The Guidelines in Practice Team Discusses the Findings of the 2022 Guidelines in Practice Readership Survey in the Context of the Restructured NHS
|Read This Article to Learn More About:|
An expert commentary by Dr David Jenner (GP, Cullompton, Devon; Guidelines in Practice Editorial Advisory Consultant on commissioning) can be found at the end of the article.
A report summarising the findings of the 2022 Guidelines in Practice survey, Staff shortages and overwork are taking a toll on primary care, was published in June 2022.
In the 2019 NHS long term plan, NHS England set out its ambition to achieve the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care, with the intention of providing more personalised, joined-up care to patients.1 To achieve this, a restructure was initiated, transforming the existing network of sustainability and transformation partnerships into local collaborations between hospitals, community and mental health trusts, primary care services, local authorities, and other care providers, termed integrated care systems (ICSs).2 By 2021, 42 ICSs had been established to deliver the place-based aspirations of the NHS long term plan, covering the whole of England and bringing resources and decision making closer to the populations served.1–3
To roll out the changes in primary care, the British Medical Association (BMA) and NHS England published Investment and evolution: a five-year framework for GP contract reform to implement the NHS long term plan, which translated the aims of the NHS long term plan into the GP services contract.4 The framework introduced automatic entitlement to a new contract for primary care networks (PCNs)—essential building blocks of ICSs comprising groups of GP practices working in partnership with local healthcare services to deliver care to local populations of 30,000–50,000 people.4 This new contract, the Network Contract Directed Enhanced Service (DES), outlined the core requirements and entitlements for PCNs.5,6 Reportedly, over 99% of general practices signed up to the PCN DES and are now part of one of the estimated 1250 PCNs across England.7
The PCN DES introduced new service specifications to be delivered by PCNs, although the implementation of some was delayed to enable the health system to prioritise its response to the COVID-19 pandemic.8 Three specifications (enhanced health in care homes, early cancer diagnosis, and structured medication reviews) were launched in 2020.5,6 Further specifications were introduced in October 2021 (cardiovascular disease diagnosis and tackling neighbourhood health inequalities, although in a reduced form) and in amendments to the PCN DES in 2022 (enhanced access, anticipatory care, and personalised care).9,10 However, in response to these contractual changes, the BMA stated that the implementation of additional specifications failed to acknowledge the unsustainable pressure currently facing primary care, and recommended a number of measures to help practices prioritise patient safety—including, if necessary, resignation from the PCN DES.11
Following calls to remove legislative barriers to ICSs,3,12 and in line with the provisions of the Health and Care Act 2022,13 ICSs were established as statutory bodies by NHS England on 1 July 2022; simultaneously, CCGs were closed down.14 According to NHS England, ‘Each ICS has an integrated care board [(ICB)], which is a statutory NHS organisation responsible for developing a plan in collaboration with NHS trusts/foundation trusts and other system partners for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the defined area.’14 However, although guidance has been issued on the composition of ICBs,1 the BMA has criticised their lack of clinical leadership.15
The Guidelines in Practice Readership Survey
In 2021, Guidelines in Practice conducted a survey of its readers to discover their experiences and expectations of the NHS restructure.16,17 Its questions invited readers to share their views on the feasibility of enacting the changes, and whether the restructure would deliver the anticipated benefits for healthcare professionals and patients—hence, its findings provided a snapshot of respondents’ attitudes towards the reorganisation while it was being rolled out.16,17 The responses showed that healthcare professionals working in primary care were open to the idea of new ways of working, and believed that the changes had the potential to improve patient care.16,17 However, many felt that the restructure was being implemented at the wrong time, and that the problems it aimed to solve—workforce shortages, unsustainable workloads, and insufficient resources, amplified by the COVID-19 pandemic—were in fact barriers to its success.16,17
many felt that the restructure was being implemented at the wrong time, and that the problems it aimed to solve … were in fact barriers to its success
Following the formalisation of ICSs as legal entities, Guidelines in Practice resurveyed its readers in May 2022 (see Box 1 for a breakdown of the participants). We hoped to understand the current state of general practice, and sought participants’ opinions on workload, workforce, and PCN development.18 This article analyses the survey’s findings in light of the progression of the NHS restructure, and asks: what does the future hold for primary care?
|Box 1: Breakdown of Survey Respondents by Sector and Role|
Of the 366 healthcare professionals who responded to the survey:
Of those surveyed:
[A] Respondents were allowed to skip questions, so the statistics reported in the article refer to the proportion of participants that answered each question.
AHP=allied health professional; PCN=primary care network
How is Primary Care Experiencing the Restructure?
