Why this, why now?

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’.

Previous Next