From 1 July 2019, all patients in England should be covered by a primary care network (PCN). PCNs are made up from groups of neighbouring general practices. New funding is being channelled through the networks to employ staff to deliver services to patients across the member practices. PCNs are not new legal bodies, but their formation requires existing providers of general practice to work together and to share funds on a scale not previously seen in UK general practice. The hope of national NHS leaders is that PCNs will improve the range and effectiveness of primary care services and boost the status of general practice within the wider NHS.

PCNs are being introduced at a very difficult time for general practice. The NHS long term plan acknowledges that investment in general practice declined relative to the rest of the NHS between 2004 and 2014, while both demand and complexity of patient needs were rising. This has contributed to a fall in patient satisfaction and increased pressure on staff, which has exacerbated shortages of GPs and practice nurses, who have left the profession at a faster rate than it has been possible to replace them. Despite a target to increase the number of GPs by 5,000 between 2014 and 2020, the number of full-time GPs was 6% lower in 2018 than in 2015.

PCNs will receive funding to employ additional health professionals such as pharmacists and paramedics. Once they are established, The NHS long term plan envisages that the networks will also be a vehicle for improvements in primary care and broader population health, and give primary care more influence within the larger Integrated Care Systems (ICS) – geographically based partnerships of NHS organisations and local authorities – which will be in place across England by 2021.

PCNs are being established rapidly at a time when general practices have limited spare time and energy to invest in creating new networks. Formally announced in The NHS long term plan on 7 January 2019, the vision of what PCNs would be, and what they might be expected to do, was outlined in the 2019/20 GP contract published on 31 January 2019. Details of the funding (how much PCNs will receive and what is expected of them in return) were published on 29 March 2019. Practices had to organise themselves into networks and submit signed network agreements to their clinical commissioning group (CCG) by 15 May 2019. NHS England expects the network contract to provide 100% geographical coverage by 1 July 2019.

Joining a PCN is not compulsory for a GP practice. But by channelling a significant proportion of the increased funding for general practice – £1.8bn of the £2.8bn promised over 5 years in The NHS long term plan – through the network contract rather than directly to individual practices, NHS England has made it challenging for practices to abstain from joining PCNs.

This briefing places PCNs in the context of previous changes to general practice funding and contracting. It examines the rationale for networks, explores relevant evidence and draws out intended benefits and possible risks for the future of PCNs.

What are PCNs?

PCNs are groupings of local general practices that are a mechanism for sharing staff and collaborating while maintaining the independence of individual practices. NHS England has stipulated that networks should ‘typically’ cover a population of between 30,000 and 50,000 people (the average practice size is just over 8,000). There are likely to be around 1,300 PCNs across England. A single practice with a list size of over 30,000 can register as a PCN, and networks of over 50,000 will be allowed in some circumstances. Networks are expected to be geographically contiguous and co-terminous with local CCG and ICS footprints.

The networks are part of a set of multi-year changes, supported by the new 5-year GP contract published in January 2019. Neighbouring practices enter network contracts in addition to their core GP contract. Groups of practices collaborating as a network will have a designated single bank account through which all network funding – a significant proportion of future practice income – will flow. NHS England has calculated that by 2023/24 a typical network covering 50,000 people will receive up to £1.47m via the network contract.

What will they do?

The new GP contract is designed to deliver commitments made in The NHS long term plan, for example on medicines management, health in care homes, early cancer diagnosis and cardiovascular disease case finding. PCNs are the key vehicle for doing this. Once they are formed, networks will have responsibility for delivering seven national service specifications set out in the contract in return for the new funding (see Table 1).

Table 1: PCN service specifications

Service specification	Introduced from	Examples
Structured medicines review and optimisation	2020/21	Directly tackling over-medication, including inappropriate use of antibiotics. Focus on priority groups including the frail elderly.
Enhanced health in care homes	2020/21	PCN members expected to support the implementation of vanguard models tested between 2014/15 and 2017/18.
Anticipatory care	2020/21	Practices in PCNs to collaborate to offer more care, and more proactive care to patients at high risk of poor health outcomes.
Personalised care	2020/21	Implementing aspects of the Comprehensive Model of Personalised Care.
Supporting early cancer diagnosis	2020/21	Ensuring high and prompt uptake of cancer screening invites.
Cardiovascular disease prevention and diagnosis	2021/22	The Testbed Programme will test the most promising approaches to detecting undiagnosed patients, with subsequent roll-out across PCNs.
Tackling neighbourhood inequalities	2021/22	Approaches will be developed through the Testbed Programme and tailored to meet the specific context of PCN neighbourhoods.

