It is easy to get lost right now in the immediate challenge of identifying practices to be in a network with, persuading someone to be the ‘accountable clinical director’, and deciding who should hold the network bank account.  But to get these short term decisions right it is worth spending some time reflecting on exactly what primary care networks are supposed to do.

This starts with their place in the wider system.  The new GP contract says, “The Primary Care Network is the natural unit for integrating most NHS care. Collective general practice can become the footprint on which other NHS community-based services can then dock. And by serving a defined place, the Primary Care Network brings a clear geographical locus for improving health and wellbeing.” (p25)

How networks will start to enact this bold claim is also spelled out in the new contract.  There are seven services networks are to provide against national specifications.  After the set-up year of 2019/20, there are two initial services to be delivered in full in 2020/21.  Networks are to provide structured medication reviews to patients, focusing on particular priority groups.  The pharmacists employed during 2019/20 will be key to the delivery of this service.

They are also to provide a new enhanced service for care homes.  This might be the first new service requiring networks to agree differential delivery across practices, e.g. a lead practice for one or even all of the care homes.  A condition of signing up the network agreement is that services will be provided equally across the network population, and it is becoming immediately apparent networks won’t work via a simple equal division of labour across member practices.

Worth a further pause at this point.  Many CCGs up and down the country have commissioned these types of schemes locally.  It would seem the use of the national GP contract, and its new network function, will lead to the replacement of many locally commissioned schemes with nationally commissioned ones.  We should watch out for how much opportunity the imminent Network Contract DES indicates there will be for local flexibility.

There are three further services that are to “commence in 2020/21 and develop over the subsequent years”.  This is where general practice is taken into slightly less well chartered territory.  While the first service, anticipatory care, is fairly common across the country (although under different names such as “proactive care”) and the idea of identifying and proactively managing the needs of high risk patients is nothing new, what is new is that this service will require a “fully integrated primary and community health team”.   Community providers will even be asked from July to configure their community teams on primary care network footprints.  The relationship (and power dynamic) between the primary care network and the newly configured community team will be critical to future success.

Which takes us back to the wider purpose.  The network is very much about enabling the integration of primary care with other parts of the NHS system.  “A Primary Care Network cannot exist without its constituent practices, but its membership and purpose goes much wider. The NHS Long Term Plan sets out a clear ambition to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. The Primary Care Network is a foundation of all Integrated Care Systems; and every Integrated Care System will have a critical role in ensuring that PCNs work in an integrated way with other community staff such as community nurses, community geriatricians, dementia workers, and podiatrists/chiropodists.” (New GP contract, p30-31).

The next service is “personalised care”.  Easy to say, hard to understand exactly what it is.  I have read the relevant parts of the new contract a number of times and I still find it hard to pin down.  It seems this is essentially about widening the support provided to individuals beyond purely medical interventions.  Social prescribing and the newly funded link workers will play a prominent role in the delivery of this service.  However it plays out, it is another step in widening the scope and role of general practice through networks in influencing the overall health of local populations.

The last service to be introduced in 2020/21 is supporting early cancer diagnosis.  What is most interesting about this service will be the role of networks in raising awareness of symptoms and uptake of screening in their local neighbourhoods.  Networks may provide a way of practices operating more freely outside of their practices with local community partners.

Finally, in 2021/22 two more services will be introduced.  Cardiovascular disease prevention and diagnosis and, more nebulously, tackling inequalities.  Whilst the former is relatively clear, the latter much less so.  The text in the contract is along the lines of “we will test some ideas and then roll out the approaches that have the greatest impact at the network level”.

Alongside these seven new services from 2020 there will be a new national “Impact and Investment fund”.  Based on a principle of “shared savings” it means networks can gain a financial return from reductions in A&E attendances, emergency admissions, outpatient costs, prescribing savings, and hospital discharge (I assume via reduced length of stay), to then invest in new staff for the network.

It seems, then, the real work begins for networks in 2020 with the introduction of these specifications.  The immediate challenge then should not be simply to tick the relevant boxes that will be sent out by the centre, but rather to use 2019/20 to develop a platform that will be able to deliver against these future requirements, or even better one that can make a real difference to the health and wellbeing of the population it will be serving.

The clock is already ticking. Following the recent publication of the new GP contract, GP practices only have until the 15th May to submit their network registration information to their CCG. Waiting until the Network Contract DES is published (promised by 29th March) will only leave 6 weeks. Starting now gives practices three months to get ready for the new networks.
But where to start? It is tempting to jump straight in to what the network will look like and how it will operate. But a better place to start is with “why?” Why will this network exist? What is its purpose? What difference is it going to make?

