Meeting the challenges of General Practice means providing coordinated and integrated care to populations through communities of care that encourage people to lead happier and healthier lives.
The delivery of improved outcomes and ensuring the sustainability of the system is at the heart of the development of Primary Care Networks.
General Practice is undergoing a significant shift, with the implementation of a Direct Enhanced Service encouraging practices to operate in Primary Care Networks of 30,000 to 50,000 patients. Wednesday 15 May 2019 marked the deadline for PCNs to submit their registration information to CCGs.
In light of the May milestone, and the refinement of governance details taking place through to June 30, Alison Westmacott, Director of Primary Care, discusses current challenges in the health system, Primary Care Networks and SCW’s development of Primary Care Network structures.
The health system is facing considerable challenges. These include workforce issues, the changing health needs of an ageing population, and an emphasis being placed on looking to local community strengths and resources to focus on prevention and early detection, as put forward in the NHS Long Term Plan.
Changing health needs
The population’s changing health needs coupled with shifts in patient expectations and challenges facing recruitment and retention in primary care is placing the health system under increasing pressure.
These changes include an ageing population, a shift from treating episodes of individual illness to helping people manage long-term chronic conditions and the expansion of new treatments. This has led to a demand for an increasing range of services.
'As the population gets older, you have more people living with chronic conditions. Due to new treatments and health progress, they are also living longer with those conditions, so there is a definite overlap.' says Alison.
There is also a noticeable shift in patients’ expectations when it comes to care.
'Our expectations of health care and care generally are also changing. What people want from their health service is changing.' Alison adds.
Acknowledging this shift, the General Practice Forward View, sets out ambitions to inject additional investment to support general practice, enabling self-care and direct access to other services, increased use of digital technology, working at scale and utilising talents of the wider workforce.
The workforce issues weaving through primary care present additional challenges.
'We’ve got significant workforce issues in primary care. We talk quite a lot about it at GP level, but it actually goes all the way through to practice nurses and people with specialist skills. Thinking about doing things very differently and implementing new ways of working in primary care could drive solutions to some of those challenges.'
The current position: Primary Care Networks and the NHS Long Term Plan
Keeping people healthy at home and strongly encouraging healthier and happier lives lies at the core of the NHS Long Term Plan.
'In the 10-year plan NHS bosses in England state that up to 500,000 lives could be saved by focusing on prevention and early detection,' says Alison.
In order to facilitate the aims of the NHS Long Term Plan, including the delivery of world-class care for major health problems and supporting an ageing population to live well, the role of Primary Care Networks is a vital foundation for Integrated Care Systems.
GPs, mental health services and community care will receive the biggest funding increases to shift the focus away from hospitals. The emphasis of the NHS Long Term Plan is to keep people healthy at home and to support them to lead happier, healthier lives.
What our customers want
What SCW’s customers want is broad, and includes:
- Healthier people
- Happier staff
- Integrated solutions and
- Sustainable systems
Establishing a Primary Care Network
Primary Care Networks are groups of practices working together to cover a population, with elements of the DES funding allocated to both the network and individual practices. While practices can choose not to join a network, one hundred per cent of a population needs to be able to access services provided by a network from 1st July 2019.
The ‘coalition of the willing’
The size and shape of a PCN can be influenced and determined by a host of factors, including historic working arrangements, current and past relationships, patient flow, the care needs of the population and the willingness of partners to work together.
Alison refers to the willingness of the practices to work together as 'the coalition of the willing'.
When it comes to establishing a Primary Care Network, certain practices will boast a natural pull to others, both geographically and because they have existing relationships. It is clear that the formation of a PCN must be driven ‘bottom up’ by individual practices in order to secure a solid foundation for the establishment and sustainability of the PCN.
'It is up to the practices. In most areas, there will already be examples of collaborative work or the formation of a federation. Some of that groundwork would have been done in some areas, but not everywhere,' adds Alison.
What’s more, many PCNs are established based on current and historical relationships.
'I believe that a high percentage of PCNs will be built on an existing foundation. It may not be perfect, but I think you will see PCNs building on what has happened in the past, on existing relationships and historic alignments,' Alison says.