The mechanism being used to channel funds to PCNs is the Directed Enhanced Service (DES). These are voluntary add-ons to the core GP contract, and have been used for several years to incentivise specific services, for example vaccination programmes, or care for people with dementia. The specific DES requirements of PCNs are set out in the Network Contract DES Specification and include the provision of extended hours (ie appointments outside the core contracted hours of 08.00–18.30, Monday–Friday). The focus of the Network Contract DES in 2019/20 is on establishing networks, with five of the seven service requirements coming in from 2020/21. Full details of the seven service requirements are yet to be published, but PCNs will be expected to deliver against an agreed set of ‘standard national processes, metrics and expected quantified benefits for patients.’

How will they do it?

PCNs will be expected to draw on the expertise of staff already employed by their constituent practices, and will receive funding to employ additional staff under an Additional Roles Reimbursement Scheme (ARRS). The work of the networks will be coordinated by a clinical director, a role that will be funded on a sliding scale depending on network size (equivalent to 0.25 of a whole-time equivalent (WTE) GP post per 50,000 patients).

The ARRS is the most significant financial investment within the Network Contract DES and is designed to provide reimbursement for networks to build the workforce required to deliver the national service specifications.

The five reimbursable roles are:

• clinical pharmacists (from 2019)
• social prescribing link workers (from 2019)
• physician associates (from 2020)
• first contact physiotherapists (from 2020)
• first contact community paramedics (from 2021).

The ARRS is intended to cover 70% of the ongoing salary costs of these posts, except for social prescribing link workers, whose costs will be 100% covered. The remainder of the cost of employing these allied health professionals will be met by member practices within the PCN. The sum invested in the ARRS will rise from £110m in 2019/20 to a maximum of £891m in 2023/24. If a network of 50,000 patients should choose to recruit all possible reimbursable roles, it would be eligible for additional ARRS funding of £92,000 in 2019/20, rising to £726,000 by 2023/24 (see Table 2). Suggested job specifications are provided, but PCNs will have flexibility to choose which staff they want and to write job descriptions tailored to local needs.

Table 2: Projected growth in funding for Additional Role Reimbursement Scheme, 2019–2024

	2019/20 (from July)	2020/21	2021/22	2022/23	2023/24
National total	£110m	£257m	£415m	£634m	£891m
Average maximum per typical network covering 50,000 people	£92,000	£213,000	£342,000	£519,000	£726,000

Source: NHS England and BMA. Investment and evolution: A five-year framework for GP contract reform to implement The NHS long term plan. 2019, p.11.

How are PCNs funded?

£1.8bn of the promised £2.8bn over 5 years of additional funding for general practice will flow through the Network Contract (see Table 3).

Table 3: Revenue streams for PCNs

Payment	From	Amount	Notes
Clinical director	CCGs to PCNs via Primary Medical Care allocations.	£0.514 per registered patient for the period 1 July 2019 to 31 March 2020.	Calculated on the basis of 0.25 WTE per 50,000 patients, at national average GP salary (including on-costs). This will be provided on a sliding scale based on network size.
Core PCN funding	CCGs to PCNs, from core CCG allocation.	£1.50 per registered patient.
Extended hours access appointments	CCGs to PCNs via Primary Medical Care allocations.	£1.45 per registered patient.	Pro rata over 12 months (equates to £1.099 per patient from July 2019 to March 2020).
Network participation payment	NHS England to individual practices.	£1.761 per weighted patient per year.
Additional Roles Reimbursement Scheme	CCGs to PCNs via Primary Medical Care allocations.	PCNs will be entitled to claim a percentage reimbursement of either 70% (or 100% for social prescribing link workers) as set out in the Network Contract DES, and subject to a maximum amount.	The roles for which payment will be made are clearly set out in the Network Contract DES, and payment will only be made once staff have been recruited.

Some of the funding (known as the network participation payment) will be received directly by practices, with the remainder of additional funding directed to the network. In addition, some funding previously received by individual practices (for provision of extended access) will now be allocated to networks instead (see Figure 1).

