Primary Care Networks : The proposed evolution of the Network Contract DES

9 JANUARY 2020

| 1 min read

The much-anticipated draft specification for the revised Network Contract Direct Enhanced Service Network Contract (DES) was released on the 19th December and is open for consultation until the 31st January 2020.

The draft specification establishes the requirements for Primary Care Networks (PCNs) in respect of five of the seven national service specifications that will ultimately be added to the Network Contract DES.

The first five services cover:

Structured medication reviews and optimisation
Enhanced health in care homes
Anticipatory care
Personalised care
Supporting early cancer diagnosis

Whilst the draft specification confirms that 99% of GP practices in England have signed up to the Network DES (creating around 1250 networks), there can be no doubt that PCNs are in their infancy and many were cautiously waiting to see how far reaching the service specifications are.

But what do the draft specifications propose?

Financial sustainability
In recognition that many PCNs have queried the sustainability of networks given that the majority of funding is geared towards specific categories of additional staffing and is (in all cases other than social prescribers) capped at a maximum of 70% of the WTE of the relevant staff member, the draft specification reiterates:
- That each PCN receives a cash payment of £1.50 per registered patient (which provides over £109,000 for a PCN covering 50,000 patients).
- That, whilst the terms remain unclear, other funding is available including funding under the Investment and Impact Fund which could, according to the draft specification, equate to circa £60,000 in 2020/21 rising to £240,000 by 2023/24.
Phasing
In recognition that PCNs are developing, the introduction of the service specification will be phased so that:
- The service specifications for Structured Medication Reviews and Optimisation along with Enhanced Health in Care Homes will apply in full from 2020/21.
- The remaining service specifications will phase in from 2020/21 to 2023/24.
Wider system

In many instances, the burden of delivering the service specifications will not just fall on GPs to deliver via the Network Contract DES. The draft specification makes it clear that there will be various requirements placed on the providers of community services and that these will be incorporated into the NHS Standard Contract from 2020/21.
Recruitment support

Where PCNs are struggling with recruitment, CCGs and wider systems should take action to support (which may include running shared recruitment processes).
Existing arrangements

In recognition of the fact that the national service specification may creep into existing locally commissioned services, CCGs are provided with some guidance on how to handle the potential duplication and the reinvestment of funding under locally commissioned schemes within primary medical care and community services.
The service specifications

Turning now to some of the key requirements under the five service specifications.
Structured Medication Reviews (SMR)
- PCNs will identify people who would most benefit from receiving an SMR (examples of the groupings of people have been included and cover all patients in care homes and patients with multiple long-term conditions).
- Only appropriately trained clinicians should undertake the SMRs (this could include Clinical Pharmacists, GPs or Advanced Nurse Practitioners).
- SMRs are expected to take longer than an average GP appointment and PCNs need to allow flexibility in appointment length depending on the level of complexity of the individual).
By April 2020

As part of delivering this service PCNs will need to satisfy a variety of conditions including:
1. identifying one clinical lead across the PCN for delivery of the service;
2. running locally determined processes twice a year (on a six-monthly basis) to identify patients that require SMRs;
3. developing processes for reactive SMR referrals;
4. offering SMRs to 100% of identified patients (albeit, and a point unique to SMRs, there is a possibility for a lower proportion to be delivered where the PCN can prove to the CCG that it has capacity/ workforce constraints); and
5. recording all SMRs.
Enhanced Health in Care Homes
- The overall aim is to improve the experience of residents in care homes, reduce avoidable admissions to A&E and provide support to allow residents to die in the place of their choosing.
- These aims will be achieved by providing residents of care homes with services that realise enhanced primary care support, multidisciplinary team support, reablement and rehabilitation and high-quality end-of-life and dementia care.
- All people that permanently live in care homes (both residential and nursing) are eligible for these services. This includes people in homes that deliver specialist support (e.g. learning disabilities and dementia units) but does not include people living in secure units for mental health.
- Whilst there is an acknowledgement that the geographical distribution of care homes will mean that PCNs will be unevenly affected, the solution (whether funding or otherwise) is yet to be determined.
By 30 June 2020

PCNs delivering this service will need to satisfy a variety of conditions including:
1. identifying one clinical lead across the PCN for delivery of the service;
2. ensuring that every person living permanently in a care home has a named clinical team (covering staff from the PCN and other providers);
3. ensuring that every care home is aligned to a single PCN (meaning that residents must register with one of the practices that make up the chosen PCN – such PCN to be agreed by the CCG);
4. establishing and managing a cross organisational multidisciplinary team to develop and monitor personalised care and support plans; and
5. establishing appropriate data sharing arrangements with wider system partners.
By 30 September 2020

PCNS should be:
1. delivering weekly, in person, home rounds for registered patients in their care homes;
2. owning and coordinating delivery of a personalised care and support plan with people living in their care homes based on assessments
3. co-ordinating one off regular support to people within their care homes based on their needs (including SMRs and activities to achieve goals);
4. identifying and assessing eligibility for urgent community response services;
5. supporting and assisting care homes on items such as the development of staff and the provision of vaccinations; and
6. establishing clear and efficient referral routes and clinical care transfer processes between care homes and providers.
Anticipatory Care
- The overall aim is to help people to live well and independently for longer through proactive care for those at high risk of unwarranted health outcomes.
- This aim is to be achieved by a process of identifying persons who would most benefit from the care and establishing a MDT that works together.
Whilst the ultimate service will be phased in, by 30 June 2020, PCNs will need to satisfy a variety of conditions including:
1. identifying one clinical lead across the PCN for delivery of the service;
2. presenting a coherent local Anticipatory Care model;
3. establishing appropriate data sharing arrangements with wider system partners;
4. Identifying a priority list of patients who are at risk of unwarranted health outcomes;
5. establishing and managing a MDT to meet regularly and co-ordinate the care to the cohort of people on the Anticipatory Care list;
6. co-ordinating and delivering needs assessments and reviews for people in the cohort; and
7. retaining overall responsibility for the delivery of a patient’s Anticipatory Care plan.
Personalised Care
- The overall aim is to empower patients and give them choice and control over the way their care is planned and delivered.
- To achieve this NHS England want to realise the “Comprehensive Model for Personalised Care” which it published in January 2019 (Universal Personalised Care: Implementing the Comprehensive Model).
- This model brings together six components being shared decision making, personalised care and support planning, enabling choice, social prescribing and community-based support, supported self-management and personal health budgets and integrated personal budgets.
Whilst the ultimate service will be phased in, from April 2020, PCNs will need to satisfy a variety of conditions including:
1. identifying one clinical lead across the PCN for delivery of the service;
2. increasing the number of personalised care and support conversations and plans for identified cohorts so that at least 5:1000 weighted population receives a personalised care and support plan;
3. promoting personal health budgets;
4. delivering shared decision-making for different clinical situations using available decision-making tools with the priority in 2020/21 being patients with MSK conditions;
5. facilitating training, shared learning and quality improvement for staff in the PCNs;
6. supporting the delivery of effective social prescribing so at least 4:1000 weighted population receive a referral; and
7. using the tool known as Patient Activation Measure to measure the knowledge, skills and confidence for set cohorts of patients (in 2020/21 this will be those newly diagnosed with Type 2 diabetes and people referred to social prescribing link workers).
Responding to the consultation

To provide feedback on the consultation, head over to NHS England’s consultation hub. Interested parties are asked to complete an online survey.

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Primary Care Networks : The proposed evolution of the Network Contract DES

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