NHSE’s Network Contract Directed Enhanced Service Specifications; What are they, and why do they matter?
Sally Greenbrook is BGS's Policy Manager. She has more than a decade of experience in the UK health policy sector, having worked for the Department of Health and, most recently, as Policy Manager for Breast Cancer Now. She has for many years had an interest in the health and care of older people, having written her MA thesis on housing for older people. She tweets at @SallyGreenbrook
Over the Christmas/New Year period, NHS England and NHS Improvement held what must have been one of the shortest and unfortunately ill-timed public consultations ever by publishing the Draft Outline Service Specifications for the Network Contract Direct Enhanced Service on 23 December and giving stakeholders just 3.5 weeks to respond. Never ones to shirk from a challenge, the holiday period saw the BGS’s dedicated officers and staff members work flat out to produce a comprehensive 11-page response (not me though, I was in New Zealand so I just helped with the finishing touches in the last couple of days). So what are the specifications, what does BGS think and what are we doing about it?
What’s this about?
Network Contract Direct Enhanced Service Draft Outline Service Specifications. Yeah, I know, it’s not exactly the catchiest or most interesting title but the importance of this document to the way healthcare is delivered to older people in England cannot be overstated.
In January last year, NHS England and GPC England agreed a five-year GP contract framework which aimed to alleviate the workforce pressures on general practice, secure investment in primary care and, in collaboration with other providers, roll out new service models. Part of the new contract framework was to establish Primary Care Networks (PCNs) through the new Network Contract Direct Enhanced Service (DES). The contract framework set out seven national service specifications that will be added to the Network Contract DES – five to start from April this year and the remaining two from April next year. This consultation provided details on the requirements of PCNs and other providers for the first five of these specifications. The final version of these specifications will form part of the annual GP contract negotiations, and all practices signed up to the DES in 2020/21 will be required to deliver these services. So this is incredibly important for how PCNs, GP practices and other community providers plan their services and deliver care to older people.
What does BGS think?
Well, the good things first. We appreciate that the short consultation period was due to the timing of both the election and the GP contract negotiations. As such, we commend NHS England and NHS Improvement for consulting on this at all and hope that this becomes the norm for important documents such as this. The overall direction of travel of the specifications is positive and much of the content will (either directly or indirectly) benefit older people. We welcome new investment to enhance primary care workforce through the Additional Roles Reimbursement Scheme (ARRS) and we support advice given on developing information sharing agreements to foster collaboration across provider organisations.
We are concerned however that the specifications dilute the focus on older people and healthy ageing that was such a crucial part of the NHS Long Term Plan, and the Ageing Well programme. The DES has a very wide scope and demands a lot of PCNs, especially as most are still in their infancy. The specifications place a large amount of extra, unfunded work at the feet of GPs and we feel that the assumption that PCNs will easily be able to recruit the workforce needed to deliver these specifications is naïve. We don’t think the specifications adequately consider the demographic differences across the country and the varying populations that PCNs will be serving. Some PCNs will serve areas of socio-economic deprivation associated with multimorbidity and frailty in mid-life while others will have a more affluent older population with higher rates of dementia and institutional care. We feel that many of the expectations in the specifications are unrealistic, not giving PCNs adequate time to get teams and systems in place to deliver what is needed for their local communities.
We also have concerns about three specific specifications that we feel have particular relevance to older people’s healthcare – structured medication review (SMR), enhanced health in care homes (EHCH) and anticipatory care.
We were pleased to see the focus on structured medication reviews to reduce inappropriate polypharmacy – we know this is a significant problem in older people, something we commented on when Age UK published a new report on the topic last year. However, the metrics for this specification include the number of SMRs conducted rather than, for instance, a reduction in the number of people with inappropriate polypharmacy or a reduction in the number of drug-related hospital admissions. The specification also does not target specific drugs – we felt the specification would have a greater patient benefit if targeted towards drugs associated with harm in older people with frailty such as antipsychotics, sedatives and anticholinergics.
We know that it is important for people living in care homes to have access to good quality on-site healthcare and that continuity of care is so important for this population. The focus on this in the ECHC specification is very much welcome. We felt that the EHCH specification failed to acknowledge the diversity in providers in the care home sector and the ongoing crisis in social care. The specification requires data sharing between care home providers and the NHS, something that would be a significant challenge in many areas given that care homes are operated by both public and private providers. The specification also introduces the idea of a weekly ward round for care home residents which must, at least fortnightly, be conducted by a GP. Carrying out this requirement would take a full-time GP away from their main primary care caseload, creating a capacity gap which is not funded.
We found the anticipatory care specification vague, particularly in terms of the population targeted. We believe that this specification could be improved by explicitly targeting people with complex multiple conditions and those with moderate-severe frailty who are not able to leave their house or are in supported living. Segmentation tools for this population group already exist (we suggest using the Electronic Frailty Index supplemented with other methods for identifying complexity) which would allow this group to be targeted for assessment and appropriate interventions.
What are we doing about it?
Informed by a survey of our members (thanks to all who responded) we have formed the above points, and many more, into a detailed response to the service specifications which we have submitted to colleagues at NHS England for their consideration. We have, where possible, suggested ways that we believe the specifications could be revised to deliver improvements to primary care to help older people with frailty to achieve better health outcomes closer to home. We have also offered NHS England the support of our members and staff team in further developing these specifications – an offer we sincerely hope will be taken up. We will keep you posted as work in this area continues to develop.