Simon Sinek talks about this lot. His book, “Start with Why”, has inspired many. For the time poor, you might want to cut straight to this 5 minute short version Ted talk to understand the essence of it. Essentially, people are inspired by a sense of purpose. It is this that motivates us to take action. Clarity on why we do things leads to much more sustained action than clarity on what we are to do or how we are to do it.

The GP contract offers a number of possible motivations for primary care networks. They are (p25):

• “Intended to dissolve the historic divide between primary and community services”
• “A way of helping GP partnerships survive and evolve over the coming decade, and provide a means of mutual support for better workload management”
• “A dedicated joint investment and delivery vehicle”, a way of enabling investment into primary care where it cannot reasonably be expected for every practice to deliver the requirements on their own”
• “Large enough to run a full multi-disciplinary team”, a way of bringing new roles into general practice”
• “A clear geographical locus for improving health and wellbeing”
• “To provide strategic and clinical leadership to help support change across primary and community health services”

Each area is different. One, some or all of these may work for you. More likely there will need to be some adaptation, some local tailoring, to create an ambition that is inspiring for your GPs and the practice staff in your network.

It will be easy to get lost in creating a network simply because you have to. Or in tactics to try and maximise income received. Or in the details of how the network will operate. But networks present a huge opportunity for general practice, not just for now but for many years to come. Decisions made in the next 3 months are like to have long lasting consequences because these networks will grow in importance.

Even though time is short, time invested now in determining the why of their network for member practices will be time well spent. It will create unity, excitement even, and a shared sense of purpose. It will make delivery down the line much easier, and sustain action well beyond the initial network submission deadlines.

On the surface the new GP contract and the GP Forward View (GPFV) appear very similar.  Both contain promises of money and staffing, as well as a determination to create a sustainable future for general practice.  But nearly three years on from the publication of the GPFV, things don’t feel much better.  Workforce, finance, workload and morale all remain challenges for general practice.  Will it be any different this time round?  We’ve been examining the differences between the two documents, and have identified 5 that give cause for optimism.

1. Type of document

While both are written documents, there is a big difference between the GPFV and the new GP contract.  The GPFV was essentially a commissioning plan – it was how NHS England, as the commissioner of general practice, was going to improve it.  It was full of aspiration, but lacking in detail of how it was going to be delivered, a concern that ultimately proved well-founded.  The new GP contract, however, is just that – a contract – and as such is clearer and more transparent, making the promises feel much more concrete than in the GPFV.

2. Money

On the surface the promise of money is similar.  In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years.  The problem the GPFV ran into was transparency in relation to the money.  The RCGP and others set up tracking mechanisms to try and check the promises made were being adhered to.  In the end, because the £2.4bn was actually to be delivered over 8 years (a retrospective starting point of 2013 was used), and because a huge chunk of it went on access and so not to core general practice, it never made the difference it should have.  The new contract is different.  Yes £1.8bn of the £2.8bn comes via the new networks, but it is still coming to practices, and how the money will be delivered is clearly laid out.

3. Implementation

Money in the GPFV came via NHS England to CCGs, sometimes to federations, and eventually to practices.  Multiple pots all had their own application processes.  The money proved difficult to access and was beset by bureaucracy.  This time the money will come via the contract, either directly to the practice or directly to the network set up by the practice.  It feels like control of the funding will sit at practice level and then work up, rather than (as with the GPFV) start at the top and slowly trickle down.

4. Policy Objective

Politicians and commissioners always want a return for their money.  In the GPFV the primary policy objective was extended access (‘we will invest this money in general practice if you deliver 8-8 working 7 days a week’).  The introduction of access stretched the already-thin workforce even further, diverted portfolio and part-time GPs away from core practice, as well as moved funding thought to be for core general practice into private providers.  In the new contract the primary policy objective is the introduction of primary care networks.  These networks are to enable general practice to integrate more effectively with the rest of the system, and allow a more robust system of out-of-hospital care to be created.  The great news for general practice is that, done well, these networks can support and enhance the delivery of core general practice.  This alignment of the needs of general practice with overall policy provides maybe the greatest hope for the new contract.

5. Workforce

One of the biggest failings of the GPFV has been its inability to successfully tackle the workforce crisis in general practice.  The service is still waiting for 5,000 of the promised 5,000 additional GPs.  The new contract, however, takes a more realistic approach.  The focus on new GPs isn’t lost, but is enhanced by a much more pragmatic (although still challenging) plan to recruit 20,000 additional non-GP non-nurse clinical staff, with the funding being directly provided to the practices via networks.  This realistic plan for staffing creates a strong foundation for optimism.