May 15 marked the deadline that PCNs needed to submit their registration information to CCGs, with a deadline of June 30 for PCNs to explore, develop and refine the required schedules.
'There is an awful lot of work to be done around the governance arrangements,' says Alison.
'There are NHS England templates, but I would say that these governance arrangements need to be bespoke and worked through by the practices and the PCNs to understand what the decision-making process is going to be,' she adds.
Queries that need to be addressed and actioned within the governance details include:
What is decision-making going to look like?
- What decisions can a small and agile leadership group make, and which decisions need to be made by all partners?
- How can differences in list sizes and numbers of GPs be managed through governance approaches?
How are they going to work together?
- How are the views of the wider practice team reflected in decision-making – consultation or engagement?
- How is the clinical director going to work with the ICS to represent the views of the PCN?
Engagement and leadership
PCNs are made up of networks of 30,000 to 50,000 patients within a geographical location. They enable a system-wide approach, greater communication and the encouragement of engagement across practices.
'The emergence of Primary Care Networks provides a platform for the provision of care across a wider population – enabling primary care to engage more cohesively across the health and care system and the implementation of new models of care,' says Alison.
'We know that a lack of social connections is as damaging to a person’s health as smoking 15 cigarettes a day,' says Alison. 'Primary Care has a huge role to play in connecting communities.'
Working at scale within PCNs also unlocks greater communication and representation across wider populations, it also provides the platform from which the view of Primary Care in the evolving ICS landscape is strengthened and positions PCNs in a system leadership role.
'For me, that’s one of the real strengths of Primary Care Networks from a system-wide approach. It has given general practice the opportunity to have a stronger voice in the system. CCGs provide a voice for general practice from a commissioner perspective, but this is very much from a provider perspective.'
The move from secondary to primary care
As the health system has been looking at changing the way services are delivered and improving outcomes for patients, there has been a real emphasis on shifting activity out of secondary care into primary care. This presents a set of challenges.
'If you’re moving activity out of secondary care it still needs to take place. If you’re moving it into Primary Care, it needs to be funded and you need to take into account the fact that GPs already have a huge workload. Taking on more work may not be a particularly attractive proposition for them, particularly if it is not appropriately funded,' says Alison.
The role of digital technology
Alison emphasises the significance of digital technologies as outlined in the NHS Long Term Plan but discusses these tech tools as ‘enablers’ for specific solutions rather than a blanket solution in their entirety.
'From my perspective, digital technology is an enabler, it isn’t a solution. It’s the transformation around digital technology that is really important. You can drop digital technology into general practice, but it doesn’t mean that the clinicians or the patients are going to engage with it,' Alison says.
'I strongly believe in starting with the end in mind. What is the change you want to see and therefore what digital enablers can you use to support the delivery of that change?' she explains.
PCN delivery and development
Alison describes the frequency of avoidable appointments in Primary Care and the need to look at who else is in the system who could support those patients, successfully freeing up GP capacity to focus on those with more complex needs and those requiring their support.
'The evidence states that 27 per cent of GP appointments are avoidable because they could be seen by somebody else in the practice. About 22 per cent of those would be better suited to another clinician; practice nurse, health care assistant, clinical pharmacist or a paramedic etc., so it’s still clinical but does not necessarily require an appointment with a GP. Based on the recent work we have done with practices I would suggest that approximately five per cent of appointments are non-clinical,' describes Alison.
PCNs can support the implementation of new models of care working across general practice and in partnership with other providers of care to ensure that the population is able to access the most appropriate care and support provided by the most appropriate service.
The scale of PCNs will also enable the sharing of roles across a network and the development and implementation of new roles. This may include the development of cross-organisational/cross-sector roles which will start to blur some of the boundaries that can cause frustrations to those accessing services.
SCW’s Primary Care Network development and delivery approach illustrates the elements of support that PCNs may benefit from - from initial network design and governance through to performance and evaluation.
Find out more
The Primary Care Team in SCW will continue to provide unrivalled support and direction to practices, Primary Care Networks and Federations in working to successfully implement the required changes and to develop their links and working with their Integrated Care System to realise the best possible outcomes from this opportunity.