Additional Support is Required to Harness the Potential of the NHS Restructure

The Guidelines in Practice Team Analyses the Complete Findings of a Recent Survey Examining Your Views on the NHS Reorganisation 

The NHS in England is undergoing a structural reorganisation that will change the way that the primary care workforce operates.¹ GP practices are joining forces to form primary care networks (PCNs) that will deliver the place-based population health strategies of integrated care systems (ICSs).^2–5 Simultaneously, the general practice workforce is expanding, generating multidisciplinary primary care teams that will wrap care around patients.^3,6 However, the NHS is currently experiencing the worst pressure in its 73-year history—caring for patients with COVID-19 and facing a backlog of care delayed by the pandemic—which may represent a barrier to the adoption of new models of care.

To understand the views of the Guidelines in Practice audience on the NHS restructure, we conducted an online survey between 24 June and 7 July 2021. A preliminary summary of the results was published in Guidelines in Practice in July 2021;⁷ in this article, we provide a full account of the survey’s findings.

Survey Respondents

In all, 270 healthcare professionals completed the survey—see Box 1 for a breakdown of the respondents.

Feasibility of Implementing the Changes in Primary Care

In the new NHS model, PCNs—local collaborations between groups of GP practices and partners such as community, mental health, social care, pharmacy, hospital, and voluntary services—will deliver integrated care centred around the health needs of local populations of around 30,000–50,000 people.^3–5 Place-based partnerships will make the best use of the resources that are available, and adapt to the varying populations, contexts, and priorities of different locations to influence local health outcomes.⁵

Guidelines in Practice asked whether it is feasible for GP surgeries to collaborate in local partnerships. The majority of those who responded to the survey do not consider that the formation of local partnerships is unrealistic: 17% (45) feel that it is very feasible, 61% (165) consider it feasible, and only 22% (60) regard it as unfeasible.

Many respondents indicated that their practices are open to new ways of working that have the potential to improve patient care and alleviate the pressure on GPs. For some, collaboration in local partnerships began before the establishment of PCNs: ‘We already work well with different practices, so bringing other primary care providers on board will just be an extension of this.’ (GP respondent). For others, partnership working was necessitated by the pandemic, during which it proved its effectiveness: ‘We have been working with two other practices—joining forces to deliver the COVID vaccinations at one central venue. This worked.’ (Nurse respondent). Many participants were optimistic about the potential for local collaborations to enable more seamless care, stating that services want to work together. However, some highlighted the difficulty of partnership working in rural locations, while others suggested that diverting patients to other services will not necessarily improve their care.

‘practices are open to new ways of working that have the potential to improve patients care and alleviate the pressure on GPs’

Progress of the Restructure and Impacts on Practice

PCNs have also been tasked with growing the general practice workforce to reduce GPs’ workload .^3,6 PCNs will recruit and retain additional GPs and nurses in line with the objectives of the NHS long term plan,^6,8 and create new posts to expand multidisciplinary primary care teams funded through the Additional Roles Reimbursement Scheme as specified in the Directed Enhanced Service contract.^6,9

Guidelines in Practice asked for readers’ observations on the additional staff that have already been recruited by their PCNs, the roles that PCNs are still looking to fill, and the impacts of the changes so far.

Workforce Expansion

Survey participants indicate that good progress has been made on the recruitment of additional staff; team members most frequently appointed by respondents’ PCNs are:

• clinical pharmacists—appointed by 75% (202)
• social prescribing link workers—appointed by 57% (155)
• physiotherapists—appointed by 48% (129).

Table 1 provides a breakdown of the additional roles filled by respondents’ PCNs at the time the survey was conducted. In addition, 12% (32) of the healthcare professionals surveyed said that other team members have been hired by their PCN, including mental health, respiratory, and prescribing support nurses, advanced nurse practitioners (ANPs), and advanced clinical practitioners.
 

Table 1: Recruitment to Additional Roles by Respondents’ PCN

Table 2 details the additional posts that respondents’ PCNs were still looking to fill at the time the survey was conducted.

Table 2: Additional Roles Yet to be Filled by Respondents’ PCN

PCNs are also still seeking mental health support workers, counsellors, healthcare assistants, district nurses, community matrons, receptionists, and administrative staff. Responses indicated that recruitment is slow, and that PCNs must vie for limited numbers of qualified individuals.

