Primary care networks: what are the implications for all community nurses?
NHS England wants primary care networks to cover the country by June and this presents both leadership opportunities and workplace challenges
By June, primary care networks are expected to cover England, presenting both leadership opportunities and workplace challenges
NHS England has set out plans for primary care networks (PCNs) with the ambition of them covering the entire country by June.
The networks are to be based on GP registered lists, will serve communities of 30,000 to 50,000 people and should be ‘small enough to provide the personal care valued by patients and GPs, but large enough to have impact and economies of scale through better collaboration between practices and others in the local health and social care system’.
The NHS Long Term Plan launched at the start of this year set out £4.5 billion of new investment to fund expanded community multidisciplinary teams, described by NHS England as an ‘army of 20,000 more staff’ such as GPs, district nurses, pharmacists and staff from the social care and voluntary sectors.
The teams will be aligned with the new PCNs requiring GP practices to work together.
Deadline NHS England has set for primary care networks to cover the whole of England
A new five-year contract for general practice across England announced at the end of January is expected to see huge extra investment for improved access to family doctors and expanded services at local practices.
According to NHS England, individual practices will enter into a network contract as an extension of their current contract and should have a designated single fund for PCN resources.
RCN head of nursing practice Wendy Preston says: ‘Greater integration between health and social care should become more regular with a focus on keeping people out of hospital, preventing ill health, and keeping them healthier and happier for longer.
‘As well as giving people a greater quality of life, this saves our healthcare system money in the long run.
‘But the success of these networks relies on having a fully funded workforce. The number of district nurses employed by the NHS, the backbone of community health services, has almost halved since 2010, and the number of community nursing staff overall has dropped by 15%.
‘In addition, cuts to training budgets have prevented nurses from joining the community nursing workforce or practice teams, prompting further staff shortages.’
NHS England claims general practice will benefit from the impact their work has on reducing avoidable emergency department attendances, admissions and delayed discharge, and from reducing avoidable outpatient visits and improvements in prescribing through medication reviews.
However, the King’s Fund has warned that it is critical that PCNs are not set up to fail by taking on too many tasks too quickly.
Nuffield Trust senior fellow in health policy Stephanie Kumpunen says that the networks are included in ambitions to create fully integrated community-based health and care services for the first time since the creation of the NHS.
‘It is likely that many GP networks and federations will welcome community teams, including nurses, into their practices and recognise the added value and skills they bring.
‘It is also likely that advanced nurse practitioners will be asked to play a strong leadership role in training and healthcare assistants an integral role in delivering integrated services.’
Challenges of integrated working
She warns that implementing integrated team working can be challenging: ‘Substantive effort will need to be put into building relationships and trust in the new integrated teams.
‘It will be important for primary and community teams to promote inspiring leaders regardless of all professional backgrounds, as well as develop learning cultures that overcome traditional professional boundaries.
‘Other enablers of day-to-day working will include approachable and engaged service management and clear accountability structures.
‘To ensure that teams are truly integrated from the outset, all proposed members of primary and community networks should be coming together immediately for initial discussions before the May deadline to agree their structures.’
Queen’s Nursing Institute (QNI) chief executive Crystal Oldman believes there are ‘exciting opportunities’ for nurses working in primary care and community services to take on the leadership of PCNs.
The QNI offers an executive nurse leadership development programme for nurses working in a variety of executive roles in the community and primary care.
Dr Oldman thinks the programme would be ideal to support a nurse moving to lead a primary care network. The first two cohorts of the programme were open only to Queen’s nurses but in this year will be open to all applicants.
Size of communities, primary care networks are designed to serve
She said: ‘I see nurses taking on these leadership positions, bringing a depth of knowledge and experience in clinical work combined with a clear vision for improvement, collaborative multi-professional team working and a ‘can do’ attitude, with personalised care at the centre of all they do.’
Dr Oldman has been supporting the development of the primary care home programme for the past four years sitting on the National Association of Primary Care (NAPC) technical advisory group and says she has witnessed first-hand the difference this kind of model can make.
‘The existing model of the primary care home created by the NAPC is predicated on exactly the same principles as PCNs, a local population served by professionals working together, located together where possible and inclusive of all stakeholders, focusing on population and individual health needs – and this model has proven to be hugely successful, with better outcomes for the community and for the workforce.’
NHS England chief executive Simon Stevens launched the primary care home programme in October 2015, NAPC has 220 primary care home programmes across England which it believes is spearheading the transformation of integrated primary care.
