In this feature, Thoreya Swage, Healthcare Consultant, describes the changes that have occurred with Primary Care Networks working with their community services partners during the first wave of the Covid-19 pandemic.
In July 2019, all GP practices in England were required to coalesce into groups called Primary Care Networks (PCNs). This was negotiated as part of the GP contract agreed in January 2019.
PCNs are natural communities based on GP registered lists up to a population size of between 30,000 and 50,000. They are small enough to deliver personalised care, whilst large enough to have a wider impact between practices, community services and social care.
PCNs are expected to enhance seven-day access to GP services including a rapid response to acute illnesses, to share the workforce and develop multi-disciplinary care for patients with complex problems. There are 1259 PCNs in England.
During 2019, PCNs were required to identify their strategy for the development of GP services in their locality, agree on the PCN specifications for selected services and establish relationships with local community providers.
The NHS Long-Term Plan, published in January 2019, stated that PCNs were expected to deliver seven national service specifications.
The following to start in April 2020.
The following to start in April 2021.
This was scaled back to three specifications to be delivered by April 2020, following feedback from GPs and negotiations with the BMA.
PCN development prior to Covid-19
Much work had started in 2019 to develop PCNs including not only establishing each PCN and their constituent practices but also their clinical directors. The funding flows were initiated to facilitate the closer working of practices within PCNs in order to set objectives and to begin recruiting extra staff, such as First Contact Practitioners (eg physiotherapists), clinical pharmacists, as well as enhance the input of other community staff, eg district nurses, podiatrists and other allied health professionals currently part of community trusts.
In addition, there was an expectation that three key areas were to be addressed in the immediate term.
Linking up primary and community nursing.
PCNs also provided an opportunity for more joined-up working between primary care and community services.
Then the Covid-19 pandemic struck in early 2020, resulting in a wholesale rearrangement of the NHS across the board to focus on the response to the novel virus.
The response to the Covid-19 pandemic
The NHS response to the Covid-19 pandemic was to redesign services to provide care for people with Covid-19 (eg increase intensive care capacity, including the setting up of Nightingale hospitals). GP appointments and outpatients which previously were face-to-face were changed almost overnight into telephone and other virtual interactions. All but emergency and urgent care were suspended.
As a consequence of Covid-19, implementation of the PCN specifications was phased in with the early diagnosis of cancer starting in April 2020, some elements of enhanced care in care homes commencing in May 2020, and medication reviews in October 2020.
Working as systems
Whilst there were a few health and social care partnerships/Integrated Care Systems across the country that had mature relationships prior to Covid-19, there were still several barriers that impeded the development of whole system working. These included:
immature relationships and poor understanding between primary and secondary care, and social care
commissioning structures and the GP contract models that discouraged collaboration between providers
Most of all, discussions between stakeholders around change would take time (weeks and months) and even then, would not necessarily, succeed.
However, the advent of Covid-19 accelerated changes within a few days as it soon became apparent that different parts of a health and social care system working separately would not be effective in responding to the challenge presented by the pandemic.
Whilst the changes to NHS services are better known within the acute healthcare sector to manage the very ill patients, community services and PCNs (and their constituent practices) were also supporting their populations.
At the beginning of lockdown in late March 2020, services in community and primary care rapidly adapted to the changed circumstances.
For example, community services redeployed their staff to support the discharge of patients from hospital (implementing “discharge to assess” rather than waiting for social services to see patients in hospital prior to receiving services at home or admission to a care home). This enabled the efficient discharge of medically fit patients in the community to ensure the availability of hospital beds as well as provide care for patients with complex needs (Covid-19 and other).
GP practices very quickly changed patient access to their services utilising virtual consultations either by telephone or video and only seeing patients face-to-face if absolutely necessary, ensuring that there were Covid-19 protection measures to maintain safety. Many community providers were able to give advice and training on infection prevention and control measures to both PCNs and care homes. For example, how to segregate GP surgeries into red and green sites for Covid and non-Covid patients.
Through triaging requests for consultations and the increased use of digital technology, practices have been able to apply the clinical time made available to care planning and proactive case management. It has also meant that requests for urgent GP appointments could be responded to within a day, either with a telephone call that same day or an appointment in the next few days. This has enhanced patient access to GPs services which prior to the pandemic has meant long waits for routine appointments.
Patients who were shielding benefitted from the enhanced provision of services offered by primary, community and social care.
The pandemic has also highlighted gaps in the capacity of primary care to which community services have responded. For example, as home visits could not be offered to patients by GPs, referrals to community nurses increased, in order, for example, to take blood for patients who were shielding or to develop care plans.
Where PCNs were functioning well, it was possible to engage other services to provide care. For less mature PCNs it has been more challenging to negotiate and deliver a coherent offer with community services to patients.
Where good collaboration has occurred, this has been due to close working between PCNs and community providers.
Services in the primary and community setting have had to be implemented in a very short space of time. The challenge now is to capture the changes that have been beneficial to NHS staff as well as to patients. It is important to embed the great expansion in the use of digital technology as a result of the pandemic which has enabled virtual consultations and remote monitoring to be used in day-to-day practice.
These changes will need to be incorporated in the PCN service specifications that have or will be implemented.
It is vital that PCNs are at the centre of the reset of services in the community, working with system partners if the learning from the past five months is to be effective.