Jonathan Hammond

The recently published NHS 10 Year Health Plan¹ envisages an NHS built around ‘neighbourhood health services’, with a significant rebalancing of investment and spending away from hospitals to services delivered in local communities. The plan is clear that each area will be free to develop its own service model, but a number of elements are highlighted as being important. These include:

Objectives Access to general practice in England is a challenging issue of enduring importance. COVID-19 precipitated various abrupt changes, exposing and compounding existing problems. The access as human fit conceptualisation provides a nuanced understanding of access that extends beyond a limited focus on appointment numbers and speed. This qualitative study explored the pandemic’s impact on access to general practice and the experiences of patients and healthcare staff in England using access as human fit as an analytical framework. Design A community-based participatory approach underpinned by qualitative semi-structured interviews and focus groups, and observations. Setting and participants The following were conducted in Northwest England (December 2021—August 2022): interviews (10 participants) with patients, general practice staff and professionals; seven focus groups (42 participants) with patients from general practice patient groups and underserved groups; and twenty observation sessions of non-clinical access encounters (seven general practice and Primary Care Network premises; 45 hours total). Analysis A rapid qualitative analysis methodology facilitated an abductive thematic approach, applying the dimensions of access as human fit to the data. Results The access as human fit framework highlighted key areas where there is a lack of fit between patients and staff. Patients expressed that the array of access options and changes made it hard to know how to be a patient; some thought general practice should be ‘back to normal’ and the pandemic was an excuse to restrict access. Providers reported working harder than ever with insufficient resources. Conclusions The pandemic created greater distance between staff and patient realities of access. Access as a human fit facilitated in-depth exploration of patient and staff experiences, improving understanding and identifying key issues. Broader adoption and application of this framework, within policy and practice, could focus improvement efforts, optimise access fit and improve patient satisfaction and staff retention.

Background: Declining continuity of care in England could disproportionately affect some patient groups. Aim: To examine patients’ perceptions of continuity of primary care, identify factors associated with continuity, and measure changes in continuity of care for different patient groups, following primary care network (PCN) implementations. Design & setting: Cross-sectional surveys were undertaken of patients from three groups (older adults with polypharmacy, patients with mild or moderate anxiety or depression, and working-age adults [18–45 years]), attending 19 practices in five PCNs in England, at two timepoints (November 2021–April 2022 and November 2022–April 2023). Method: Relational continuity was measured using the Nijmegen Continuity Questionnaire (NCQ) score. Differences between patient groups and two timepoints were tested using multiple linear regression. Results: Survey response rates were n = 362/1547 (23%) and n = 350/1528 (23%). Adults with polypharmacy experienced significantly better continuity than adults with anxiety or depression and younger working-age adults after adjusting for PCN, practice, and population-level characteristics ( P < 0.05). Those who always or sometimes saw their preferred GP experienced significantly better continuity than those who never did ( P < 0.01). PCNs with pre-existing inter-practice collaborations were not associated with differences in relational continuity. Conclusion: We found differences in experienced continuity of care between patient groups. Relational continuity depends on seeing a preferred GP, not a non-preferred GP or other healthcare professional (HCP). Better continuity was associated with larger practice networks.

Objectives: To develop a model to support health systems in clarifying how they might target action to reduce health inequalities, and to use it to understand current policy on health inequalities in England. Methods: We used the wider literature on the definitions of health inequalities to draw together a schematic model which attempts to link together the different conceptualisations of health inequalities present in the literature with potential sites of action that could be taken by local health systems. We then undertook a document analysis of the policy documents and programmes underlying the recent reorganisation of the NHS in England. Results: The need to tackle health inequalities is cited as one of the main rationales underlying the changes. However, there is a lack of clarity within the documents around: the type of inequality being addressed; the identification of the group(s) suffering from inequalities; and the ways in which the assumed ameliorative mechanisms will work in practice. The documents place considerable emphasis on the assumption that closer partnership working will address inequalities, although the mechanisms by which this will be achieved are not specified and previous research demonstrates how difficult this can be. Conclusions: The aspiration to tackle health inequalities through newly constituted Integrated Care Systems and Boards is welcome. However, it is well known that the contribution that health care services can make to addressing inequalities is relatively limited. Greater clarity is required of policy and local strategy if efforts are to be appropriately targeted.

