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How do primary care networks and integrated care systems intersect?

How do primary care networks and integrated care systems intersect?
By Valeria Fiore
25 June 2019

Primary care networks are expected to go live in July, but it is unclear how they will fit into  the wider NHS. Valeria Fiore investigates

In recent years, general practice’s role within the NHS has been overlooked at both national and local levels. As NHS England acknowledged in its next steps on the NHS Five Year Forward View, published in 2017, funding for hospitals has been growing ‘twice as fast’ as for GP services.

NHS England documented its first steps towards resolving this imbalance in the General Practice Forward View, in which it spelled out the need for a greater focus on prevention at primary and community level, and increased collaboration between different healthcare providers.

However, in January this year, NHS England introduced a welcome change for general practice. As part of the NHS long-term plan, it pledged to allocate a much-needed extra £4.5bn a year to primary and community care by 2023/24. This announcement was soon followed by a five-year framework for GP contract reform, which will give general practice almost £1bn of core funding over the next five years, plus £1.8bn to establish primary care networks (PCNs).

But what are PCNs, and where do they fit into the NHS commissioning framework?

What are PCNs?

NHS England defines PCNs as groups of GP practices working together in their locality and collaborating with local providers across the community, social care and voluntary sectors. PCNs have informally existed for several years, as some practices have worked collaboratively within their neighbourhood, sharing resources and services.

However, the new GP contract has formalised any previous unofficial arrangements of joint working through the introduction of the PCN contract – an extension to the core GP contract going live on 1 July. Typically serving a population of between 30,000 and 50,000 patients, the contract specified that PCNs will become ‘an essential building block of every integrated care system (ICS)’.

Where do PCNs fit into ICSs?

Each PCN will support and shape emerging ICSs through their appointed clinical director, who will give a voice to primary care in developing local plans in line with the NHS long-term plan, according to the GP contract. However, at present it is unclear how this arrangement will work in practice. The long-term plan states that every ICS will have ‘a partnership board drawn from and representing commissioners, trusts, PCNs and local authorities, the voluntary and community sector, and other partners’.

Dr Anna Charles, senior policy adviser to the chief executive at The King’s Fund, said there isn’t ‘strict guidance’ on how the interface between ICSs and PCNs will operate. Instead, she believes this will be open to discussions to allow systems to ‘create something that is locally sensitive and works for the structure they already have in place’.

One of the biggest challenges PCNs could face, Dr Charles believes, is making their voices heard in an ICS. ‘Each PCN has been asked to appoint an accountable clinical director who would act as the single point of contact to the ICS into that PCN,’ she says. ‘It is not going to be possible, or feasible, in most cases, for all accountable clinical directors from all the PCNs to sit on the ICS partnership board. If you look at some of the biggest systems, that would be more than 50 people just from primary care.

‘It is not only the primary care voices that need to be represented at that level; it’s also voluntary and community sector organisations, community providers, acute providers, local authorities and commissioners. However, the PCNs offer you a first step to getting that organised voice in general practice,’  Dr Charles says.

How will they communicate their needs  to ICSs?

The long-term plan states that each ICS will have ‘full engagement with primary care’ through a named accountable clinical director in each PCN. However, how this will work in practice is for each system to decide, according to Dr Charles. For instance, PCNs might come together in forums, or choose a smaller number of representatives to attend ICS meetings.

Ben Gowland, director at Ockham Healthcare – a think-tank and consultancy focusing on general practice – agrees that representation at ICS board level is an issue that needs to be resolved locally. ‘If an ICS covers a population of 500,000, that means there will be at least 10 PCN clinical directors – that’s too many to sit on the ICS board, so there needs to be a subcommittee or something similar,’ he suggests.

Mr Gowland explains that it’s important for those sitting on PCNs to appear united. ‘My advice to PCNs would be to argue in private and agree in public,’ he says. ‘Different clinical directors are going to have different views about things, having disputes in public, the voice of general practice under PCNs could be lost. ‘There needs to be a place where PCNs in an ICS get together and work out their collective view and then find a way of delivering this into the ICS discussions.’

BMA General Practitioners Committee member Dr Krishna Kasaraneni agrees it is unlikely that all PCN clinical directors will sit on the ICS board. For this reason, he says the BMA will support clinical directors through a PCN forum, which he hopes will allow clinical directors in an ICS to make joint decisions to bring to the ICS table.

How can PCNs and ICSs best work together?

