The concept of “primary care networks” is one of the most confusing I have come across in recent times. This is saying something given the plethora of new acronyms and ideas that have sprung to prominence in the last few years (think STP, PACS, MCP, PCH etc). Here I try and unpick what they actually are.

Primary care networks have something of a mysterious past. They first appeared in NHS England’s update last year on the Five Year Forward View, where they claimed they would,

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care networks or hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access. They also involve working more closely with community pharmacists, to make fuller use of the contribution they make. This can be as relevant for practices in rural areas as in towns or cities, since the model does not require practice mergers or closures and does not necessarily depend on physical co-location of services. There are various routes to achieving this that are now in hand covering a majority of practices across England, including federations, ‘super-surgeries’, primary care homes, and ‘multispecialty community providers’. Most local Sustainability and Transformation Plans are intending to accelerate this move, so as to enable more proactive or ‘extensivist’ primary care. Nationally we will also use funding incentives – including for extra staff and premises investments – to support this process.”

I remember reading this last year and thinking that it looked anomalous, out of kilter with the prevailing rhetoric of supporting GPs to manage their way out of the current crisis with the promise of extra resources and extra staff. They had not featured in the GP Forward View, where you would expect such a dramatic change for general practice to take centre stage, or even before that in the Five Year Forward View.

Maybe there had been a mistake, some sort of internal breakdown in communications within the towers of NHS England. But no, in an article in GP Online from March last year, NHS England’s Director of Primary Care Dr Arvind Madan said of these networks,

“This now becomes the new delivery scaffolding across the system. And it may be how they organise themselves in terms of access, and population and place-based care, and how they will be meaningful neighbourhoods for services to patients in terms of the offer they get too.”

But then all went quiet again on the primary care networks front. Despite the boldness of the earlier claims, nothing was seemingly happening to make these stated ambitions a reality. Efforts focussed on supporting practices through clinical pharmacists, resilience support and the like.   Until, that is, the recent planning guidance was published, which mentioned “incipient primary care networks” (like they are even a thing) and CCGs were told to “actively encourage every practice to be part of a local primary care network”.

What should we make of this? What is a primary care network? I can imagine CCG leads reading the words in the planning guidance and scratching their heads at what exactly it is they are being asked to do.

The use of “primary care network” seems to have appeared because learning from the vanguards demonstrated that for accountable/integrated care systems to work, they require general practice to be joined together into populations of 30-50,000, as the building blocks of the new system. This joining together of practices, how it happened and what it looks like is very different within each of the vanguards, although was consistently borne out of a huge investment of time, relationships and effort into building and developing trust. The term on its own, however, merely describes the end-state.

It also appears to be a term used to retrospectively fit the move in general practice towards operating at a greater scale into a policy direction. According to NHS England the “routes” to primary care networks include “federations, super-surgeries, primary care homes, and multispecialty community providers”. All very different things. Yes, they all involve previously separate GP practices working together, but they cover a very broad spectrum of what that means in practice. The term primary care network is seemingly used as a generic descriptor of where different areas who have embarked upon a journey of practices working together have arrived.

Herein lies the complexity. A primary care network is not an actual thing that can be defined or described in any detail. This is because the journey for each group of practices that chooses to work together is different and will lead to a wide range of different destinations. For some it will end up in super-practices, for others a federation, for others a primary care home, and for others something totally different. Most confusingly, very few (if any) will end up at a place that is called a “primary care network”.

So let’s not add “primary care network” to the already full lexicon of NHS terminology. Joint work across GP practices is a journey not a destination, and use of the term primary care network pulls focus unhelpfully away from the journey and onto the destination. Let’s hope CCGs do not take their new commands to heart, and that a new industry doesn’t arise in trying to create something that we can’t define.