Figure 1: Funding for practices and networks, excluding new roles reimbursement

Note: Extended hours payments previously received directly by practices will now be paid to PCNs. A variable ARRS sum (not shown in Figure 1) will be added to the network payment, depending on the number of staff employed.

Although the plans for nationwide implementation of PCNs seem to have emerged very recently, they build on recent policy to encourage general practices to work at greater scale.

The 2014 Five year forward view for the NHS in England set out a vision for greater collaboration between general practices, as well as collaboration between general practices and wider community health services, hospitals and social care. GPs could opt to become involved in developing several new care models, including multispecialty community providers (MCPs) – networks of GPs that would integrate services with other health and care professionals in the community – and primary and acute care systems (PACS), which involved closer integration between primary care and hospital services for a local population.

The 2016 General practice forward view continued in a similar vein, promising the introduction of a voluntary MCP contract to integrate general practice services with wider health care services, encouraging GPs to work at scale across practices to collectively provide extended access, and promising additional allied health professionals in extended practice roles within primary care. In 2017, Next steps on the five year forward view announced an intention to ‘encourage’ practices to work together in hubs or networks of between 30,000 and 50,000 patients. The benefits of larger-scale models of general practice were described as allowing the employment and sharing of a greater range of staff (such as community nurses and pharmacists) without closing practices or forcing co-location of services.

Prior to The NHS long term plan, the approach had been to emphasise the voluntary nature of any collaboration and offer a variety of different forms through which collaboration might happen. Two elements differentiate PCNs from most pre-existing collaborations in general practice:

1. Practices working in formal collaboration with each other under a shared network agreement.
2. A shared income stream across practices forming a primary care network.

In most localities this represents a sizeable change to the way that general practice is run and funded. By formalising PCNs, the 2019 GP contract goes further than any previous effort in giving clarity and direction on both form and function of general practice at scale in England. In particular, it is intended that new kinds of staff, including pharmacists, physiotherapists and paramedics, will become ‘an integral part of the core general practice model throughout England,’ rather than optional add-ons who could be ‘redeployed at the discretion of other organisations’.

According to NHS England, the networks will ‘enable greater provision of proactive, personalised, coordinated and more integrated health and social care’.

Three key rationales put forward for PCNs in both The NHS long term plan and the 2019 GP contract (the latter in conjunction with the British Medical Association (BMA)) are set out below.

1. A pragmatic response to chronic workforce challenges

The GP contract acknowledges that, despite the commitment to increase GP numbers by 5,000, progress in recruiting new doctors has been ‘more than offset’ by GPs leaving the profession or going part-time. Progress in increasing the number of practice nurses has also been slow and, as a result, many practices had been recruiting to other roles – such as pharmacists – in the wider primary care team faster than had been expected. Hence the decision to give a ‘major boost’ to recruitment of these roles through the PCN route. The choice of target roles is also pragmatic: NHS England and the BMA estimate that (in contrast to GPs) there is, or soon will be, adequate supply of these roles – pharmacists and link workers immediately, physiotherapists and physician associates by 2020 and paramedics by 2021, to avoid ‘net transfer from the ambulance service’.

It is hoped that these wider roles will take some of the pressure off GPs and practice nurses, indirectly helping to ease workforce pressures. Policies already underway to increase the numbers of GPs and practice nurses will continue.

2. Consolidating general practice in the wider health system

PCNs are policymakers’ new answer to an important gap in the local organisation of the NHS. Better integration of primary care with secondary and community services has long been a policy goal, but has been held back by several challenges, including how to actively involve general practice – a key provider of services but generally in small units – in wider decisions about how services are organised and delivered across geographical areas.

PCNs are intended to be more than a vehicle for employing additional shared staff between practices. The NHS long term plan sets out a vision of care delivered at ‘system, place and neighbourhood level’, with PCNs representing a new unit of ‘neighbourhood’ level general practice within the larger units of ICSs. The new clinical directors are expected to provide leadership for PCNs and represent their constituent practices, acting as a conduit between general practice and the ICS. The GP contract makes clear that PCNs and their clinical directors will have access to better data, including predictive risk data, from the network practices and ‘robust activity and waiting time data’ at both individual practice and PCN level by 2021.

