'Primary care networks could actually worsen health inequalities'

Oxford GP Dr Becks Fisher, a senior policy fellow at the Health Foundation, outlines the opportunities and challenges for fledgling PCNs in two articles for GPonline. In this second article she examines the challenges.

Dr Becks Fisher
Dr Becks Fisher

Picking holes in policy is a particularly favoured pastime in policy-wonk land. As I lay out below some of the challenges facing primary care networks (PCNs), I’m hoping that my first article on the opportunities they present acts as a counterweight.

Our recent Health Foundation briefing offers a wider perspective on what we perceive the challenges facing PCNs to be. Chief among them is simply the sheer speed of implementation that is required. PCNs were news to most of us in January but by May we were expected to be signed up to one – having agreed not only whom we would partner with but also how we would start going about it.

Although some areas – those with primary care homes for instance – have been working in networks for a while, for many of us it will be a massive undertaking to get practices to collaborate in a way that will realise the potential of PCNs. Developing relationships and building the trust required to share resources, including staff and funding, takes time – and there’s been precious little of it so far.

Short-term decision making

That lack of time, and the requirement for networks to form at speed, increases the risk of decisions being based on what is possible or easy to do rather than allowing PCNs the time to consider how best to structure themselves to meet the needs of their population, or even meaningfully engage with their population to ask what they think they need.

One of the great hopes of PCNs is that the new allied health workers funded by the directed enhanced service will alleviate some of the pressure on GPs. NHS England has promised more than 20,000 allied health professionals but there’s no publicly available data to allow us to check the numbers.

Even on the assumption that they will exist, there’s limited evidence to suggest that expanding the skills mix in primary care will alleviate pressures. GPs will speak to the reality of supply-induced demand, and PCNs might also (inadvertently) reduce GP time available for consulting. If new clinical directors drop clinical sessions to take up PCN posts, consulting time is lost. Likewise supervising and supporting our new co-workers draws on GP time.

And all of this assumes that we have somewhere appropriate for our new colleagues to work from, when 50% of GPs responding to a GPC survey said that their premises don’t meet current needs let alone the needs of an expanded workforce. Funding to fix the premises problem would have to come from a spending review but it has been indefinitely delayed by government, and the recent pattern of decreased capital spend on NHS infrastructure is not a promising sign.

Vicious cycle of under-recruitment

In our recent briefing on PCNs we also raised concerns that they could paradoxically make health inequalities worse. Workforce and funding are among the worries here.

The weighted component of per capita funding for PCNs is based on the Carr-Hill formula which systematically under-funds practices with the most need. And we already know that the workforce crisis in general practice disproportionately affects deprived areas. There is no policy to level the playing field for recruitment to PCNs, so we may see available allied health professionals gravitating towards more affluent areas, inadvertently perpetuating a vicious cycle of under-recruitment to areas with most need.

A final limitation may be self-inflicted. A fledgling PCN ‘maturity matrix’ does exist but I suspect few would be able to articulate a strong vision for what a ‘good PCN’ would look like or what it would feel like to be a patient in a highly functioning network.

PCN leaders have been given a set of tools but a very limited set of instructions for how to make them work effectively, and only a thumbnail sketch of what they are trying to create. In the infancy of PCNs, the biggest challenge may be finding the time, space and imagination to consider the art of the possible, set a vision for what could be achieved and enable those tools to be put to the best possible use.

Dr Becks Fisher is a GP in Oxford, a Senior Policy Fellow at the Health Foundation and one of the authors of the briefing paper: Understanding Primary Care Networks. Follow Dr Fisher on Twitter: @becksfisher

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