Introduction

On the 1st March 2022, NHS England published its intentions for commissioning care from General Practice in England between 2022/23 (1).  The announcement was met with dismay from professionals who have struggled to understand the rationale behind the imposed changes (2).  This paper highlights key challenges in the policy framework.

The current terms of the GP contract were negotiated in 2019 and were expected to last five years (3).  Launched as the “Five-year-framework” the broad-reaching plan introduced new concepts like the additional roles reimbursement scheme (ARRS), impact and investment fund (IIF), and primary care networks (PCNs).  These schemes have not been without controversy and have induced excitement and criticism in equal measure (4).  The biggest challenge moving forward is likely to be in maintaining stakeholder confidence in the PCN policy.

PCNs and integrated care

PCNs are an English health policy designed to encourage providers of primary care to work together at scale to deliver a range of identified health outcomes by utilising a broad range of allied healthcare professionals.  In essence, PCNs are a form of integrated primary care.

Whilst the English PCN has no direct comparator, similar models can be found across the globe including the integrated care model in the Netherlands (5) and the medical home model in the USA (6).

Integrated care is now new.  In 2016, the World Health Organisation (WHO) helped to clarify that integrated care could be “a possible solution to the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients.” (7).

Are we ready for change?

Whilst integrated care is championed by governments around the world, the support for integrated care amongst English front-line clinicians is less clear.  In England, the fall in clinician numbers is often cited as a vote of no confidence toward systemic adoption of integrated care, however, unmanageable workloads, physician burnout, and an exodus from the health service are also symptoms of a struggling system that might benefit from integrated care.

What is clear, is that there is no industry-wide appreciation of the need to integrate primary care services in the form of English PCNs.  Indeed, in 2021, the British Medical Association (BMA) undertook an indicative ballot of its members that revealed 58% of respondents would consider withdrawal from their PCN by April 2022 (9).  This could indicate a failure of policy to meet the expectation and needs of patients and clinicians, or a failure of healthcare leaders to bring the medical profession on a journey of change.

The evidence

The evidence in favour of integrated care is, on balance, positive.  However, whilst integrated care seems to enhance patient satisfaction, increase the perceived quality of care, and increase access to services, the evidence of its cost-effectiveness is less apparent (8).  In any health economy with increased demand and finite resources, cost-effectiveness must be considered as a key feature of policy success. 

Of the £190.3 billion allocated to the NHS in 2021/22, English general practice received less than 10% of the budget yet delivered close to 90% of the patient contacts.  For business-owning primary care clinicians, the need to maintain an effective service on a small budget is sacrosanct.

General practice has a global reputation of being the most efficient and cost-effective part of a health care system (10) with additional cost benefits seen in those systems administered by nurse practitioners (11).  Cuban primary care providers, for example, are famed for providing world-class healthcare outcomes despite economic hardship and political turmoil.  Introducing change to a healthcare system where the outcome could be reduced cost-effectiveness is an obvious barrier to successful policy uptake and implementation, without a promise of increased funding.

Change fatigue and inertia

The challenge in maintaining stakeholder confidence in the PCN policy may be the lack of impetus for change.  After four years of a five-year framework aimed at transitioning primary care into an integrated model, English physicians may be suffering from change aversion and change fatigue, on top of their difficult day jobs.  Despite this, policymakers have signalled toward a new five-year deal that would seek to create further change and weave PCNs deeper into the fabric of the NHS.

To address this inertia, work has begun to engage with stakeholders in describing the future of primary care, based on the assumption that the current model is widely considered not fit for purpose.  There is little expectation that this will result in a significant policy shift away from integrated primary care and PCNs.  Instead, the review to be published later this year is likely to pave the way for a renewed emphasis on primary and secondary healthcare provider collaboration.  The WHO refers to this as vertical and horizontal integration of services (7).

The next five-year framework

The end to the shifting sands of system reform seems to have vanished, with 2024 likely to herald the next stage of healthcare system integration.  In areas where integrated care has become embedded into the healthcare community a great deal of work has been done to facilitate system redesign, clinician support, and subsequent policy adoption (12).  To enable successful policy deployment, English healthcare leaders and commissioners must 1) educate front-line clinicians on the need and benefits of change, 2) equip them with the tools necessary to make deliberate, meaningful, and coherent change, and then 3) provide a stable environment within which the policy can become embedded, and its impact properly assessed.

References

  1. NHS England. NHS England» Letter: General practice contract arrangements in 2022/23 [Internet]. www.england.nhs.uk. 2022 [cited 2022 Mar 17]. Available from:https://www.england.nhs.uk/publication/letter-general-practice-contract-arrangements-in-2022-23/
  1. Philpotts E. “The imposed deal must be legally tested”: All the reaction to 2022/23 GP contract [Internet]. Pulse Today. 2022 [cited 2022 Mar 17]. Available from: https://www.pulsetoday.co.uk/views/contract/this-is-demolishing-gps-spirit-all-the-reaction-to-2022-23-gp-contract/
  1. NHS England. NHS England» A five-year framework for GP contract reform to implement The NHS Long Term Plan [Internet]. www.england.nhs.uk. 2019 [cited 2022 Mar 17]. Available from: https://www.england.nhs.uk/publication/gp-contract-five-year-framework/
  1. NHS Confederation. PCNs call for more funding, support and autonomy to shore up the health and wellbeing of their local communities and the NHS Long Term Plan | NHS Confederation [Internet]. www.nhsconfed.org. 2021 [cited 2022 Mar 17]. Available from: https://www.nhsconfed.org/news/pcns-call-more-funding-support-and-autonomy-shore-health-and-wellbeing-their-local-communities
  1. Holterman S, Lahr M, Wynia K, Hettinga M, Buskens E. Integrated Care for Older Adults: A Struggle for Sustained Implementation in Northern Netherlands. International Journal of Integrated Care [Internet]. 2020 Jul 13 [cited 2022 Mar 23];20(3):1. Available from: https://www.ijic.org/articles/10.5334/ijic.5434/
  1. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, et al. Creating Patient-centered Team-based Primary Care IN PRIMARY CARE RESEARCH [Internet]. https://www.ahrq.gov/ncepcr/tools/pcmh/defining/index.html. 2016 Mar [cited 2022 Mar 23]. Available from: https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf
  1. World Health Organisation. Integrated Care Models: an Overview [Internet]. https://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf. 2016 [cited 2022 Mar 23]. Available from: https://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf
  1. Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Services Research [Internet]. 2018 May 10 [cited 2022 Mar 23];18(1). Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3161-3
  1. Iacobucci G. Over half of general practices in England would quit primary care networks, indicative ballot shows. BMJ [Internet]. 2021 Nov 26 [cited 2022 Mar 23];(375):n2924. Available from: https://www.bmj.com/content/375/bmj.n2924
  1. Australian Medical Association. Report shows that general practice is efficient and cost effective [Internet]. Australian Medical Association. 2015 [cited 2022 Mar 23]. Available from: https://www.ama.com.au/media/report-shows-general-practice-efficient-and-cost-effective
  1. Venning P. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ [Internet]. 2000 Apr 15 [cited 2022 Mar 23];320(7241):1048–53. Available from: https://www.bmj.com/content/320/7241/1048.full.pdf+html
  1. Agency for Healthcare Research and Quality. Tools for Implementing the PCMH | Agency for Healthcare Research and Quality [Internet]. www.ahrq.gov. 2021 [cited 2022 Mar 24]. Available from: https://www.ahrq.gov/ncepcr/tools/pcmh/implement/index.html