Providers of community services are also being asked to configure their services to match network boundaries by July 2019, although there is no detail yet about how this will be implemented.

3. Improving population health

The NHS long term plan sets out an ambition for all NHS organisations to have more of a proactive focus on improving ‘population health’. The term ‘population health’ is used in various ways in The NHS long term plan, but includes action to find and offer services to people at risk of deteriorating ill-health, as well as prevention of illness. NHS England believes that the 30,000–50,000 population size of PCNs breaks population groups in to more manageable chunks for the delivery of interventions to improve population health (single practices being generally too small and CCGs too large). What these interventions look like in practice isn’t currently clear, although it is clear that PCNs will be expected to play a role in the prevention of cardiovascular disease and tackling neighbourhood inequalities, as both of these have been singled out as future PCN service specifications.

From 2020, there will also be an Investment and Impact Fund – a savings scheme tied to the development of community-based services that enable reductions in hospital activity – available to networks via their ICS. Guidance has not yet been developed, but the GP contract notes that any monies earned from the Fund are ‘intended to increase investment for workforce and services, not boost pay’.

There is no directly comparable precursor to PCNs from which to draw evidence, but there has been some evaluation of different forms of networks and collaborations in general practice in the NHS. This section places PCNs in their historical context, considering the evidence related to general practices working at greater scale as both commissioners and providers of services.

Previous forms of general practice at scale

Commissioning

General practice has evolved over time (see Figure 2). From a 1950s model of predominantly single-handed practice, the 1960s and 1970s saw multiple-partner practices become the norm, with falling patient list sizes per GP and improved facilities.

Throughout the 1990s and 2000s, there were opportunities for GP practices both to have greater control over budgets and to collaborate to do so. From 1991, GP fundholding allowed GPs to hold budgets with which to purchase primarily non-urgent elective and community care for patients. GPs had the right to keep any savings, with policymakers hoping that this would financially incentivise GPs to manage costs while applying competitive pressure to acute providers. By 1997/98, 57% of GPs had opted to become fundholders. From 1994, the ‘total purchasing pilot scheme’ enabled GP practices – either individually or in groups – to commission all services for their patients (although in reality few chose to do so).

Though fundholding was phased out in 1997, from 2005 to 2013 practice-based commissioning (PBC) gave participating practices control over their budgets to purchase secondary care. Practices were given indicative budgets, based on their historic spending, and although they weren’t allowed to directly pocket the savings (the key distinction between PBC and fundholding), a proportion of any savings could be recycled into improving patient care. Though both fundholding and PBC were voluntary, the involvement of GPs in CCGs (replacements for primary care trusts created through the Health and Social Care Act) is not. All general practices are required to be members of their local CCG, but only a minority of GPs have a formal role with the CCG.

Figure 2: Trends in the commissioning and provision of general practice in England

Providing services

In the 1990s, practices started working collaboratively to provide out-of-hours care through GP cooperatives – a trend largely reversed when the 2004 GP contract removed the obligation for GPs to provide 24-hour care for their registered patients.

More recently, there has been a trend towards collaboration between GP practices, pushed in part by reductions in practice funding, rising patient and administrative demands, and workforce shortages, and pulled by new funding opportunities for large-scale GP providers (for example from the Five year forward view).

In 2016, the Nuffield Trust estimated that almost three-quarters of practices were working in collaboration with other practices, and by 2017 this had risen to 81%., The survey reported practices often belonging to multiple collaborations, operating at different levels in the system and for different purposes. A relatively small proportion of practices were working in nationally funded collaborative models (eg as MCP ‘vanguards’ supported through NHS England’s ‘new care models’ programme) and only half of practices reporting collaboration felt that it had been formalised in any way. Existing forms of collaboration in general practice (for providing services) have varied widely in both form and function.

NHS England state that as of 30 November 2018, 93.4% of practices across England considered themselves to be part of a ‘network’, but it is likely that the majority of these networks are not working at the level of collaboration required of PCNs. A more recent study (in press) suggests that previous estimates of levels of at-scale working have been much too high, the actual proportion of practices working together in some form (defined as collaborations that serve more than 30,000 patients) is closer to 55%. The same study estimates the proportion of general practices working closely together at scale to be less than 5%.

How are PCNs different from previous forms of general practice at scale?

