Dr Karen Kirkham explains how primary care networks will work within integrated care systems to deliver place-based care in a restructured NHS

KIRKHAM, Karen_resize

Dr Karen Kirkham

Read this article to learn more about:

  • the role of general practice in realising the objectives of the NHS Long Term Plan
  • how primary care network (PCN) service specifications contribute to the delivery of place-based care
  • the relationship between GP practices, PCNs, and integrated care systems in the changing NHS.

Read this article online at: GinP.co.uk/XXXXXX.article

Implementation actions for STPs and ICSs

Practical implications for primary care

In January 2019, the British Medical Association and NHS England jointly published Investment and evolution,1 a 5-year framework for GP contract reform to deliver the aims and objectives of the NHS Long Term Plan.2 We are now almost midway through the delivery of this ambition to stabilise general practice; it is a good time to reflect on what has happened over the past 2 years, and to consider what may lie ahead for general practice.

Investment and evolution set out five main goals for general practice to realise the aims of the NHS Long Term Plan (see Box 1).1 These goals were designed to embed a new contract for primary care networks (PCNs)—networks of GP practices working in partnership with community, mental health, social care, pharmacy, hospital, and voluntary services, serving confluent geographical areas with a population size of between 30,000 and 50,000 people.1 The new contract enables PCNs to deliver new service specifications in addition to core services, alongside growing the general practice workforce to generate multidisciplinary primary care teams.

Box 1: Implementing the NHS Long Term Plan —five goals for general practice1

  • Secure and guarantee the necessary extra investment
  • Make practical changes to help solve the big challenges facing general practice, not least workforce and workload
  • Deliver the expansion in services and improvements in care quality and outcomes set out in theNHS Long Term Plan, phased over a realistic timeframe
  • Ensure and show value for money for taxpayers and the rest of the NHS, bearing in mind the scale of investment
  • Get better at developing, testing, and costing future potential changes before rolling them out nationwide.

© British Medical Association, NHS England. Investment and evolution: a five-year framework for GP contract reform to implement the NHS Long Term Plan. London: BMA and NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

Reproduced under the terms of the Open Government Licence 3.0.

PCN service specifications

The four PCN services introduced as part of the directed enhanced service contract specification in 2020 were:3

  • extended hours access via the creation of additional clinical appointments
  • early cancer diagnosis through a review of screening, monitoring, and referral practices
  • enhanced health in care homes via the establishment of multidisciplinary teams and personalised care and support plans
  • structured medication reviews to optimise the quality of local prescribing.

The introduction of four additional service specifications—on personalised care, anticipatory care, tackling neighbourhood inequalities, and diagnosing cardiovascular disease—has been delayed to allow practices and PCNs to focus on their response to the COVID-19 pandemic.4

The positioning of PCNs in a changing NHS

In conjunction with measures introduced to deliver the ambitions of the NHS Long Term Plan, significant changes are also taking place in the wider NHS. On 26 November 2020, NHS England and NHS Improvement published Integrating care: next steps to building strong and effective integrated care systems across England, setting out a vision for ‘stronger partnerships in local places between the NHS, local government and others, with a more central role for primary care in providing joined-up care’.5 There will be a requirement for provider organisations to form collaboratives that allow them to operate at scale, and the development of strategic commissioning with a strong focus on population health outcomes.2 Digital technologies and data use will drive system working, connect providers, allow for personalised care, and provide insights to improve care pathways.5 In time, financial flows must enable new, integrated ways of working.

Figure 1 shows the relationship between GP practices, PCNs, and ICSs in the new NHS model.

New NHS model Figure 1

Figure 1: The new NHS model

ICS=integrated care system; PCN=primary care network

Contains public sector information licensed under the Open Government Licence v3.0.

Place-based partnerships

The King’s Fund uses the word ‘place’ to refer to the geographical level below an integrated care system (ICS) at which most of the work to join up budgets, planning, and service delivery for routine health and care services (particularly community services) occurs.6 These are often coterminous with local authority boundaries. In Developing place-based partnerships: the foundation of effective integrated care systems, The King’s Fund states that place-based partnerships can contribute to the improvement of population health and wellbeing and the reduction of health inequalities by developing a shared local vision, forming local community relationships and building on existing services, and investing in multi-agency partnerships, including with the voluntary sector.6 In this place-based approach, ICSs will work closely with Health and Wellbeing Boards (which operate at the place level) to achieve joint health and wellbeing strategies, as specified by the White Paper Integration and innovation: working together to improve health and social care for all.6,7

The GP practices that have formed the approximately 1250 PCNs will be the foundations of ‘place-based care’—consequently, for most people, their day-to-day care will be met locally in the place they live. The offer to the local population will feature:

  • a strong preventative focus, with advice on staying well
  • access to joined-up care and treatment
  • proactive support to those at higher risk of deterioration
  • management by a skilled, multiprofessional workforce alongside traditional GPs.

