Last reviewed 27 May 2019
In January 2019, NHS England published: Investment and Evolution, A five-year framework for GP contract reform, to implement the NHS Long Term Plan which outlines five main goals and establishes the intended direction for primary care for the next 10 years, Deborah Bellamy explains.
Changes to the 2019/20 GMS contract have been described as the most ‘significant reforms’ to GP services since 2014. Under this new GP contract, practices will be entitled to an automatic entitlement to Primary Care Network Contract (PCNs). General practice is seen as pivotal to the formation of these new PCNs and this Direct Enhanced Service (DES) forms a fundamental part of Integrated Care Systems.
This article outlines what the changes in the Network Contract DES will mean for general practices.
Funding for the Expanded Network Workforce
Funding for GP practices overall will increase by 1bn over a 5-year period with an additional £1.9 billion being earmarked to support the establishment of PCNs. Practices will be enabled to work collaboratively to provide care to patients across an extended geographical area. This will characteristically cover between 30,000-50,000 patients, but according to the BMA, there will be alternative arrangements for rural practices in “exceptional” circumstances.
In order to be eligible for funding, from July 2019, practices will have to appoint a clinical Director/lead and join a PCN. They will subsequently need to focus on specific service specifications, founded on the aims of the NHS long-term plan.
The former extended access DES will be transferred into the Network Contract DES. As with existing GMS contracts, this will be supported by financial entitlements. In addition, Clinical Commissioning Groups (CCGs) could augment local investment via Supplementary Network Services.
If, as anticipated, 100% of the national Network Entitlements is taken up incorporating a recurrent £1.50/patient support and a contribution to clinical leadership, by 2023/24 £1.799 billion would move through the Network Contract DES nationally.
In its initial phase this DES will enable networks to employ a minimum of one social prescribing link worker and one clinical pharmacist. It is anticipated that subsequent years will see the workforce expanded by over 20,000 new staff and practice based extended roles being developed such as:
Clinical Director Role
Every PCN will need to appoint a named accountable Clinical Director or lead and a network agreement will need to be in place establishing PCN member collaboration.
It is envisaged the role of the Clinical Directors will be essential in determining and developing their Integrated Care Systems and dissipating the long-standing division between primary and community service delivery.
The Network Contract DES
The Network Contract DES supports all sizes of practices collaborating within neighbourhoods. They will be established in line with Directions given to NHS England and eligibility is determined by meeting registration requirements.
The Network Contract DES has three main components:
National Network Service Specifications which outlines what networks will have to deliver.
National schedule of Network Financial Entitlements, comparable to existing Statement of Financial Entitlements (SFE) for the practice contract. There will be transparency requirements which include subcontracting arrangements.
Supplementary Network Services. CCGs and Primary Care Networks may develop additional local schemes. These are complimentary to the Network Contract and supported by additional local resources.
National Service Specifications
Seven specific national service specifications will be introduced under the Network Contract DES. These are focused on areas where Primary Care Networks are perceived to have a significant impact against the “triple aim”. These are specific NHS Long Term Plan goals for primary care, not previously covered by improvements to Quality and Outcomes Framework, access and digital.
The triple aim refers to:
improving health and saving lives from diseases such as: heart attacks, strokes and cancer
improving quality of care for those co-morbidities via holistic and personalised care, supporting planning with structured medication reviews and enhanced support for patients in greatest need, including residents in care homes
facilitating a more sustainable NHS in several ways, including reduction of avoidable hospital admissions.
It has been acknowledged that a great deal of work is has been undertaken in primary care in these areas.
During 2019 and 2020, NHS England will develop seven service specifications from the NHS long-term plan and seek to agree these with GPC England as part of annual contract changes.
Once agreed, from 2020 practices will need to work towards these specification aims:
structured reviews of medication
enhanced support provided to care homes
proactive or anticipatory care for patients at the upmost risk of hospitalisation
personalised care, including joint decision-making and personal budgets
increased screening and early diagnosis of cancer
Cardio Vascular Disease detection and case finding
confronting health inequalities.
Five of the seven will begin in April 2020: which will be: structured medication reviews, enhanced support in care homes, anticipatory care (with community services), personalised care and supporting early cancer diagnosis.
The others: cardio-vascular disease case-finding and locally agreed action to confront health inequalities will commence by 2021.
NHS Long Term Plan commitments
The annual increase in funding for the Additional Roles Reimbursement Scheme is based on the 7 national Network Service Specifications being approved and their successive delivery.
The national service specifications will further develop these foundations by the expansion of national minimum requirements.
Each of these will incorporate benchmarked national processes, metrics and anticipated benefits for patients. These will be developed with the General Practitioners Committee as part of annual contract negotiations.
Urgent care services
PCNs are perceived to be the way forward for integrating future urgent care delivery in the community. Funding and responsibility for providing the current CCG-commissioned enhanced access services will be transferred to the Network Contract DES by April 2021.
From July 2019, the Extended Hours DES requirements will be introduced across every network, until March 2021. Following an Access Review in 2019 more wide ranging access arrangements will be implemented in 2020 and amalgamated in the Network Contract DES with total coverage anticipated by 2021/22.
In 2019, 111 direct booking into practices will be introduced nationally. As part of these access arrangements £30 million of extra annual recurrent funding will be added into the global sum from 2019/20.
NHS Digital will publish monthly activity and waiting times data from 2021 from both GP and hospital data. Publication of the data will reveal discrepancies in access between networks and practices.
There are to be a series of roadshows organized by NHS England to help those involved understand the full implications.
Further guidance is being released regularly and more information may be found at www.england.nhs.uk.