Guidelines in Practice asked for further details of how localities are implementing the changes. This revealed that PCNs are evaluating patients’ needs, drawing up priorities, developing additional roles, consulting with stakeholders, sourcing funding, and planning the coordination of care between teams. In addition to hiring, others are engaging with practical issues—such as finding rooms for new team members and building relationships between practices—and with other services, suggesting that preparatory work, although delayed by the pandemic, is underway. However, many respondents said that they were uncertain how the restructure is being implemented, or that it awaits implementation. Some stated that a lack of time and resources is being exacerbated by increasing patient demand and restructure-related work; as a consequence, they have had to follow up with patients themselves to ‘fill in the gaps’ (GP respondent).

‘preparatory work, although delayed by the pandemic, is underway’

Effects on Practice

Guidelines in Practice readers report some positive outcomes of the restructure:

• 50% (136) are already enjoying a better skill mix within teams
• for 39% (105), the reorganisation has led to improved communication with community care services.

However, the survey responses also showed that:

• the changes have freed up time for fewer than one-third of participants (31%; 84)
• even fewer respondents (26%; 71) report a positive impact of the changes on GP workload.

These figures are striking given that growth of the general practice workforce, which is integral to the reforms, is intended to alleviate the burden on GPs.⁶
 

‘the changes have freed up time for fewer than one-third of participants’

Figure 1 shows the benefits of the restructure on practice at the time that the survey was conducted, as reported by respondents.

Supporting comments from respondents showed that they value the ability to refer patients to another member of the multidisciplinary primary care team with more appropriate expertise, such as physiotherapists. Allied health professionals (AHPs) now working in multidisciplinary primary care teams highlighted that they have ‘more time and specialism to review patients in detail with respect to medicines management … [freeing] up GP time for more acute and complex case management.’ (AHP respondent).

‘[respondents] value the ability to refer patients to another member of the multidisciplinary primary care team with more appropriate expertise’

However, others said that there have been no tangible benefits for healthcare professionals and practices, particularly as many services have yet to return to normal in the aftermath of the COVID-19 pandemic, with some stating that the restructure has actually increased primary care workload. GPs reported that they are now tasked with supervising additional staff members who cannot work independently, while simultaneously managing the most complex, unwell patients. This is increasing the risk of burnout among GPs, and also affecting members of the wider team—who must pick up additional work to help their overburdened colleagues—as indicated by comments such as ‘We were supposed to be an addition, not a replacement.’ (ANP respondent).

‘GPs … are now tasked with supervising additional staff members who cannot work independently, while simultaneously managing the most complex, unwell patients’

The Potential of the Restructure to Improve Patient Care

Building on the aims of the NHS long term plan to provide personalised, joined-up care to people where they live,⁸ PCNs—in collaboration with local authorities and other care providers—will undertake shared decision making to meet the health needs of the populations they serve while introducing anticipatory care initiatives, improving the diagnosis of conditions such as cancer and cardiovascular disease, optimising medication use, and addressing inequalities.^2–6,10 Increased use of data analysis and digital technologies will support these changes, helping PCNs to shape care pathways and putting patients at the heart of their care.³

Guidelines in Practice asked whether the restructure has the potential to improve patient care. Participants were invited to report any positive effects of the changes for patients to date, and were asked for their opinion on the potential pitfalls of variations in care between localities.

The Benefits of Multidisciplinary Primary Care Teams

The majority of survey participants think that diversification of the primary care workforce will lead to improved outcomes for patients: 65% (174) agree that a wider skill mix in primary care teams will lead to more comprehensive care for patients. In contrast, 8% (22) disagree, and the remaining 27% (71) are unsure.

Outcomes for Patients To Date

The survey found evidence of emerging benefits for patients. According to 43% (116) of respondents, communication between different healthcare professionals has improved, 37% (99) said that patients are beginning to benefit from care tailored to their individual needs, 36% (96) pointed to faster access for patients to the appropriate healthcare professional, and 30% (80) cited smoother transitions between care teams.