• Homogeneity of form: All practices signing up to PCNs are signing the same network agreement and agreeing to the same contractual terms. While there will be variation in how PCNs choose to operate, how they employ staff and how they deliver services, there will be a common basic operating and funding model for all practices in PCNs across England.
• Homogeneity of function: In signing the PCN network agreement, practices will be agreeing to deliver the seven service specifications to be set out by NHS England. Networks are expected to have flexibility to tailor the services they offer to the needs of their neighbourhood, but core contractual obligations will be the same nationwide.
• Requirements on size and location: Although the PCN DES allows for a degree of flexibility around PCN size and geographical footprint, existing forms of general practice at scale (such as super-partnerships, primary care homes and existing networks) vary by size and are not all grouped into neighbourhoods. The advent of PCNs is likely to challenge and potentially disrupt some of these existing forms of collaboration in general practice. GP federations will not usually be allowed to hold the Network Contract DES, and although PCNs may choose to subcontract services to their local federation, the extent to which they do so is likely to vary.

What can the evidence on general practice at scale tell us about PCNs?

Recent examples of scaled-up general practice and networked provision of services provide no clear evidence of impact on quality of care, patient experience or cost-effectiveness. Two studies of networked general practice in one region reported improvement in clinical outcomes and perceived benefits from the perspective of clinicians, but the region in question has had a long track record of using quality improvement approaches to raise standards in primary care.,

Pettigrew et al’s 2018 systematic review searched for evidence of the impact of GP collaborations to explore whether scaled-up general practice can deliver better quality services while generating economies of scale. Their conclusion – that there isn’t enough evidence to confidently conclude that the expectations placed on GP collaborations will be met – was accompanied by a warning that further evidence, together with learning from evaluations of current approaches, is needed before large-scale general practice is pursued as national policy. The review is part of a larger report including case reviews of eight at-scale GP providers. Analysis of 15 quality indicators across these providers was unable to detect marked differences in quality of care compared to the national average, and reported mixed views from patients, some of whom valued new forms of access, while others were concerned about the potential loss of a trusted relationship with their own GP.

NHS England have pointed to primary care homes as a successful precursor to PCNs. Launched in October 2015, there are now over 225 primary care homes in England, at various stages of development, serving 10 million patients. The primary care home model brings together general practices with a range of health and social care professionals to deliver care to populations of 30,000–50,000. There are obvious similarities to the new PCN model on network size, a service delivery model based on a multidisciplinary workforce, and an ambition to combine personalised care with improving population health. Evaluation of primary care homes is ongoing, but an early review by the Nuffield Trust found that participation had strengthened inter-professional working and stimulated formation of new services tailored to the needs of different patient groups. There had, however, been a cash injection of £40,000 from NHS England for each of the primary care homes they evaluated, and the report concluded that developing primary care homes requires significant investment of money, time and support.

Without a substantial body of evidence from existing GP-at-scale organisations to guide policymakers, Mays et al sought to understand the lessons that might be learned for large-scale general practice from other inter-organisational health care collaborations. Their findings are relevant to PCNs in three core domains:

• network size
• leadership
• continuity of care.

Network size

No consistent relationship has been found in primary care between the size of health care organisations and their performance. Mays et al identified trade-offs between being small enough to have flexible and inclusive decision-making processes, and large enough to influence the local health economy. This is of direct relevance to PCNs, which are intended, at least in part, to bridge a gap between individual general practices and emergent ICSs.

Leadership

The time and resources required for health service reorganisations are often underestimated. Strong leadership is often cited as essential in overcoming these challenges, but the primary care workforce has historically been relatively unengaged in leadership training and development.,

Continuity of care

Evidence suggests that continuity of care in general practice is associated with higher quality care for particular patient groups.,, Offering extended hours access will be a core requirement of PCNs, but this responsibility will be shared across practices in a network and between different allied health professionals. PCNs can meet their contractual obligations by offering extended hours appointments with nurses, physiotherapists and other multidisciplinary team members. Any evaluation strategy for the networks should include monitoring the effect of PCNs on continuity of care.

How does evidence on GP contracting and commissioning relate to PCNs?

Some studies of previous approaches to GP commissioning have indicated that linking clinical decisions with financial responsibility can deliver improvements in performance, but these have tended to be more modest than had been anticipated. A 1998 evidence review from The King’s Fund found that GP fundholding was associated with increased transaction costs and created a two-tier system in access to care for patients of fundholders and non-fundholders.