PCNs are still evolving, but NHS England wants their creation to be a bottom-up process. General practice should drive their formation and CCGs limiting their intervention to cases in which patients risk being left uncovered by a network – as is specified in the GP contract.

The risk for general practice to lose its voice within the system is real, however, if emerging ICSs fail to support and involve PCNs from the off. According Dr Kasaraneni, the ‘current ongoing crisis, with many practices overwhelmed by rising workload and stagnating resources, means many GPs will struggle to find the time or resources to become substantially involved’ with their ICS plans.

Therefore, it is essential that ICSs ‘support PCNs rather than have their own agenda for primary care. GPs need to be included, along with resources and  a mindset of open collaboration,’ he says. Dr Charles recognises the potentially negative effects of ICSs issuing directions down to primary care. However, she says the risk did not materialise across the 14 existing ICSs, because a lot of the work ICSs must achieve in integrating services needs to happen locally.

PCNs are an opportunity for ICSs to engage with primary care, and for integrated systems to hear from clinicians what their needs are, rather than imposing their vision from the top, Dr Charles says. ‘It is not possible to make the types of changes they are trying to make at a population level of a million or more. It is necessary to have a local footprint within them.

‘If you look at any ICS, particularly the larger ones, such as Greater Manchester or West Yorkshire and Harrogate, those leading these systems are clear that the needs of the population within those systems are not uniform. There are distinct places within them, and they have distinct needs,’ she says.

In Bedfordshire, Luton and Milton Keynes (BLMK) ICS, PCNs regularly feed back to the ICS what their needs are at a local level. ‘The essence of working in a network is about practices working together for a population,’ says Dr Nina Pearson, GP at Luton’s Lea Vale Medical Group and GP lead for BLMK ICS.

‘Our clinical leads are involved with the governance of our CCG; they are able to feed information, intelligence and recommendations up through different levels of our organisation. The intention is that they work very much around their population but are involved in the strategic planning for the much wider population,’ she explains.

To what extent must they work together?

NHS England specifies that although PCNs need to develop in a way that allows them to meet the need of their local population, they must also have a consistent level of integration within their ICS. PCNs will mature at different speeds; however, they might follow what NHS England calls the ‘PCN maturity matrix’ – a scheme it co-produced with the initial 14 ICSs setting out the development journey of PCNs.

According to the matrix, over time PCNs will be expected to deliver new models of integrated care and population health, have ‘fully interoperable IT, workforce and estates’ and have full decision-making powers as part of an ICS.

Is there funding to support integration?

To support their work in their locality, PCNs will benefit from a new national network Investment and Impact Fund next year, which will rise from £75m in 2020/21 to around £300m in 2023/24. The GP contract specifies that the purpose of this fund is to help ICSs deliver the long-term plan.

PCNs will have to decide with their ICS how they will spend the money received from the fund, which is ‘intended to increase investment for workforce expansion and services’. Part of the fund will be used by PCNs in line with the long-term plan ‘shared savings’ scheme, which will reward practices that are part of a network with benefits for achievements such as cutting A&E attendances, emergency admissions and delayed hospital discharge, according to the GP contract.

At this stage, although several ICSs across England have agreements in place that allow them to pool their resources, NHS England says there is no requirement for PCNs to pool their budgets with the wider system. However, they do need to consider how to work collaboratively within an ICS to deliver ‘the ICS’s overall strategic aims’.

Dr Charles says she doesn’t think that ‘PCN funding will be sucked elsewhere in the system because it is tied to certain things being delivered in the PCN contract’. Nevertheless, she thinks it would be positive for integrated systems to use their resources in a more coherent way, which would help them make the best choices for people in their area.

Contrarily, Dr Farzana Hussain, an east London GP and clinical director of Newham Central One network, hopes that her area will follow the example of other ICSs that have pooled their budgets. At present, she feels that primary care could end up carrying out work to ease the financial burdens of their local trust.

‘I am hoping our financial drivers will all be aligned, and once [our finances] all sit in one pot, we won’t be battling with each other, we will be working, number one, for the patient, and number two, to give the best value to taxpayers,’ she says.

What is the deadline for integration?

Despite the fact that guidance has been issued on the formation of primary care networks, uncertainty remains about their involvement within their ICS, as they are expected to go live from 1 July. It is undeniable, however, that the introduction of this tight deadline has helped different parts of the system to join forces and understand how to make patients’ experience as integrated as possible – as instructed by the long-term plan.

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