Primary care Networks

Background In its 2014 Five Year Forward View, NHS England (now NHS England and Improvement) identified the need for new models of care to improve collaboration across health and social care services. This plan suggested that GP practices work together (and with other primary care providers) in a more systematic, sustained and organised manner. As a result, primary care networks were introduced in 2019 to bring together groups of general practices to hold shared budgets through a collective contract, and develop new and more integrated services. Hence, primary care networks have a formal, incentivised and almost compulsory feel compared to many predecessor schemes of collaborative primary care. There were (in May 2020) 1259 primary care networks in England, serving populations ranging from 20,000 to well above the 50,000 suggested in national guidance. Networks sometimes build on prior GP collaborations such as super-partnerships or federations, which can provide organisational infrastructure and support to newly formed networks. However, some primary care networks also bring together practices that had not worked collaboratively in the past. Objectives The purpose of this evaluation was to produce early evidence of the development and implementation of primary care networks. We sought to answer these research questions (RQs): RQ1: What was the policy context within which primary care networks were introduced? RQ1.1: What were the pre-existing forms of GP collaborative working across primary care in England? RQ 1.2: How have new networks been implemented in a sample of urban and rural settings? RQ 1.3: How do new primary care networks relate to pre-existing GP collaborations? RQ2: What was the rationale and motives for general practices to enter into new primary care networks? RQ3: What evidence exists about the impact of establishing GP collaborations and how does this relate to primary care networks? RQ4: What are the barriers to and facilitators of effective collaboration across GP practices? RQ5: What does this evidence suggest in terms of the likely progress of primary care networks in the NHS in England, including in light of the Covid-19 pandemic? Methods A mixed methods cross-comparative case study evaluation with four case study sites, comprising four work packages (WPs): WP1: Rapid evidence assessment: We conducted a review of published evidence on GP collaborations to inform the design of our evaluation. This included English-language evidence summaries (published from 1998-2012) and primary care research studies and reviews (published from 2013-2018), using key search terms in titles and abstracts in PubMed, Ovid MEDLINE, Web of Science, and Scopus. WP2: Stakeholder workshop: We held a workshop with academics, policy experts and patient and public involvement representatives, to explore findings from the rapid evidence assessment. This enabled us to clarify evidence gaps and develop evaluation questions for WP3. WP3: Comparative case studies of four primary care networks: We undertook multi-faceted sampling to select four rural and urban case study sites. Interviewees (N=25) were purposively sampled and asked about the primary care network, its implementation, facilitators, barriers and early impact. We collected data through: analysis of key documentation; non-participant observations (N=10) of strategic meetings; and an online survey (N=28) of network staff. We used content analysis for documentary reviews and observations, and framework analysis for interview data. The Covid-19 pandemic caused data collection to cease earlier than planned. WP4: Analysis and conclusions: We synthesised our findings to develop suggested lessons for commissioners, providers and policy makers about the future development of primary care networks. Results The rapid evidence assessment identified important lessons for primary care networks, including the time required for networks to become properly established, and the level of high-quality management and leadership capacity required for success. The review also revealed the wide range of formal and informal collaborations across English primary care, and their importance as context for the implementation of primary care networks. Key themes from our data analysis were: Purpose of primary care networks Leaders of primary care networks support the overarching policy aims, and general practices across England have seized the opportunity to access new funding to form networks. Although keen to improve service integration, primary care networks often prioritise the sustainability of general practice, addressing workload pressures, and improving the availability of local primary care services. Primary care networks are expected to meet local population health needs, whilst meeting nationally-specified requirements to employ certain professionals and introduce defined services, which was a source of tension for the primary care networks in our evaluation. Prior GP collaborations In all four case studies, the new primary care network was established in the context of a prior GP collaboration. These helped the networks build on previous successes such as strong relationships between practices and integrated service delivery. Prior collaborations often provided the new network with additional operational and management support. There were also some tensions where the new network was perceived as un-doing the work of the previous collaboration, where aims of the two organisations did not align, or where practices from two previous collaborations joined a single network. Engagement in primary care networks This evaluation revealed a tension between the desire for local autonomy within primary care networks, and the top-down nature of national PCN policy. This led to some differences between local and national priorities, and struggles with local clinical commissioning groups. Networks were therefore aware of the need to take time to clarify roles of primary care networks within the local health system, and develop shared goals and objectives within the network itself. Time and resource for organisational development were important for this process, including through staff away days, and joint training events across the primary care network. Leadership and management The need for effective leadership and management support for primary care networks was a strong theme in the evaluation, particularly the capacity required for implementing and managing networks (e.g. for meetings, recruitment of staff, implementing new services). Time pressures for those leading network development was reported as an acute concern, especially for clinical directors and practice managers. The range of leadership and management expertise on the part of network clinical directors raised a concern about the sustainability of these roles longer term. Funding and incentives A consistent message was that primary care networks had been established in a near universal manner due to NHS England and Improvement using them as the mechanism to offer significant funding to general practices. For some respondents, the experience of setting up the primary care network, establishing cross-practice working, and having to use new resources largely to deliver services required by NHS England and Improvement, had led to frustration and even talk of leaving the network. This was based on an assessment of the work entailed in running a primary care network and its shared services, and the burden experienced by practices 'losing' GP and management time to support the new organisation. Relationship with the wider NHS system The relationship between clinical commissioning groups and primary care networks varied - some clinical commissioning groups had supported networks development, providing resource and expertise to help establish inter-practice working, hire new staff, and operate contracts. Others had attempted to hold onto control delegated to primary care networks, closely monitoring budgets and spending decisions, and not operating within the spirit of national PCN policy. This evaluation took place during the first nine months of operation of primary care networks when they in their formative phase, learning how to work as a collective of practices, and forming relationships with their clinical commissioning group(s), local NHS trusts, and other partners. The experience of rural primary care networks We sought to study the experience of rural as well as urban primary care networks. Two of our case studies were in rural areas while another was semi-rural. Some of those in more rural areas felt that national PCN policy had been developed more with urban networks in mind, not accounting adequately for the experience of providing primary care in rural areas. A key aspect cited was that rural primary care has well-established ways of collaborating to meet local service needs, and patient populations who may be unwilling or unable to travel further to access new shared services. Conclusion We propose the following implications for local and national decision makers: 1) increasing engagement of GP practices and wider primary care teams with primary care networks; 2) building further leadership and management capacity; and 3) clarifying how primary care networks fit into the wider health and social care system, especially in the context of the Covid-19 pandemic and its aftermath. In further research, a mix of quantitative and qualitative measures will be needed to understand how networks contribute to improved sustainability, efficiency and integration in and beyond primary care. Studies will need to answer the question: do general practices need to collaborate to achieve these outcomes and if so, what policy, support and investment are required?