Health Foundation analysis from 2004 of commissioning changes made in the 1990s did not find any substantive evidence to demonstrate that any approach had made a significant or strategic impact on secondary care services. Neither GP fundholding nor practice-based commissioning showed any significant improvement in outcomes.,

What can be learned from attempts to scale general practice in other health systems?

Experiences over the past two decades of attempts to deliver networked general practice in New Zealand, Australia and Canada highlight trade-offs between voluntary and mandatory participation. Where joining a network was incentivised but not mandatory, a sizeable minority do not participate, but mandating collaboration is shown to risk clinician disengagement and even resistance. In Scotland, the new GP contract mandated that practices became part of a geographic quality cluster, but early evaluations are mixed and clusters seem to be struggling in areas where practices face different issues and struggle to agree priorities. In Wales, 64 clusters of practices covering between 30,000 and 50,000 patients were set up from 2014 to improve the planning and delivery of local services. An inquiry published in 2017 found that, while there were some impressive examples of collaboration, clusters as a whole were still immature, needed more support with their development, and were finding that financial and demand pressures on primary care were hindering progress in some areas.

Evidence base for the interventions to be used by PCNs

Many of the intended benefits of PCNs hinge on the capacity of the additional staff to free up GPs, using the multidisciplinary team to deliver a range of more effective and personalised services to patients. The BMA’s PCN handbook offers some evidence of the probable benefits relating to the new roles. We have not reviewed the evidence on the individual roles and interventions that the PCNs are likely to deliver, but the evidence for the impact of some of these roles is not always clear – for example, for social prescribing link workers (and for social prescribing interventions more broadly).,

The National Association of Link Workers (NALW) highlights that there is currently no research exploring the knowledge, skills, experience and support needs of existing link workers. Ultimately, the success of social prescribing is contingent on the availability of services within communities to effectively address identified needs. Of the link workers who responded to a small NALW survey in 2019, 74% identified ‘a lack of resources and/or funding in the community and difficulty in accessing resources in the community/council’ as the most challenging aspect of their role.

The ambition of policymakers to scale up general practice is not new, but the scale and pace of the change required to deliver PCNs is. Implementing the networks in the context of major pressures in general practice represents a risk for NHS England. For PCNs to meet the broader objectives of policymakers for primary care, they are likely to require:

• funding – which must represent a genuine increase, distributed equitably
• the promised workforce – distributed equitably
• improved recruitment and retention of GPs
• time and support for implementation, including organisational development and leadership support
• meaningful monitoring, and a support offer for struggling networks
• the ability of the wider system – including nascent ICSs and established secondary care, community care and social care providers – to work collaboratively with PCNs.

Underpinning all of this is the importance of building relationships to create meaningful collaboration. PCNs require practices to move beyond their traditional boundaries. Sharing financial resources can both generate and strain relationships, and practices will have to trust each other if sharing both staff and data is to benefit patients.

From a policymaking perspective, PCNs may have evolved partly as a pragmatic solution to the difficulties in recruiting and retaining GPs – but the networks also contain a bold vision for the future of general practice and primary care. They are simultaneously a vehicle for stabilising general practice, and one through which significant change and service improvement is expected if the pledges of The NHS long term plan are to be met.

For patients and the public, much will depend on what happens once the agreements are in place and contracts put in motion. If PCNs meet national expectations, patients stand to benefit from access to a wider range of services through a stabilised general practice. Better use of medications, less reliance on hospital care and improved links with other services in the community are among the prizes on offer.

There is no one version of what success for PCNs will look like – and neither is it clear what failure would entail. It is patients who will feel the effects of either scenario. PCNs are a significant change within a complex system – and general practice isn’t embarking on it from a position of strength. The same need that has in part driven the formation of PCNs means that there will be little resilience left in general practice should they falter or fail.

It is vital that a safety net is created to identify and support PCNs that struggle, and to ensure that resources are distributed equitably, in proportion with deprivation and health need. The challenge of implementing PCNs must not be underestimated. Sufficient time and support must be given for genuinely collaborative relationships to develop in a part of the health system that has historically placed great value on its independence and close relationships with its patient population. Otherwise the breakneck pace of PCN implementation risks undermining the ambitions of the policy.

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