I have always wondered who actually reads NHS planning guidance. It contains really important information, but it is always so dry and impenetrable (deliberately?) that most will rely on “bluffers” briefings from others. So here is my “bluffers” briefing for you (although it is here in full for the brave hearted). There are three key messages for general practice:

1.The Obsession with GP Access Continues

Buoyed by the apparent success of introducing extended access across groups of practices at evenings and weekends, the timetable for 100% coverage across the country has been moved up by 6 months to 1^st October this year. How much of the heralded 52% of the country that is already covered have permanent (as opposed to pilot) arrangements in place is not known, so expect a plethora of hastily put together procurements to emerge in the coming weeks. These are likely to represent something of a risk to local systems, because if the tenders are not awarded to local practices it will mean a fifth of the GPFV investment going elsewhere (£500m of the promised GPFV £2.4bn is for extended access), and GP engagement in integrated working may suffer as a result.

2.The Rise and Rise of STPs and Integrated Care Systems

And integrated working, as I am sure you already know, is now king. The furore over accountable care systems/organisations has led to a renaming as “Integrated Care Systems”. That should do it. More interesting is some of the insight the narrative provides as to how these will operate in future.

In the short term, the power and influence of STPs will rise. They will have “an increasingly prominent role in planning and managing system wide efforts to improve services”. They are expected to develop their management infrastructure. They will be the conduit for capital allocations.

It doesn’t stop there. Over time “we envisage Integrated Care Systems (ICSs) will replace STPs”. These ICSs will have one plan across all their constituent organisations, rather than there being a collection of individual organisational plans. It will be the role of the ICS to assure and track the progress of its member organisations. If an individual trust or CCG has financial or quality issues “the leadership of the ICS will play a key role in agreeing what remedial action needs to be taken”. This is code for ICSs being able to fire the CEOs of the member organisations, the key determinant of where the power lies.

What role this leaves for CCGs (the guidance also all but outlaws the use of contract penalties) is very difficult to identify. Most likely is an acceleration of the merging of CCG teams and the development of a (heavily reduced) “strategic commissioning” functions coterminous with the STP/ICS area.

The development of ICSs will also impact general practice directly. For an area to become an ICS they need “compelling plans to integrate primary care, mental health, social care and hospital services using population health approaches to redesign care around people at risk of becoming acutely unwell. These models will necessarily require the widespread involvement of primary care, through incipient networks”.

Incipient networks? Anyone? All becomes clearer later on in the guidance as CCGs are directed to “actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000”.

“Geographically contiguous” is new. I know plenty of areas that have encouraged practices to form networks with like-minded practices, regardless of geographical location. They won’t be happy. It is all very reminiscent of CCG-formation days. And what “actively encourage” means is anyone’s guess. Carrot or stick? Time will tell.

3.There is No New Money

Were you expecting any? The message for general practice is essentially investment will continue as outlined in the GP Forward View (and if you missed it, here’s a quick reminder of why the promised £2.4bn is not £2.4bn) – i.e. there is no additional, previously unannounced money. You should still expect the balance of the £3 a head one-off commitment from CCGs between 2017 and 2019, as well as the remaining sustainability and resilience funding to be spent next year (75% by December 2018, and 100% by March 2019).

Financial pressure in the system means “non-elective demand management” is to make up the majority of the CCG Quality Premium scheme. Urgent care will be a focus, but the elective position essentially just must not get any worse. GP referrals are assumed to remain flat (“increase by 0.8% i.e. no change per working day” – whatever that means). And, the guidance confidently states, “there will be no additional winter funding in 2018/19” (there will).

There is a push on CCGs to reduce the routine prescribing of 18 ineffective and low clinical value medicines, and savings against this are “assumed” for CCGs, so expect more pressure here. There is also a national consultation on reducing prescribing “of over-the-counter medicines for 33 minor, short-term health concerns, as well as vitamins and probiotics”.

Finally, there is one other bizarre addition I wanted to point out – a requirement for CCGs to ensure every practice implements at least two of the high impact “time to care” actions. Make of that what you will, but it does seem to highlight the persistent inability of the system to distinguish between top down and bottom up.

There you go – the essentials of the planning guidance in one five-minute chunk – now you can bluff with confidence!