Primary care networks: well intentioned but overambitiousBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5311 (Published 05 September 2019) Cite this as: BMJ 2019;366:l5311
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Primary care networks: The risk of ‘mission creep’ and the need for focused ambition in the early years
Findings from our research align with Wilson and Lewis' recent Editorial (1) and previous commentaries (2) in which well intentioned, but potentially overambitious, hopes for Primary Care Networks (PCNs) are highlighted.
We examined evidence on the development and impact of a breadth of large-scale inter-organisational healthcare collaborations from the UK and internationally to find what lessons these could provide for organisations such as PCNs (3). We found that while positive impact seems plausible as a result of becoming a network or increasing organisational size, it is not a given. Unintended consequences frequently emerge. Clinical outcomes or patient experience do not necessarily improve and may in fact worsen. Rather than producing economies of scale, dis-economies of scale can emerge. Evidence also suggests that it can take decades for large-scale inter-organisational collaborations to mature and function effectively across a range of aspects of care. Collaborations labelled as ‘successful’, were often so because they had had very focused and measurable goals (e.g. improving diabetic care or childhood vaccine uptake), as well as an array of support to achieve their goals (e.g. timely data, good IT dashboards, dedicated managers, financial incentives and academic input) (4).
Delivering the PCN Directed Enhanced Service (DES) will involve PCNs building working relationships with the wider health system, including, sustainability and transformation partnerships, clinical commissioning groups, GP federations, training hubs, local authorities, community providers, social care providers, patient groups and the third sector. Building these relationships is important. However, ‘mission creep’ by PCNs themselves and importantly by other stakeholders seeing PCNs as the vehicle to solving complex health system problems in their early years risk overwhelming, and likely disengaging PCNs.
With this in mind, PCNs should be ambitious. However, their ambitions need to stay focused. In the first instance the focus should be on the PCN DES specifications and local priorities, as defined by the PCNs themselves. Of course, some PCNs will excel and exceed expectations. These will do the rounds at national conferences as the ‘poster-boys’ of success. However, most PCNs will quietly plough-on doing their best to make the most of the new funding stream, with general practices learning to work with one another and integrate a new multi-disciplinary workforce. Most of these PCNs will need breathing space and in all likelihood will need longer than the current five-year timeline provided by the DES to deliver on, at least some of, the wider ambitions.
1. Wilson and Lewis. Primary care networks: well intentioned but overambitious. BMJ 2019;366:l5311 doi: 10.1136/bmj.l5311 (Published 5 September 2019)
2. Kumpunen and Baird. Caution needed over ambitions for new primary care networks. TheBMJOpinion. Jan 2019
3. Pettigrew LM, Kumpunen S, Rosen R, Posaner R, Mays N. Lessons for ‘large-scale’ general practice provider organisations in England from other inter-organisational healthcare collaborations. Health Policy. 2019; 123(1): 51–61.
4. Pettigrew LM, Kumpunen S, Mays N, Rosen R, Posaner R. The impact of new forms of large-scale general practice provider collaborations on England’s NHS: A systematic review. British Journal of General Practice. 2018; 68(668): e168–e77
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or Department of Health
Competing interests: No competing interests