The figure of a dragon-like and unsympathetic receptionist primarily focused upon keeping patients out of practices² remains sadly prevalent,¹ despite research going back decades highlighting the complex realities underlying the trope,³ and the experience of practice staff of increasing abuse as they sit on the front line of an access crisis.⁴ Against this backdrop, Ban et al’s¹ review is timely. They found that, despite receptionists operating as key members of the practice team, with the potential for a significant impact on both patient experience and safety,^5,6 they continue to operate without adequate recognition or training. They highlight the extent to which reception roles involve clinical decision making, without either training or support for this aspect of their role.

The physical spaces in which primary healthcare is delivered matter and have the potential to profoundly affect both patients and staff. This potential is illustrated by academics, who describe the connection between the spaces in which care is delivered and how cared for, and well, patients feel.^1,2,3 Considering healthcare space as a ‘passive background’¹ underestimates its impact.¹ Instead, conceptualising space as ‘active’ better describes its role as ‘participative in the very making of care and health’.¹ While many existing studies focus on hospital settings, there is evidence to suggest that the same is true for primary care.

Background: Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities.Aim: To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities.Design and setting: A sequential mixed-methods study of PCNs in England.Method: Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019–2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020–March 2022).Results: Across 1243 networks in 2019–2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022–2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally.Conclusion: Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.

Background: The Additional Roles Reimbursement Scheme (ARRS) provides funding to Primary Care Networks (PCNs) in England to recruit additional staff into specified roles. The intention was to support general practice by recruiting an extra 26 000 staff by 2024, increasing access and easing workload pressures.Aim: To explore the establishment of the ARRS as part of PCNs’ development to understand their role in supporting general practice.Design and setting: A longitudinal, qualitative case study involving seven geographically dispersed PCNs across England.Method: Data were collected from July 2020 to March 2022, including 91 semi-structured interviews and 87 h of meeting observations. Transcripts were analysed using the framework approach.Results: Implementation of the ARRS was variable across the study sites, but most shared similar experiences and concerns. The COVID-19 pandemic had a significant impact on the introduction of the new roles, and significant variability was found in modes of employment. Cross-cutting issues included: the need for additional space to accommodate new staff; the inflexibility of aspects of the scheme, including reinvestment of unspent funds; and the need for support and oversight of employed staff. Perceived benefits of the ARRS include improved patient care and the potential to save GP time.Conclusion: The findings suggest the ARRS has potential to fulfil its objective of supporting and improving access to general practice. However, attention to operational requirements including appropriate funding, estates, and management of staff is important if this is to be realised, as is clarity for the scheme post-contract end in 2024.

Objectives This study aimed to evaluate primary care networks (PCNs) in the English National Health Service. We ask: How are PCNs constituted to meet their defined goals? What factors can be discerned as affecting their ability to deliver benefits to the community, the network as a whole and individual members? What outcomes or outputs are associated with PCNs so far? We draw policy lessons for PCN design and oversight, and consider the utility of the chosen evaluative framework. Design and setting Qualitative case studies in seven PCN in England, chosen for maximum variety around geography, rurality and population deprivation. Study took place between May 2019 and December 2022. Participants PCN members, staff employed in additional roles and local managers. Ninety-one semistructured interviews and approximately 87 hours of observations were undertaken remotely. Interview transcripts and observational field notes were analysed together using a framework approach. Initial codes were derived from our evaluation framework, with inductive coding of new concepts during the analysis. Results PCNs have been successfully established across England, with considerable variation in structure and operation. Progress is variable, with a number of factors affecting this. Good managerial support was helpful for PCN development. The requirement to work together to meet the specific threat of the global pandemic did, in many cases, generate a virtuous cycle by which the experience of working together built trust and legitimacy. The internal dynamics of networks require attention. Pre-existing strong relationships provided a significant advantage. While policy cannot legislate to create such relationships, awareness of their presence/absence is important. Conclusions Networked approaches to service delivery are popular in many health systems. Our use of an explicit evaluation framework supports the extrapolation of our findings to networks elsewhere. We found the framework to be useful in structuring our study but suggest some modifications for future use.