benefit from an SMR, which must include those: in care homes; with complex and problematic polypharmacy; on medicines commonly associated with medication errors; and with severe frailty. PCNs should offer a range of extended appointment slots to cater for new SMRs and follow-up consultations, as well as for any patients identified reactively. The number of SMRs that a PCN is required to offer will be determined and limited by its clinical pharmacist capacity. PCNs and commissioners must discuss and agree a reasonable volume of SMRs on this basis.
Early cancer diagnosis
From 1 October, every PCN must review referral practice for suspected cancers, including recurrent cancers, by checking its practices’ referrals against NICE guidelines. PCNs must also ensure a ‘consistent approach’ to monitoring patients who have been referred urgently with suspected cancer or for further investigations, ensuring safety netting is in place. Networks must contribute to improving local uptake of national cancer screening programmes, and set up a group of practice-level clinical staff to support delivery of all service requirements as well as provide learning events.
When the plans were unveiled at the start of 2020, there was consternation about GPs having to attend at least fortnightly care home rounds with residents when there were no details of extra money. PCNs and LMCs began advising practices not to sign up to the next year’s PCN DES, citing capacity and financial constraints.
But following revisions, the service now launches on 1 October, with weekly home rounds to be conducted by any of the multidisciplinary team and funding of £120 per bed.
For some PCNs, the changes were not enough and there have been casualties. The Skegness and Coast PCN in Lincolnshire, serving 80,000 patients, collapsed in June after its practices assessed that recruitment and resourcing issues made them ‘unable to envisage’ delivery of the care home service.
And NHS England controversially introduced some elements of the DES in May, with chief executive Simon Stevens demanding ‘virtual’ care home rounds take place in response to Covid-19, with threats of potential regulatory action if practices failed to deliver it. A Pulse survey of 454 GPs revealed the service has been taking up an average of three hours a week for practices.
Clinical director of Newham Central PCN Dr Farzana Hussain tells Pulse a lot of anxiety remains about delivering the three new service specifications that begin in full this month.
‘I think they are the correct content – cancer, structured medication reviews and particularly care homes are absolutely right – but it does feel a bit overwhelming still’, she says. ‘There’s probably never a right time, but we are feeling nervous.’
From NHS England’s perspective, these requirements should be more than offset by the new staff they are funding for networks. For example, clinical pharmacists were offered to support medication reviews as well as work in care homes, with input from physiotherapists also funded by NHS England.
Extra funding – of £3.7bn – was committed to help PCNs recruit 26,000 extra clinical staff by 2023/24, with £110m available in 2019/20. But recruitment under the ARRS has proved difficult. Only 42% of the funding was used in the first year of PCNs to pay for the additional roles, Pulse’s FOI reveals.
These figures chime with a Pulse investigation last year, which revealed only half of PCNs had managed to recruit clinical pharmacists, with a similar proportion successfully hiring social prescribers – the only two roles then on offer – yet it seems there has been little improvement this year.
Almost two-thirds (64%) of clinical directors told Pulse’s PCN survey their network had so far failed to fill its full ARRS allocation for 2020/21.
‘We’re not as far advanced as we would hope with the DES this year’
In Herts Valley, to get hold of a clinical pharmacist has proved something of a challenge because of the lack of availability of trained medical professionals.
Last year, three pharmacists replied to our advert, but we found they’d all applied to other PCNs in the area. So inevitably they went to the networks paying the most money – and they were offering 40% more than the salary reimbursed by NHS England.
We’ve had to be flexible – for example, our priority was a competent clinical pharmacist rather than a link worker. Through some imaginative recruitment, we finally managed to get a pharmacist for two days a week in June 2020.
We’re not as far advanced as we would hope to be in terms of delivering the specification of the DES this year. Sprinkle a bit of Covid on top and it’s been a perfect storm. At the moment, the ARRS and the PCN DES are far too prescriptive for us to achieve anything meaningful.
I’ve heard some areas are getting a lot of support in developing and recruiting but it feels ours has had less. Getting the unspent money has been predictably slow and complicated. I believe there are sensible plans locally to use it for a bolstered flu campaign but I haven’t seen any details.
Dr Mike Smith is clinical director of Abbey Health PCN in Herts Valley.
