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Editorials

Primary care networks: well intentioned but overambitious

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5311 (Published 05 September 2019) Cite this as: BMJ 2019;366:l5311
  1. Tim Wilson, honorary clinical fellow1,
  2. Richard Lewis, visiting senior fellow2
  1. 1Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
  2. 2Nuffield Trust, London, UK
  1. Correspondence to: T Wilson tim.wilson{at}phc.ox.ac.uk

Delivery will take years and substantially more investment

A lot of confidence is being placed in primary care networks to deliver substantial positive change within the NHS in England.1 Indeed, NHS England has outlined ambitious plans for these networks.2 They are expected to stabilise the general practice partnership model, solve the primary care workforce crisis by recruiting 20 000 non-medical staff, dissolve the divide between primary and community care, implement new service specifications for priority clinical areas, demonstrate improved patient care, and become a “proven” platform for local NHS investment.

Primary care networks are groups of general practices collaborating with other community providers to serve populations of 30 000 to 50 000, providing an expanded range of community based services and reducing reliance on hospital care.3 Most (£1.8bn; €2bn; $2.2bn) of the £2.8bn of extra funding for general practice in England over the next five years is being distributed through primary care networks. So it is hardly surprising that 99.7% of English practices have already signed up to network agreements and that 1259 primary care networks were expected to go live on 1 July 2019.2

The context in which these networks are being established is challenging. The share of the total NHS budget dedicated to general practice fell from 9.1% in 2005-06 to 8.1% in 2017-18, while costs associated with running general practices have risen, resulting in a drop in real terms income for general practitioners.4 Workload has also increased. Face-to-face consultations increased by 12.4% and telephone consultations by 99.6% between 2007 and 2014.5 Laboratory and other testing increased 3.5-fold between 2000 and 2015.56

Great expectations

The new investment in and attention on primary care, and general practice in particular, is welcome. And the ambitions for primary care networks all seem laudable. Why be concerned? Firstly, the sheer number of complex tasks laid at their door is immense. The pressure from, and on, NHS England to justify this investment in general practice is high; hence its expressed desire to show results within five years.2

Secondly, evidence going back decades shows that extended primary care teams have a positive effect on patient health, including those living in deprived neighbourhoods.78 But this pioneering work, along with more recent case studies,2 emphasises the extra time and effort required to incorporate new staff into effective teams.

Thirdly, the evidence for many of the developments expected of primary care networks is mixed. “Anticipatory care,” one of the new national service specifications,9 sounds good, but what it might look like in practice is unclear. Furthermore, attempts to introduce such care have failed to deliver expected reductions in emergency hospital care.10 For other proposals, such as screening for atrial fibrillation and other cardiac conditions, the evidence does not support their introduction.11

Finally, networks are being asked to perform these tasks while engaging with wider reforms such as the creation of integrated care systems. Exactly what is expected of integrated care systems is evolving, although primary care networks are considered a key component.

Can it work?

Given these concerns, how can we ensure that primary care networks fulfil their potential? Primary care networks need much clearer priorities as well as the time to achieve them. Although NHS England has introduced some phasing into its expectations, the task still feels overwhelming.

In addition, overly precise financial incentives and contractual requirements should be used with great care. Reliance on specific incentives often means you get only what you pay for (and sometimes less of the items not incentivised). Given the uncertainty surrounding some of the changes being proposed, relying on contract specifications is risky.12

There is rich learning to be had from both successful and unsuccessful implementation of complex tasks. So now is a good time to develop and deploy programmes that encourage sharing of experiences and evaluations. Investment in learning, time, and resources should reflect the scale of the changes proposed and the large number of primary care networks planned. This should be the focus for the development resources promised by NHS England.

These reforms are well intentioned but hugely ambitious. They were informed by case studies that were built on years of relationship building, trust, and determined leadership by innovators.13 One of the most important enablers of change will be patience.

Acknowledgments

We thank Perihan Colyer for her comments on various versions of this article.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: TW is managing director of the Oxford Centre for Triple Value Healthcare, a social enterprise that receives fees for capacity and capability building in health systems that want to deliver value based healthcare. RL is the director of RQL Consulting and receives fees from health industry clients for advice. RL is also a member of the National Association of Primary Care’s Primary Care Home Faculty, which offers development support to primary care organisations.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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