NAPC non-executive director Julie Bolus leads on the organisation’s nursing work and says they are a form of established primary care networks: ‘They serve 9 million patients, 16% of the population. We are also spreading the model across three integrated care systems (ICSs) and more than a dozen sustainable transformation partnerships (STPs).’
She adds that the NAPC is working closely with NHS England to improve access to leadership development opportunities for general practice nurses in primary care homes and other PCNs.
‘There are a number of strands to this work including continuing to raise the profile of general practice nursing through our Nurses' Voice network, identifying nurse leaders in our primary care home sites and by working in partnership with NHS England through ICSs on developing nursing leadership roles.
‘This is an exciting time for general practice nursing but there is still much work to do to ensure nurses can effectively influence the new models of care being designed to meet the needs of the populations they serve.’
Debbie Brown, a Queen’s nurse and clinical director of NHS Lewisham clinical commissioning group says that PCNs are enablers for general practice nurse leadership which can develop from one or two practice nurses to whole teams of clinical and non-clinical teams coming together.
Ms Brown was part of a recent session held by the NAPC about nurse involvement and leadership in PCNs and spoke to practice nurses who were part of a PCN.
‘They said it was great for the nursing team as it was the first time they had worked with other nurses from single practices, they have been able to share and learn together, have peer support, increase their competencies and have witnessed improved patient care.
‘For some nurses, PCNs mean a fantastic opportunity to be part of a wider team and the chance to grow nurse leaders of the future. For other nurses, they worry about what it all means. Will they have to go to another practice down the road if it is short of a nurse for the day? Will their hours and pay have to change?’
Effect on pay, terms and conditions
Ms Brown believes that pay, terms and conditions is still a huge discussion around PCNs and due to the variation in general practice nurses’ wages some, who are earning more than others within the PCN, may have to accept a lower salary to align with other nurses in the network.
However, she adds, this will also benefit those who are on a lower than acceptable salary for their role, skills and competencies.
‘The way primary care nurses work is going to change beyond recognition, but we must be involved in discussions about setting up PCNs so we can embrace this next stage of the NHS and work collaboratively.’
How the model is already working
Angus Murray-Brown, chair of the South Manchester GP federation and deputy chair of the Manchester Primary Care Partnership says Manchester has had its embryonic PCNs in place for over a year.
investment to expand community multidisciplinary teams to work with primary care networks
Dr Murray-Brown explains: ‘The city is currently divided into 12 neighbourhoods ranging from 30,000 to 70,000 people.
‘The neighbourhoods do not all have the full gamut of extra services as described in the new GP contract.
‘However, like the rest of the country we are looking at our options. In many ways the new GP contract will actually need new structures created – we think practices will want direct oversight of the networks – otherwise you run the risk of handing future control to external agencies, an action which could threaten independent general practice.
‘Although the contract says GPs will be the clinical directors, we feel this is short-sighted as there may be reasons why practice nurses may be better suited to the clinical director role in some areas. We expect this rule to be relaxed in the full guidance.
'We support the general direction of travel but need to analyse the full contract to properly plan for the future.’
An NHS England spokesperson says: ‘We have seen that where PCNs are successfully up and running across the country there are clear benefits for patients and staff.
‘As detailed in the NHS Long Term Plan and the latest GP contract, billions of pounds of additional investment will be made available to support the development of primary care networks across the country, with the aim that networks cover the whole of England by June 2019.’
Example of integrated working
Pioneered in New Zealand, HealthPathways (HP) has been piloted in the UK in South Tyneside, with the University of Sunderland evaluating its impact and potential to be rolled out nationally.
HP acts as a central online source for hundreds of care pathways for specific conditions, which have been developed locally and are designed primarily for general practice teams, but are also available to specialists and other health professionals in the region.
Each pathway is evidence-based and reflects national standards of care. Tailoring information to reflect local services means that it will be easier for practitioners to identify what is available to support patients and determine their criteria for referrals.
Joy Akehurst, who led the research into HP and was previously a senior nurse in primary care, community nursing and acute nursing, said an early evaluation of the South Tyneside programme showed that doctors, nurses across primary and secondary care, and primary care staff found the agreed pathways of care clarified evidence-based practice and referral routes to secondary care or alternative providers.
Ms Akehurst said: ‘Participants reported that this not only improved patient care, but the process of developing the pathways collaboratively, as part of joint clinical education meetings, while time consuming, helped develop relationships between primary care and secondary care professionals.’