In May 2022, 79.3% of respondents said that their practice was part of a PCN, and 2.4% that their practice was planning to become part of a PCN in future. The sum of these participants, 81.7%, is less than the ‘over 99%’ of practices that NHS England states are involved in a PCN.7 What does this discrepancy reflect?
One explanation is that PCNs are continuing to evolve—forming, changing, and dissolving. Accordingly, 1.8% of respondents stated that that their PCN had recently been or would soon be terminated, and 16.5% said that their practice was not currently involved in a PCN.
1.8% of respondents stated that that their PCN had recently been or would soon be terminated, and 16.5% said that their practice was not currently involved in a PCN
Why Are Some Practices Opting Not to Participate in PCNs?
Although most of the participants said that their practice is able to meet the PCN DES service specifications that have been introduced in full (see Figure 1), many identified barriers to their implementation—the biggest being the workforce shortfall in primary care (see Figure 2).
Figure 1: Is your Practice Able to Meet the Requirements of the PCN DES?
Figure 2: Are There Any Obstacles to Achieving PCN DES Requirements?
Furthermore, 58.1% said that implementing these service specifications was hampering their practice’s ability to provide other services. Analysis of the responses by role revealed that 71.4% of GPs felt that complying with PCN DES requirements was an obstacle to the delivery of routine care, compared with 50.6% of nurses and 46% of pharmacists.
71.4% of GPs felt that complying with PCN DES requirements was an obstacle to the delivery of routine care
Workforce: A Key Barrier to PCN Development
One of the principal ambitions of PCN development is to expand the primary care workforce, firstly via the recruitment of new GPs and nurses in line with the objectives of the NHS long term plan,1,3,4 and secondly via the expansion and diversification of the primary care team through the creation of new posts.3,4,5,10,19,20
However, the Government has failed to fulfil successive commitments to recruit more GPs and nurses,21,22 and the resulting pressure on general practice, coupled with an ageing primary care workforce, has led to an exodus of primary care staff.21,23 Furthermore, the Additional Roles Reimbursement Scheme (ARRS), introduced in the PCN DES and providing funding for 26,000 additional members of the multidisciplinary primary care team, has not relieved the pressure on GPs as anticipated.5,10,19,20 The findings of the 2021 Guidelines in Practice survey revealed that the ARRS had actually increased the pressure on GPs: participants cited difficulties related to recruiting, accommodating, and training ARRS staff.16,17
In response to the 2022 survey, 64.0% of respondents said that they had vacancies in their primary care team. Of these vacancies, 46.8% were clinical, 6.8% were administrative, 2.1% were ARRS posts, and 44.2% were a combination of all three.
When asked about the impacts of these unfilled posts, 84.9% felt that they would impact patient care, and 89.7% that they would harm team morale. Notably, 60.6% said that they thought vacancies in the practice will affect PCN development—implying that, for some, the restructure has become self-inhibiting.
60.6% said that … vacancies in the practice will affect PCN development—implying that, for some, the restructure has become self-inhibiting
Other consequences of the workforce shortfall on the primary care team are shown in Figure 3.
Figure 3: What Aspects of Your Work Will be Affected by Unfilled Vacancies?
Consequences of the Pressures Facing Primary Care
At a time of unprecedented pressure on the NHS—with rising demand, a backlog of care created by the pandemic, and insufficient resources—staff shortages are compounding the burden on a system that is already overstretched. When asked about their workload over the preceding year, 54.4% of respondents reported that it had been heavier than normal, and 25.6% said that it had been unmanageable. Furthermore, 76% of participants anticipated that their workload would be getting heavier in future.
54.4% of respondents reported that [their workload] had been heavier than normal, and 25.6% said that it had been unmanageable
The measures employed by respondents’ practices to manage workload are shown in Figure 4. These included employed include new ways of working adopted during the pandemic, such as remote consultations, and measures made possible by the restructure, such as redirecting patients to members of the multidisciplinary primary care team.
Figure 4: What Measures Have Been Used by Your Practice to Manage Workload?
However, when we asked how useful these measures have been at reducing workloads in primary care, the survey participants were divided on their effectiveness (see Figure 5). Similarly, there was little consensus on whether the measures conferred benefits for patient care (see Figure 6). The most helpful measures cited by the respondents for reducing workloads and improving patient care were:
- redirecting patients from GPs to other members of the primary care team (59.7% and 64.4%, respectively)
- increasing workforce capacity (56.7% and 64.4%, respectively).
Figure 5: Have These Measures Been Successful at Reducing Workload?
Figure 6: Have these Measures Been Successful at Improving Patient Care?
