Primary Care Networks, Integrated Care Partnerships and Integrated Care Systems
The architecture of the NHS is fundamentally changing, driven by the integration and efficiency agenda. It is a common belief that the fragmentation of the NHS has not served patient care well and leads to significant delays, transaction costs and inefficiencies. We now have Integrated Care Systems, Integrated Care Partnerships and Primary Care Networks. None of these are legal entities at this moment.
Primary Care Networks (PCNs)
PCNs are groups of General Practices working closely together, with other primary and community care staff and health and care organisations, providing integrated services to their local populations. There are X PCNs across Lancashire and Cumbria, listed here.
There has always been a recognition within primary care of the importance of joined up care, but previous NHS reforms seemed to compromise this principle. More recently a series of academic papers have been coming out from such bodies as the Kings Fund and RCGP advocating a model of integrated neighbourhood provision with a greater emphasis on prevention, holistic care and patient / community empowerment. The Primary Care Home initiative championed by NAPC built on this work.
The NHS Long Term Plan, published in January 2019, picked up this concept and linked it to the growing “multiple challenges – with insufficient staff and capacity to meet rising patient need and complexity.” (para 1.5) The aim was to “finally dissolve the historic divide between primary and community health services” and invest substantial money to “boost out of hospital care.”
The answer within the Long Term Plan was to create expanded community multi-disciplinary teams aligned with new Primary Care Networks based on neighbouring GP practices. The full range of community staff, social work and voluntary sector would be aligned to the network footprint (par 1.9)
The importance of Primary Care Networks is reiterated in the revolutionary Contract Deal struck between NHSE and GPC in February 2019. The “Investment and Evolution 5 Year Contract Reform” stated that “Primary Care Networks are an essential building block of every Integrated Care System,” with “general practice taking the leading role in every PCN”
In April 2019, GPC and NHS England agreed a DES (Directed Enhanced Service) to fund and support, individual GP practices to establish/ join PCNs covering populations of between 30,000 to 50,000 in England.
The Network DES is reviewed each year with increasing investment and responsibilities given to PCNs. Allied to this investment is the “Additional Roles Reimbursement Scheme” (ARRS) whereby certain specified funded roles become available to PCNs. In the first year each PCN was allowed one clinical pharmacist (70% funded) and one social prescriber. (100% funded) In the second year there was a major disagreement between the profession and NHSE about the over prescriptiveness and demands placed on PCNs by the service specifications published in draft form. In the subsequent negotiations the Service Specifications were simplified and streamlined and the expanded roles under the Additional Roles reimbursement scheme were all funded at 100%. The 20/21 DES is here.
Then along came the COVID pandemic and the requirements of the Service Specifications were rolled back as many PCNs took on an operational role to coordinate the primary care response to the pandemic. At the time of writing there is still uncertainty as to when and in what form the service specifications will be reinstated.
The nature of PCNs is somewhat confusing. They are not legal entities in themselves but do have some element of legal structure around them. Their mandate is simply to perform the commissioned responsibilities set out in the Network DES (an extension of the GMS contract of each practice) and this is a collective responsibility of all the practices within the network. Each must appoint a Clinical Director whose accountability is to the PCN members (para 4.4.2 – Network Contract DES) There is no specified accountability upwards.
It is very clear that there is a massive operational agenda in managing, planning and delivering community and primary care services, linking in with social and voluntary sector providers. It is also abundantly clear that there is currently very little infrastructure or planned infrastructure to allow this to happen. So whilst GPs are nominally in charge they do not have the tools or the time to do the job.
Then there is the aspiration to undertake population health management which will bring a whole new level of complexity, analysis and management into primary care.
Over and above this operational management challenge there is an expectation that PCNs, through their Clinical Director and acting collectively with other PCN CDs, will play a critical role in shaping and supporting their Integrated Care Partnership, helping to ensure full engagement of primary care in developing and implementing local system plans. (para 4.4.2.c - Network Contract DES)
Integrated Care Partnerships
Place Based care, as it is called, is delivered by Integrated Care Partnerships, based on acute hospital catchment areas which, to some extent, do reflect natural communities. It is at this level that the full range of general health and care services (ie not specialised Regional services) are available for a population. Largely they coincide with local government and third sector footprints.
Therefore, the ICP is where all the organisations providing health and care services naturally meet to assess their health and care needs, assess priorities and plan the delivery of services to meet needs. In doing so they need to effectively manage the interface between their respective services.
Functions of the ICP (adapted from a Kings Fund publication - Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England – 2108) are as follows:
- agree a performance contract with the ICS to deliver faster improvements in care and shared performance goals
- manage funding for a defined population by taking responsibility for a system ‘control total’
- create effective collective decision-making and governance structures aligned with accountabilities of constituent bodies
- demonstrate how provider organisations would operate on a horizontally and vertically integrated basis,
- deploy rigorous and validated population health management capabilities to improve prevention, manage avoidable demand and reduce unwarranted variations
- establish clear mechanisms by which residents can exercise patient choice over where they are treated.
There are five in Lancashire and South Cumbria, although rather confusingly they all have their own names:
- Pennine Lancashire – Together: A Healthier Future
- Central Lancashire – Our Health Our Care
- West Lancashire – Building for the Future
- Fylde Coast – Healthier Fylde Coast
- Bay Health & Care Partners – Better Care Together
North Cumbria, also based on the acute trust catchment area, is also an ICP
Integrated Care System
We have two ICS’s in Lancashire and Cumbria. The largest is “Healthier Lancashire and South Cumbria Integrated Care System and covers 1.8million people and the five ICPs listed above. North Cumbria is part of the North East and North Cumbria (NENC) ICS, made up of 4 ICPs with a combined population of 3.1 million people.
The ICS operates at a level above the ICPs. It is the new system driver for NHS reform and will be held to account for total system performance at a regional level by NHSE/I. In turn it will hold ICPs to account for their performance. In effect they will be the Regional Police Force of the NHS on behalf of central government. In previous years such a role was carried out by Regional Health Authorities and then Strategic Health Authorities.
The functions that will be carried out at this level are being developed, but will include strategic planning and commissioning, strategic resource allocation and overseeing implementation of the NHS Long Term Plan by performance managing ICPs.
There are certain functions that make sense being managed at this level, including rationalisation of acute services and regional specialist services. There is also the concept of doing things once that only need to be done once and providing frameworks for initiatives that need to be tailored for local implementation in each ICP.