The new service specifications will incentivise the delivery of new care models to support local populations.

Delivering integrated care

PCNs will play an important role in the development and delivery of place-based strategies within each ICS. In line with the ambition of the NHS Long Term Plan that all parts of the country would be served by an ICS by April 2021, 42 ICSs have been created from the existing network of sustainability and transformation partnerships.2,8 Subject to Parliamentary decision, ICSs are likely to become statutory bodies from April 2022, bringing together commissioners and providers of NHS services with local authorities and other partners to plan and manage services at a greater scale than can be managed at place and with the principle of subsidiarity.5,6,9 CCGs will cease to exist, but there will be a strategic commissioning function within each ICS; budgets for primary care—which are currently held by CCGs—will be moved into one pot administrated by the ICS, and all core functions of the CCG will become core ICS business.5 It is also anticipated that pharmacy, dentistry, and optometry will become part of the ICS,5 which represents a huge opportunity to further strengthen the role of primary care within the system.

A population health-based approach

Ensuring a single, system-wide approach, each ICS must assess the health needs of the population it serves, plan and prioritise how to address them, and tackle any inequalities that exist.5 To achieve this, data and predictive analysis will be employed to shape services.5 PCNs will play a significant part in this approach—general practice is well placed to influence prevention and health promotion, and understands where health inequalities lie—and, therefore, PCNs must have a voice within the ICS to influence change.

The COVID-19 pandemic has shone a light on the importance of good health; post-COVID-19, general practice must place increased emphasis on prevention, whether by immunisation and screening, weight reduction, smoking cessation, promoting exercise, or improving diabetic and hypertensive control, to name but a few approaches. As general practice returns to delivering its core contract, each ICS will have the opportunity to invest in PCNs to improve local health outcomes6 —for example, in integrated frailty, nursing, mental health, and urgent care teams. All of these areas require a new relationship between primary care and community and mental health services,6 but ICS commissioning here will contribute to the delivery of the NHS Long Term Plan ambition to boost out-of-hospital care,2 protecting acute hospital flows for those most at need. Admission prevention and enhanced discharge need a multidisciplinary approach to planning and targeting care; however, in association with social care and with planned, long-term investment in community and primary care, they can achieve truly integrated care and, in turn, better outcomes for patients (see Figure 2).

New NHS structures - Figure 2

Figure 2: How ICSs can use data to shape post-COVID-19 recovery

MDT=multidisciplinary team

© Dr Karen Kirkham

New models of care

All systems are likely to develop new local care pathways that join primary, community, and secondary care more closely and allow for the development of best-practice care models for a variety of conditions. Working with local communities and local authorities, and the forging of closer links with the local voluntary care sector, will allow networks to deliver care with increased non-medical support to patients, focused around the needs of local communities.

Medicines management and optimisation committees have a clear role within the developing ICS architecture,3 supporting pathway work and connecting regions as regional clinical networks develop. Pharmacists must be part of discussions locally,3,5 and ICS-integrated pharmacy leads will play a critical leadership role within each system. Data will show where efforts must be focused to drive the insights needed to develop new local care models.5 Just as pharmacists are becoming integral to PCNs, pharmacy leads will have the opportunity to improve prescribing and medicines optimisation, reduce variation, and be part of wider clinical team development within ICSs.10 They are well placed to take on clear leadership roles within PCNs and, in particular, shape the delivery of routine long-term condition management.

Prescribing and guidelines

The new model for the NHS creates the right environment for the integration of pharmacy—including community pharmacy—within systems, allowing ongoing development of local formularies and guidelines for use in each ICS, and influencing prescribing to optimise medicines, reduce antimicrobial resistance, promote safe use of medicines by patients, decrease or stop ineffective medicines, and increase appropriate use of biological and generic medicines. Local data will be critical to driving change and optimising health outcomes; however, we have already seen the importance of having pharmacists within our teams during the pandemic—particularly for the delivery of the vaccination programme, to which they have been integral.