Additional benefits for patients identified by participants included easier access to different healthcare professionals and services, and improved patient experience and satisfaction. However, not all agreed that there have been discernible improvements for patients, with a suggestion that the changes have had negative consequences for patients, and comments such as ‘more disjointed care for patients with a lack of continuity’ (GP respondent), ‘patients sometimes just feel more confused with more people involved’ (GP respondent), and ‘substandard care … [creates] more queries and return visits’ (GP respondent). One suggested that restricted access to GPs during the pandemic has persisted, leaving patients feeling ‘abandoned’ (Pharmacist respondent), and others that the health service is now less easy for patients to navigate than it was before the restructure.

‘the health service is now less easy for patients to navigate than it was before the restructure’

Predictions around Variations in Care

There are concerns that variations in arrangements between places will have negative consequences for patient care—24% (66) of respondents expect patients to encounter service restrictions in some areas, and 18% (48) fear unequal access to specialist centres or cutting-edge procedures between localities; 8% (22) are worried that variations in care will lead to diagnostic delays, and 14% (38) foresee treatment delays. Some also anticipate an increase in negative feedback from patients about services and care (24%; 64).z

Other issues identified by participants include an increase in complaints and litigation, and variations in leadership and service quality between areas.

Obstacles to the Implementation and Success of the Restructure

Guidelines in Practice also asked about potential barriers to the restructure, leading some respondents to reveal concerns that the reorganisation will not deliver the anticipated improvements for general practice. 

COVID-19

On the timing of the restructure and whether the benefits can be realised in the aftermath of COVID-19, 67% (182) say that the backlog of care caused by the pandemic represents the most significant obstacle to the success of the reorganisation (see Figure 2) and three-quarters (75%; 202) lack confidence that it will improve patient care; 41% (111) think it will make no difference, and 34% (91) that it should be reconsidered. Only 25% (68) believe that the restructure will result in improvements to patient care.

‘the backlog of care caused by the pandemic represents the most significant obstacle to the success of the reorganisation’

Many respondents said that the timing of the changes is inappropriate: ‘We need to recover from the pandemic and reassess’ (GP respondent), and ‘I don’t think now is the time to implement it, until we know what the new normal is’  (GP respondent). At the very least, participants predicted that delays caused by the pandemic will have a knock-on effect on delivery of the restructure: ‘There is a backlog of work now to get through due to COVID; this has caused added pressure on services and … I don’t think [the new structure] will have much impact on delivery of services for some time.’ (Nurse respondent). However, others stated that new ways of working—such as virtual, video, and text message consultations, with limited face-to-face appointments—were effective during the pandemic and should be retained going forward, and stated that positive experiences of collaboration on vaccine delivery have improved attitudes towards future partnership working.

‘positive experiences of collaboration on vaccine delivery have improved attitudes towards future partnership working’

Funding

Under the restructure, primary care budgets, formerly administrated by CCGs, will become the responsibility of ICSs; decisions on resource allocation will be made as close as possible to local communities, and ICS leaders will be empowered to distribute funding to the areas of greatest need.^3,5

However, 59% (160) of those who responded to the survey identify funding as one of the biggest barriers to the success of the restructure (see Figure 2). Moreover, more than half (59%; 159) say that funding is insufficient to support the development of a multidisciplinary workforce, and a further 22% (59) are uncertain (see Figure 3).

‘funding is insufficient to support the development of a multidisciplinary workforce’

According to one participant, ‘Variation [in care between places] will not be the main problem. Insufficient resource in all areas will.’ (GP respondent). Several respondents expressed concern that there is too little information on how the changes will be funded, and that funds will be diverted from primary care. One respondent made the point that, whereas funding for GP training is adequate, funding to enhance the clinical skills of other staff is lacking. GPs must also now oversee the work of additional staff members, which is compounding the problem—hence, one GP respondent stated that the restructure is a ‘false economy’. Another recurring theme was that the restructure is a poor substitute for funding for more GPs and nurses: ‘We need GPs, not a dilutional system to cope with the lack of GPs’ (GP respondent).
 

‘the restructure is a poor substitute for funding for more GPs and nurses’

Other Obstacles

Among other barriers reported (see Figure 2) are workforce shortages, recognised as an obstacle by 77% (208), and competing priorities, such as Quality and Outcomes Framework targets,¹¹ identified by 51% (137).