Lancashire GP partner Dr Russell Thorpe, who chairs the Lytham St Annes PCN meetings, says: ‘We’re building a team but we’re all in competition with the other people playing the game.’
Dr Hussain says: ‘London weighting is not included so it’s really difficult to attract those people to come. The reimbursement just doesn’t cover that. So if we don’t put our own money in, we’re not going to get anybody.’
NHS England stresses it has made changes to the ARRS for 2020/21. A spokesperson said: ‘Expanding the primary care workforce remains a top priority to achieve improvements in patients’ care, and support practice staff. We have taken significant steps this year to support PCNs, including raising the reimbursement rate for new staff, increasing PCN roles from two to 12, and providing more support for recruitment.’
But for many practices, even when they do recruit, the roles aren’t helping much. ‘The problem with the pharmacists is that initially we were wanting to recruit them to look at practice workload and help GPs be more resilient, but their workload is going to be taken over by the DES’, says Wokingham North PCN’s Dr Joshi.
‘And GPs are still going to have to do more work because there will be complicated nursing home patients that need overall clinical input done by GPs.’
And one GP, who wishes to remain anonymous, says the appointment of a clinical pharmacist at her old practice was ‘basically useless’. She says: ‘In my practice, and others I know in the same PCN, the pharmacist appointments were unused nearly every week. It hasn’t relieved any pressure at all on surgeries.’
Leicestershire GP Dr Grant Ingrams goes a step further, saying the roles actually increase workload. ‘When you’ve got additional members of staff, you need to be supervising them and you need to sort all the HR, so they’re not workload-neutral’, he says. ‘It isn’t actually transferring extra money into general practice, it’s transferring extra work into general practice.’
There was supposed to be a safety net for any failure of the ARRS. NHS England guidance, released last summer for 2019/20, said ‘in the unlikely event’ of an ARRS underspend, CCGs were ‘strongly encouraged’ to use the financial entitlement on other PCN work.
However, Pulse‘s FOI figures show 22% of the additional roles funding – equating to around £24m when extrapolated across England – was still unspent in June, two months after the end of the 2019/20 scheme, while 36% was spent on ‘other activity’.
Dr Geetha Chandrasekaran, clinical director of North Halifax PCN and a GP partner in the town, says the PCN under-recruited last year but she has ‘no idea’ where the unspent funding went.
‘If we could have used the funding for other things, even training for existing ARRS roles or supervision and support, we might have actually been able to recruit more people… it’s a shame that the money will get lost to primary care.’
All this means an imbalance between workload and resources for many GPs. ‘You have to be really careful when you’re doing the work for PCNs that what you provide is within what funding you’re getting,’ says Dr Ingrams.
There is also the promise of more service requirements next year – among them anticipatory care (with community services), personalised care, cardiovascular disease case-finding and locally agreed action on inequalities.
Practices are further burdened by the clinical directors’ workload taking them away from practice work. Pulse’s survey reveals clinical directors spend 2.5 hours on average on this work. They estimate they are losing around 19 appointments a week.
But it is not all gloom. The survey revealed 67% of clinical directors feel positive about PCNs, with only 6% being negative and the vast majority (85%) saying they’re either ‘likely’ or ‘very likely’ to continue with the DES in 2021/22.
And PCN membership during the pandemic has fostered relationships many practices have come to rely on. It is this solidarity that encourages belief that PCN problems can be overcome. Dr Hussain says: ‘Covid over the last few months has definitely bought practices together. Hot hubs have been network-based in a lot of places, so that has all in a way accelerated some relationships.’
The flu campaign is another case in point. Networks have been working together to target 30 million patients in England, with one Dorset PCN organising a ‘flu bus’ to tour rural areas for those unable to attend its drive-through clinic – which is based at an airstrip. A PCN in Manchester has pooled vaccine stock and set up a drive-through system in a leisure centre car park.
For singlehanded GPs like Dr Thorpe in Lytham St Annes, the benefits of working together will keep the PCN momentum going for now.
He says: ‘It’s not been completely plain sailing for us locally but then from my point of view, there have also been positives, for example that I get to see more of some of my colleagues.
‘There’s some optimism, I think.’
This feature originally appeared in print with different ARRS FOI figures. The print version was incorrect and the figures have since been updated for this online version.