Since July 2019, almost all general practices in England have formed primary care networks (PCNs) under the network contract DES, a key plank of the updated GP contract. Practices have been given new funding, via shared budgets, to employ staff to deliver new services, with the aim of improving patient care.
As of May 2020, there were 1,259 PCNs, serving local populations that range from 20,000 to well above the intended NHS England maximum of 50,000.
Despite the national roll-out of PCNs, the experience of implementation has been far from uniform. In particular, GPs in rural settings have faced unique challenges introducing networks into local health systems. These include the recruitment and retention of additional clinical staff and determining how to make the most of their GPs' skills to care for a geographically dispersed population often residing far from acute hospitals and inpatient mental health services.
In addition, primary care policy is perceived by rural GPs to be largely devised with urban contexts in mind, leading to local frustrations when it is translated to rural areas.
As part of a National Institute of Health Research-funded study of the implementation and early development of networks, we interviewed, surveyed and observed a range of clinical and non-clinical staff, including clinical directors, from four PCNs across England to find out how their network had responded to the challenges of delivering primary care in rural settings.
Challenges for rural areas
Many primary care challenges are intensified in rural settings. For example, recruiting staff as part of a multidisciplinary team approach to patient care can be difficult due to unwillingness on the part of some recruits to travel extensively to see patients.
Others recruited from cities and towns may be unfamiliar with how local health and social inequalities present within rural communities, such as social isolation amongst the elderly. This, coupled with challenges with coordinating different community health services across dispersed rural areas, can make is difficult to monitor, support and treat patients with complex health needs.
Furthermore, there are unavoidable costs of delivering healthcare in rural settings which can prove detrimental to the sustainability of rural general practice. A recent study by National Centre for Rural Health and Care (NCRHC) found that a lack of NHS staff per capita and large geographical spread in rural general practices contribute to these increased costs, as does the urban focus of much primary care policy development.
One size doesn’t fit all
So where are rural PCNs now? Understanding the vulnerability of rural primary care is essential. Stakeholders from our evaluation felt that policy had in some ways failed to capture the scale of the challenge faced by those delivering care in rural areas. They said: 'what doesn’t work is the urban model in the rural location'.
Collaborative working across practices remains a contentious matter for rural general practices. They have fewer options in terms of who to work with and therefore may find it hard to find practices that share common goals (and hence make sense to be PCN partners) when compared with those in urban areas.
Yet, there is a well-established history of smaller rural practices working collaboratively.
Questions remain about whether the network contract DES is fit for purpose in rural communities. A poignant example raised in our evaluation was extended access, where a service had been set up that was rarely accessed by patients due to the extra distance they had to travel and the fact that most patients preferred to speak with GPs with whom they were familiar.
Staff face particular challenges working in rural PCNs. Smaller rural practices often lack the resources to allow staff to set up, operate or engage with the PCN, despite the additional funding brought in via the DES – they simply do not have enough people.
Opportunities to reform rural primary care
The findings from our evaluation also suggest that PCNs in rural areas may comprise a greater number of smaller practices, and arguably be accustomed to being more independent in how they work.
Our rural case studies wished to pursue the PCN policy, but appeared to be finding it more difficult to coalesce as networks and develop a clear rationale and plan for new services. Despite NHS England injecteing new funding to address the challenges of recruitment and collaborative working, the policy has, for now, had less of an impact for rural networks.
As for moving to the longer term, after a sprint to get PCNs operational, commissioners and policymakers must now think how to make networks work for all not just the many.
Dr Manbinder Sidhu is BRACE research fellow at the Health Services Management Centre, University of Birmingham; Sarah Parkinson is an analyst at RAND Europe; Professor Judith Smith is professor of health policy and management and director of the Health Services Management Centre at the University of Birmingham
- Our rapid evaluation on the early evidence of the development of primary care networks is available here