Actions That Practices May Take in Response
In recognition of the burden on primary care, the BMA has encouraged practices to prioritise the safety of their patients and staff by considering a range of actions, from auditing their practice workload and prioritising tasks, to closing their registration lists to new patients and even discontinuing with the PCN DES.11 We asked our respondents what measures, if any, their practices were planning to implement if unable to meet the PCN DES requirements. The responses are shown in Figure 7.
Figure 7: If Your Practice is Unable to Meet PCN DES Requirements, What Action Could it Take?
The measure most commonly reported by those surveyed in response to being unable to meet PCN DES requirements was workload prioritisation (65.4%), followed by auditing workload (33.0%). However, 9.9% of participants stated that their practices would consider resigning from the PCN DES.
9.9% of participants stated that their practices would consider resigning from the PCN DES
When we analysed the responses by role, more nurses (75.0%) and pharmacists (70.4%) cited workload prioritisation than GPs (56.7%). Likewise, more nurses (41.2%) and pharmacists (37.0%) selected auditing workload than GPs (23.3%). However, many more GPs (20.0%) than nurses (2.5%) or pharmacists (7.4%) chose resignation from the PCN DES.
Attitudes Towards the Future of the Restructure
Given current pressures, it is perhaps unsurprising that 67.1% of the survey participants felt that implementation of the next round of PCN DES specifications should be delayed. Analysis of the responses by role showed that 88.5% of GPs agreed with delaying further service specifications, compared with 59.8% of nurses and 60.7% of pharmacists.
88.5% of GPs agreed with delaying further service specifications, compared with 59.8% of nurses and 60.7% of pharmacists
Those surveyed did identify some opportunities for general practice in the restructured NHS (see Figure 8), including the delivery of more integrated, personalised care, faster and closer to patients’ homes. Of the participants, 58.5% were looking forward to an increased skill mix in the primary care team, and 48.3% anticipated that patients would be more in control of their own health.
Figure 8: What Opportunities Lie Ahead for Primary Care?
However, several respondents offered written responses suggesting that there are not many opportunities open to primary care (see Box 2). Indeed, when asked about challenges facing primary care, it is clear that many respondents were not optimistic about the future of primary care, and felt that only challenges lie ahead (see Figure 9).
|Box 2: What Opportunities Lie Ahead for Primary Care? ('Other' Responses)|
‘None of these above options are opportunities. They are proposals, but all rely on having the workforce and capacity to change yet again. There are no realistic opportunities on the horizon.’
‘I don’t know—I've resigned from my partnership to go elsewhere as [a] salaried GP before the overload and burnout permanently damage my mental and physical health.’
‘[I] cannot see that more change is going to help primary care.’
‘We need more trained and skilled staff [for all of the opportunities listed in Figure 8].’
‘It’s okay to have several additional roles, but they are all disjointed: too many cooks ruin it all while just doing a half job.’
‘I am not sure any [of the opportunities listed in Figure 8] … will result in improvements.’
‘Time to have an improved model of care that looks after staff too.’
‘I can't see any opportunities without massive investment in the whole NHS—a very long-term commitment to it with more, much more, money.’
‘Working at scale is damaging for practices and patients—patients get less continuity and less care, professionals become depersonalised, and morale is low.’
‘Not really sure [what opportunities lie ahead for primary care] due to workforce [shortages] and [the] growing patient population.’
Figure 9: What are the Biggest Challenges Facing Primary Care?
The 2022 Guidelines in Practice readership survey has provided insight on respondent’s attitudes to the restructuring NHS, and revealed the limiting effect of workforce shortages on implementation of the changes in primary care. The survey’s findings suggest that the restructure has brought primary care to a tipping point: without an increase in workforce capacity, practices may be forced to adopt measures to prioritise patient and staff safety, calling the future of the restructure into question.
By Dr David Jenner, GP, Cullompton, Devon; Guidelines in Practice Editorial Advisory Consultant on commissioning
'You can’t do owt with nowt' is an old Northern expression, and if we could summarise the response to the Guidelines in Practice readership survey on PCNs in just a few words, it would seem very apposite. In this case, 'owt’ relates to staff, especially clinical staff, rather than money, from what we can interpret from readers' responses.