Responses also referred to constant increases in patient demand, the difficulty of finding rooms for new team members in practices, historic financial deficits, increased bureaucracy, poor job satisfaction, and low staff morale.

In addition, according to 38% (103), NHS information technology (IT) and data systems are inadequate to support the aims of the restructure.

‘NHS information technology (IT) and data systems are inadequate to support the aims of the restructure’

At practice level, participants cited ‘broken applications and systems’ (Primary care administrative respondent) and, at place level, PCNs do not have the funding to purchase the necessary IT equipment, leading to a lack of uniformity between areas and hindering population health management.¹² Poorly kept medical records were also identified as a barrier: ‘A huge percentage of medical records … are very unclear (the active problems and the history of significant diagnoses are not well recorded). The more you share access to [medical records],the more disorganised [they]will get.’ (GP respondent). With an increasing number of healthcare professionals involved in each patient’s care, straightforward access for all services to a single, comprehensive electronic medical record becomes essential.

The Place of Primary Care in the Changing NHS

Through representation at all levels of the ICS, PCNs will help to shape joined-up, efficient services for patients. Guidelines in Practice asked whether PCNs will have sufficient influence in ICSs, and at what level local guideline and formulary development is expected to occur.

Influence in ICSs

Most participants (93%; 252) disagree with the statement that PCNs will have sufficient authority after the restructure (see Figure 4). Although a small number (14%; 37) feel that PCNs and ICSs are working well together, 50% (135) think that ICSs exert top-down control over PCNs, and 30% (80) believe that PCNs will have little or no influence in ICSs.

‘most participants … disagreed with the statement that PCNs will have sufficient authority after the restructure’

Some respondents were optimistic that close working between GPs, PCNs, and ICSs has the potential to ‘maximise efficiency and quality and reduce variation’ (GP respondent), and that, with more dialogue at every level, ‘more seamless services can be provided’ (Pharmacist respondent). However, many expressed concern that GPs are being sidelined in the changing NHS, with responses such as ‘Too top heavy. Primary care will be given more work and little resources’ (GP respondent), and ‘Too much input from the hierarchy of management and not enough input from those actually doing the job’ (Nurse respondent).

‘many expressed concern that GPs are being sidelined in the changing NHS’

Development of Local Formularies and Guidelines

Many respondents anticipate that PCNs and/or ICSs rather than GP practices will develop local formularies and guidelines. Only 19% (51) expect that local formularies and just 17% (45) that local guidelines will be developed at GP practice level.

Some were uncertain about where local formularies will be developed, and expressed a desire for secondary care involvement. Others preferred national guidance, saying that there are too many local guidelines; it was also asserted that, too often, GPs are not consulted in the creation of local guidance.

Philosophy of the Restructure

In addition to scepticism about the degree of influence for primary care in ICSs, some participants questioned the reasoning behind the restructure, expressing a lack of confidence in those orchestrating the reorganisation. Comments included: ‘Good ideas, but promoted in the absence of any understanding of day-to-day pressures’ (GP respondent) and ‘ [The changes are] sacrificing a lot of good in the CCG system’ (GP respondent). This may explain why respondents feel that they are having to ‘bend over backwards’ (GP respondent) or are ‘failing miserably’ (GP respondent) in implementing the changes.

There are also doubts about whether the restructure will bring about real change in the health service, because of ‘politics—old entrenched views’ (GP respondent); participants stated that ‘archaic systems remain in place’ (Nurse respondent), and ‘nothing really changes from the patient’s point of view’ (GP respondent).

Summary

The Guidelines in Practice readers who responded to our survey have demonstrated that they are open to new ways of working that have the potential to improve everyday practice and patient care. However, many of the flaws of the previous system that the restructure aims to address—such as workforce shortages, excessive workload, and insufficient funding—are themselves barriers to the implementation and success of the changes. Their effects have been amplified by the COVID-19 pandemic, and the resulting backlog of care has further impaired the ability of the health service to harness the potential benefits of the reorganisation. Additional funding and greater representation in ICSs will be required if the restructure is to deliver the anticipated improvements for primary care.

Nina Buchan, PhD

Features Editor,  Guidelines in Practice