Clinical areas of focus

As we enter a period of recovery, general practice needs to refocus on the basics: screening, immunisation (including the COVID-19 vaccination programme), reviews for long-term conditions, medicines optimisation work,6 and meeting the requirements of the Quality and Outcomes Framework.11 Cardiovascular disease prevention—through identification and optimisation of the treatment of hypertension, atrial fibrillation, and hypercholesterolaemia—is going to be a key priority for primary care in late 2021.12 We should be thinking now about how to optimise care using a ‘Making every contact count’ approach.13 Mental health conditions across the age spectrum will also be a key focus, as will focusing on earlier cancer diagnosis. The vaccination programmes for COVID-19, and an extended influenza vaccination programme this autumn, will be additional requests for us in the primary care setting, and we should use the experience of working together to deliver the hugely successful COVID-19 vaccination programme as a basis for future delivery models at scale.

Clinical leadership

Now is the time for primary care leadership to ensure its representation at all levels of the ICS. Clinical directors (whether doctors, nurses, pharmacists, or allied health professionals) have rapidly grown in stature and maturity throughout the past year, and have shown themselves to be true system thinkers, leading their PCNs and influencing their local systems. Primary care, in its widest sense, must be represented at all levels—at place, ICS, and region. This will provide primary care with a degree of influence within the NHS not seen to date.

Looking ahead

There is still much to be worked though if these proposals are to become law within the year. Systems are working at pace to establish themselves, and there are significant opportunities for primary care to shape local systems and place-based partnerships and to establish itself as the driver for improved care in local communities. Better use of data and analytics, and a population health management approach, will facilitate the creation of new care models.

There will be obstacles along the way; we will need to take a broad view over entire systems, to address variation in care that arises, and to create the right conditions and trusted relationships to flex and adapt to local decision making. This could generate challenges around the allocation of resources. We must move to focus on outcomes, and this will bring opportunities for the redesign of pathways and fresh accountability for delivery. The legislation must not stifle innovation.

The pandemic has left a legacy of an enormous backlog of work. Inclusive recovery means addressing not just elective waiting lists, but also prevention in primary care. There are significant residual risks remaining across the workforce—numbers, workload, burnout and stress adding to potential delays in delivery of the ambitions of the NHS Long Term Plan —and we will need to support the profession through the next difficult years, aligning key priorities with incentives. Much will become clearer in the next few months, as we see the development of the form and functions of the ICS.

Summary

Despite the inevitable churn within systems that will occur as a result of yet another major reorganisation, we must hold our nerve through this important period in NHS history. These changes will be pivotal for the next generation of primary care—with the potential to shape strong and sustainable out-of-hospital, integrated community and primary care. General practice has always been agile and responsive, and has the opportunity to emerge as a strong and resilient partner within local systems. The conditions are now right for primary care to ensure it cements its rightful place as the bedrock upon which ICSs will be built.

Key points

  • Subject to Parliamentary decision, ICSs will become statutory bodies by 2022—primary care is a foundational building block within these systems
  • Place-based partnerships will become increasingly important as ICSs mature
  • PCNs will play a pivotal role in the provision of local services, and have an opportunity to shape the way place-based care is delivered
  • Prevention of ill health, and health promotion, will be at the core of PCN services
  • Uptake of population health management—using data to drive insights and reduce health inequalities—will be a key change to the way we work
  • Local health and care services will need to work more closely and interconnectedly than they have previously to design and deliver care for their communities
  • Clinical and professional leadership will have a prominent role in ICSs.

ICS=integrated care system; PCN=primary care network

Dr Karen Kirkham

Senior Medical Advisor, Systems Development and Population Health Management, NHS England and NHS Improvement; Clinical Lead, Dorset ICS

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Be aware of the potential for change in local healthcare systems resulting from this new legislation
  • Be realistic about what is planned and what is possible as a result of the impact and legacy of the COVID-19 pandemic and workforce challenges
  • Understand that, although PCNs are seen as a vital part of place-based systems, they are voluntary for GPs and an extension to the GP contractual framework, and are not yet statutory bodies
  • Investigate the potential risks and benefits of pooling budgets locally; history suggests that this drives expenditure towards specialist care and away from primary care and public health budgets
  • Check the health of GP practices and PCNs before expecting them to take a larger role in a coordinated healthcare system—many of them are struggling to cope with their current workload, and carry many vacancies in key clinical and management staff.