PCNs evoke mixed emotions among GPs and primary care staff, with some seeing definite improvements to care through the recruitment of additional staff, but others feeling frustrated that they cannot recruit enough of the approved staff, or cannot get ARRS funding for the staff they need—in particular, GPs, nurses, nurse practitioners, and managers. It is difficult to judge the success of PCNs in the light of the COVID-19 pandemic, which has affected the NHS and wider society so deeply, but Freedom of Information requests in 2022 showed that 40% of the available ARRS funding was left unspent in the first 2 years of the scheme.[A]
There was also what appeared to be a fundamental policy precept at the outset of the 5-year GP contract that recruiting other members of staff would help to mitigate the shortfall in qualified GPs and nurses, and relieve them of work. As demonstrated by the 2021 Guidelines in Practice readership survey,[B],[C] this does not seem to reflect reality, with many respondents citing insufficient time and resource for recruiting, managing, training, supervising and even physically accommodating these staff. Undoubtedly, some—like paramedics and pharmacists—can relieve part of the workload facing GPs, but byzantine stipulations in the PCN DES about the need for qualifications and training for these staff meant that the pool of available, ready-qualified staff was quickly exhausted.
Supply of pharmacists has been a particular problem in many areas, leading to widespread shortages of pharmacists in community pharmacies, and many PCNs not being able to recruit. Pharmacists have now been added to the Government's Reserved Occupations list to allow easier overseas recruitment—although we were assured at the start of the 5-year contract they were in plentiful supply.
Where practices have been able to recruit new clinical staff, they have found appropriate redirection of work to be beneficial to them and their patients.
PCNs remain a critical element of current NHS strategy, yet they remain very much in transition—organisations that have grown out of a contract settlement that had no accompanying workforce, capital, or premises plan. So it is perhaps little surprise that problems are being encountered.
In response to the 2022 survey, most practices said that they were able to deliver the specifications of the PCN DES, but in truth, most CCGs and now ICBs have never really monitored or enforced the contract specifications due to the pandemic and now extreme NHS pressures. Much of the IIF reward framework has slipped or been paid anyway in recognition of the pressures practices face, and attitudes may have been different if contracts had been rigorously enforced.
Very few practices have opted out of PCNs altogether, but the LMC Conference has mandated the BMA GPC to remove practices from PCNs by 2023, a mandate that seems unlikely to be fulfilled.
Subsequent to this survey, the cross-party Health Select Committee recommended in its report The future of general practice that ARRS funding be made more flexible, and that funding should be provided for training and supervision of these staff.[D] It also recommended that the QOF and the IIF be abolished, and the monies reinvested in the core GP contracts.
The report also stated this about GP partnerships:[D]
'It is regrettable that during a time of intense pressure for GPs, following a massive effort by GPs to lead the vital covid-19 vaccination programme, that GP partners were subjected to such open speculation and uncertainty about their futures. It is welcome that the Government and NHS England have confirmed that there is no policy to end the partnership model, which is a positive first step to reassuring GP partners.'
However, for GPs, it is extremely disappointing that the Shadow Secretary of State for Health and Social Care, Wes Streeting MP, started 2023 by saying 'I’m minded to phase out the whole system of GP partners altogether and look at salaried GPs working in modern practices alongside a range of other professionals.'[E]
So, PCNs and GPs face an uncertain future, with the 5-year contract deal expiring in March 2024 and the BMA seeking to renegotiate a contract that includes the PCN element—and potentially featuring a more radical reorganisation, if a Labour government is elected in future.
Readers have mixed views, but in my experience, people welcome the introduction of PCNs as a concept and the additional resources that come with them (both financial and workforce)—but the accompanying overbureaucratic and overspecified PCN DES has been a disaster.
[A] Carter R. Up to 40% of ARRS funding unspent in first two years of scheme. www.pulsetoday.co.uk/news/pulse-pcn/up-to-40-of-arrs-funding-unspent-in-first-two-years-of-scheme (accessed 27 January 2023).
[B] Buchan N. NHS restructure survey: grounds for optimism, but barriers remain. www.medscape.co.uk/s/viewarticle/nhs-restructure-survey-grounds-optimism-barriers-remain-2022a100184q (accessed 13 October 2022).
[C] Buchan N. Additional support is required to harness the potential of the NHS restructure. www.medscape.co.uk/s/viewarticle/additional-support-required-harness-potential-nhs-2022a10015nv (accessed 13 October 2022).
[D] UK Parliament website. The future of general practice. publications.parliament.uk/pa/cm5803/cmselect/cmhealth/113/report.html (accessed 27 January 2023).
[E] Taylor H. Labour ‘would tear up contract with GPs’ and make them salaried NHS staff. www.theguardian.com/society/2023/jan/07/labour-would-tear-up-contract-with-gps-and-make-them-salaried-nhs-staff (accessed 27 January 2023).
PCN=primary care network; ARRS=Additional Roles Reimbursement Scheme; DES=Directed Enhanced Service; ICB=integrated care board; IIF=Investment and Impact Fund; LMC=local medical committee; BMA=British Medical Association; GPC=General Practice Committee; QOF=Quality and Outcomes Framework