Despite greater health needs in poorer areas, general practice in the most deprived parts of England is under-funded and under-doctored. This inverse care law is not new, but attempts to fix it have failed. Efforts have often been small in relation to the problem, and the Carr-Hill funding formula – which fails to account for the impact of deprivation on health needs – has been used since 2004.
Creating primary care networks (PCNs) in 2019 wasn’t intended to fix the inverse care law. But PCNs are – amongst other things – supposed to tackle health inequalities.
In 2019, we raised concerns that if additional funding and staffing for PCNs were skewed towards affluent areas, networks might paradoxically widen health inequalities. The Health Foundation has now analysed PCN funding and workforce data, and interviewed PCN leaders in deprived areas to find out whether that’s happened.
PCNs in deprived areas employ fewer staff
In theory, PCNs are allowed to recruit equal numbers of staff via the Additional Roles Reimbursement Scheme (ARRS). But once we adjusted for the higher needs of local patients, PCNs in the most deprived areas of England employed six fewer full-time equivalent (FTE) staff per 100,000 patients. Paramedics, care coordinators, pharmacists, and pharmacy technicians are the roles with the biggest deficit in PCNs in more deprived areas.
The clinical directors we interviewed were clear that although ARRS roles can add great value in areas of high deprivation, recruitment is hard.
GPs have limited time to recruit, supervise, mentor, and embed new staff. And high workload, patient complexity and the emotional toll of being unable to meet patients’ full health and socioeconomic needs can make retention challenging.
Some expressed frustration that ARRS staff – especially in-demand roles like paramedics and pharmacists – left for better paid or less complex work in more affluent areas. Being upfront about the challenges of working in deprived areas and recruiting staff with shared personal values around addressing inequalities were identified as useful recruitment strategies.
PCN funding skews towards more affluent areas
PCNs are funded through a mix of income streams, calculated in different ways. Since 2019, NHS England has moved three funding streams to the Integrated Care Board allocation formula – the approach that currently best accounts for deprivation. But the remaining four population-based funding streams – accounting for around 65% of PCN funding – either have no weighting (i.e are per registered patient) or use Carr-Hill.
Our analysis found that once need is accounted for, PCNs in more deprived areas get less funding than networks in more affluent areas. If these four payment streams were switched to the ICB allocation formula, PCNs in the most deprived areas would collectively receive an extra £18.6m in 2023/24.
Clinical leaders told us that this gap in funding matters: it doesn’t reflect patient need and leaves networks struggling to resource themselves adequately. This has knock-on effects on staffing (more pressure drives a vicious cycle of recruitment and retention problems) and on the ability of networks to deliver interventions intended to tackle neighbourhood health inequalities.
All doom and gloom?
Despite challenges, clinical directors in deprived areas were optimistic about the potential of PCNs. Many felt that PCNs had boosted capacity and workforce, alleviating pressure on core general practice, offering new services or both. Many hoped that PCNs could play a meaningful role in tackling health inequalities – for example, by building bridges with local public sector organisations and voluntary, community and faith groups. Many also thought that relatively minor changes to the PCN contract – such as more flexibility in the roles that could be recruited – could help PCNs better meet local needs.
But leaders were also clear that increased need must be matched by increased resources. And that pressures in core general practice are negatively impacting their ability to make change.
Clinical directors pointed to the vital role of commissioners in supporting their efforts. Some felt that the transition from clinical commissioning groups to integrated care systems has resulted in the loss of trusted relationships with commissioners and that the capacity and quality of commissioning support they receive has decreased.
So, what next?
It’s clear that PCNs can play a meaningful role working within communities to reduce health inequalities – but the current failure to fund and staff PCNs in line with population need limits their potential.
A new PCN contract in 2024 is an opportunity to course-correct. In the short term, switching all population-based PCN funding streams to use the formula that best accounts for need would help. PCNs in deprived areas also require bespoke support from commissioners, including with recruitment and retention of staff.
A new inverse care law has been created in general practice; in the distribution of funding and workforce in PCNs. This compounds the existing inverse care law in core general practice. While these inequities persist, the role of general practice in tackling health inequalities is compromised. New contracts for general practice and for PCNs, and a new Government provide opportunities for remedy. These must be taken, otherwise PCNs may widen health inequalities they are supposed to narrow.
Dr Rebecca Fisher is a GP and senior policy fellow at the Health Foundation and Jake Beech is a policy fellow at the Health Foundation.
