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 socio-economic 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 (PCNs), 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.
Addressing the funding problems
The Carr-Hill formula – used to weight funding for GP practices – has frequently been criticised for not sufficiently taking the impacts of deprivation into account. 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 fewer resources.
There is a commitment that down the line PCNs 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 A&E 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. Policymakers must consider the impact of deprivation on the ability to unlock funding specifically, 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 PCNs.
Breaking the workforce cycle
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% of areas fell by 511, in contrast to the wealthiest 20% 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, thereby perpetuating the current problem of under-doctoring in these areas.
In danger of a domino effect
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 geographical area of a PCN is 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, PCNs are an exciting opportunity. General practice can and must do more to reduce health inequalities, but the areas with the highest socio-economic 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 policymakers recognise the problems and work to find solutions.
This blog was originally published in the BMJ on 8 May 2019, and was jointly authored by Dr Rebecca Fisher (@BecksFisher), Policy Fellow at the Health Foundation, and Beccy Baird (@BeccyA), Senior Fellow at The King’s Fund.
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