PCNs in their historical context – what’s the evidence for where we’re going?

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


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.


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.

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