STP=sustainability and transformation partnership; ICS=integrated care system; PCN=primary care network

Practical implications for primary care

written by Johnny Skillicorn-Aston, Communications and Engagement Consultant, Conclusio Ltd

  • PCNs are pivotal stakeholders in our health and care systems, a prime agent within primary care reconfiguration and transformation, and cover a key clinical geography in which to drive improved patient outcomes and experience as changes in the NHS unfold
  • As average GP appointment waiting times grow and workforce and workload pressures increase, PCNs are in an ideal position to lead a change of direction in primary care, bringing together existing assets to develop healthcare at a place-based level
  • Digital health approaches offer some important opportunities for triage and consultation; however, as we recover and restore positions held prior to COVID-19, there will be a degree of expectation among patients that ‘normal service’ will be resumed. Not every patient will be suitable for, or welcome, a digital clinical interface—complexity will be a rate-limiting factor
  • PCNs have the opportunity to coordinate care for patients with one or more long-term condition or polypharmacy needs within a multidisciplinary framework that operates as a collaborative clinical cascade. Resource in community provider groups and community pharmacy can be used effectively to extend the points of access to care in primary care—maximising the input of community pharmacy can provide more support for clinical services
  • Driving forward a new primary care and population-based health model requires PCNs to consider non-medical aspects of care. Both health and social aspects must be included in the ongoing development approach, with social prescribing adding its own value in terms of promoting wellbeing and managing avoidable medicalisation.

Conclusio Ltd is a transformation consultancy that adds value to organisations working across the entire health and social care supply chain.

PCN=primary care network

References

  1. British Medical Association, NHS England. Investment and evolution: a five-year framework for GP contract reform to implement the NHS Long Term Plan. London: BMA and NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf
  2. NHS England website. Online version of the NHS Long Term Plan. www.longtermplan.nhs.uk/online-version/ (accessed 3 June 2021).
  3. NHS England and NHS Improvement. Network contract directed enhanced service (DES) contract specification 2020/21—PCN entitlements and requirements. London: NHSE&I, 2020. Available at: www.england.nhs.uk/publication/des-contract-specification-2020-21-pcn-entitlements-and-requirements/
  4. British Medical Association website. Primary care networks (PCNs). www.bma.org.uk/advice-and-support/gp-practices/primary-care-networks/primary-care-networks-pcns (accessed 3 June 2021).
  5. NHS England and NHS Improvement. Integrating care—next steps to building strong and effective integrated care systems across England. London: NHSE&I, 2020. Available at: www.england.nhs.uk/publication/integrating-care-next-steps-to-building-strong-and-effective-integrated-care-systems-across-england/
  6. The King’s Fund. Developing place-based partnerships: the foundation of effective integrated care systems. London: The King’s Fund, 2021. Available at: www.kingsfund.org.uk/publications/place-based-partnerships-integrated-care-systems
  7. Department of Health and Social Care. Integration and innovation: working together to improve health and social care for all. London: DHSC, 2021. www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all
  8. NHS England website. NHS achieves key Long Term Plan commitment to roll out integrated care systems across England. www.england.nhs.uk/2021/03/nhs-achieves-key-long-term-plan-commitment-to-roll-out-integrated-care-systems-across-england/ (accessed 3 June 2021).
  9. NHS England and NHS Improvement. Legislating for integrated care systems: five recommendations to Government and Parliament. London: NHSE&I, 2021. Available at: www.england.nhs.uk/publication/legislating-for-integrated-care-systems-five-recommendations-to-government-and-parliament/
  10. NHS England and NHS Improvement. Integrating NHS pharmacy and medicines optimisation into sustainability & transformation partnerships and integrated care systems. London: NHSE&I, 2018. Available at: www.england.nhs.uk/wp-content/uploads/2018/08/ipmo-programme-briefing.pdf
  11. NHS England and NHS Improvement. 2020/21 General medical services (GMS) contract quality and outcomes framework (QOF). London: NHSE&I, 2020. Available at: www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0713-202021-General-Medical-Services-GMS-contract-Quality-and-Outcomes-Framework-QOF-Guidance.pdf
  12. NHS England. CVDPREVENT. www.england.nhs.uk/ourwork/clinical-policy/cvd/cvdprevent/ (accessed 3 June 2021).
  13. Health Education England. Making every contact count. www.makingeverycontactcount.co.uk (accessed 3 June 2021).