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Primary care networks and the deprivation challenge: are we about to widen the gap?  

The newly emerging primary care networks provide an opportunity to tackle health inequalities in England but, as Rebecca Fisher and Beccy Baird explain, they will have to be careful to avoid perpetuating the problem

In the face of a growing health gap between rich and poor in England, the NHS long-term plan explicitly commits to a focus on “health inequality reduction.” The roots of socioeconomic inequalities lie deep within communities, and general practice—itself rooted in communities—is key to addressing the problem. As practices scrabble to organise themselves into primary care networks, making meaningful progress towards reducing health inequalities requires these networks to be part of the solution. But unless a combination of quirks, oversights, and loopholes in their design and contracting are addressed, there is a risk that they could perpetuate the problem.

Funding

The Carr–Hill formula—used to weight funding for GP practices—has frequently been criticised for not sufficiently taking the impacts of deprivation in to account. [1] Despite promises from NHS England and the British Medical Association to address this, the new GP contract fails to do so. As a result, the weighted component of per-capita funding for primary care networks is based on a formula which systematically under-funds practices in areas with the most need. Some of the other sources of income for primary care networks (an annual uplift of £1.50 per patient from clinical commissioning groups (CCGs), and funding for extended hours and extended access) aren’t weighted at all—meaning that networks servicing populations with the greatest needs will continue to do so with disproportionately less resource.  

There is a commitment that down the line primary care networks will be able to unlock extra funding from an “investment and impact fund”—essentially a savings scheme accessible to them if they are able to achieve specific targets. Examples given include reductions in accident and emergency attendances and delayed discharges, but these are likely to be easier to achieve in some areas than others. A variety of mechanisms could be used to mitigate this—offering higher payments in deprived areas being one example. Policy makers must specifically consider the impact of deprivation on ability to unlock funding if there is to be equality of access to funds for those with the greatest need, let alone access in proportion to need.

Outside the contract, there are potentially other sources of funding available—NHS England is clear that it expects CCGs to use some of their additional funding for inequalities to boost primary care capacity and access. However, we have heard reports of CCGs withdrawing locally incentivised services which tackle health inequalities, citing the need to free funds to make the £1.50 per head “core funding” payment for primary care networks.

Workforce

It’s already clear that the workforce crisis in general practice is disproportionately affecting deprived areas. Between 2008 and 2017, the number of GPs working in the most deprived 20 per cent of areas fell by 511, in contrast to the wealthiest 20 per cent, where 134 additional GPs were recruited. The opportunity to expand teams, deliver care in different ways, and reduce GP workload by drawing on the army of physiotherapists, pharmacists, and paramedics announced alongside the contract is exciting, but must be equally available to all primary care networks.

Even on the optimistic assumption that the promised 20,000 additional staff will be available to primary care networks, there aren’t yet mechanisms to try to level the playing field for recruitment. Although some of them will decide to work in areas of greater need (and often greater workload), opening an early discussion about other levers—financial or otherwise—to attract more seems sensible. Otherwise there’s a risk that the PCNs serving the most deprived populations will be least able to recruit, perpetuating the current problem of under-doctoring in these areas.

Danger dominoes

The number of practices closing has risen rapidly in recent years, and the most affected areas have strikingly similar profiles. Areas with older, poorer populations and older GPs (often rural and coastal locations where attracting new staff has been particularly difficult) have borne the brunt of practice closures, with knock on increases in pressure for the practices still standing. Geographically grouping practices might allow primary care networks to offer more attractive and diverse job roles and to reduce workload by streamlining back office functions. But where the entire geography of a primary care network is an area of high deprivation, increasing inter-dependence between neighbouring practices that are already vulnerable risks a domino effect—where the failure of a single practice drags others with it.

In networks with only small pockets of deprivation within more affluent areas, or where a very small area has a particular defined need (such as a practice specifically providing care to homeless people), a single practice serving that group may find itself and its specific needs isolated within a larger network of practices. How primary care networks address these very specific and local needs will be important, taking care to ensure that the priorities of the majority do not mean the needs of minorities are not met.

Problems to recognise, opportunities to grasp

Although the timelines for their development are ambitious, and details of support and evaluation strategies rapidly required, primary care networks are an exciting opportunity for general practice. General practice can and must do more to reduce health inequalities, but the areas with the highest socioeconomic need will often require the most support. The risks outlined above demonstrate some of the ways in which primary care networks could widen an inequality gap, but this is far from inevitable if policy makers recognise the problems and work to find solutions.

Rebecca Fisher, Policy Fellow, The Health Foundation

Beccy Baird, Senior Fellow, The King’s Fund

Competing interests: None declared

References:

  1. Kontopantelis E, Mamas MA, van Marwijk H, Ryan AM, Bower P, Guthrie B and Doran T (2018). ‘Chronic morbidity, deprivation and primary medical care spending in England in 2015-16: a cross-sectional spatial analysis’. BMC medicine16(1), p19.