Risks and challenges

PCNs are a core part of The NHS long term plan’s vision of achieving more proactive, coordinated care through greater collaboration between GPs and other services in the community. Drawing on the skills of a wider range of health professionals is a pragmatic response to rising demand and shortages in the GP workforce. PCNs have the potential to improve coordination of services for patients and to support GPs to deliver high-quality care. They may also support GP involvement in wider NHS decision-making.

The decision to direct much-needed additional funding and resource through PCNs rather than direct to practices is a clear signal that policymakers see scaled-up general practice as the best route to a more secure footing for general practice and better care for patients.

But PCNs are not without risks. This section analyses potential barriers and risks to the successful roll-out of PCNs, and what they might mean for general practice.

Speed of implementation

The most immediate challenge is the extremely tight timetable for setting up the networks. Practices across the country have had to understand the policy, form themselves in to networks, appoint clinical directors and agree ways of working sufficient to sign their network agreements, all in very little time.

In their design of the network policy, NHS England and the BMA have attempted to strike a balance between top-down guidance and allowing room for practices to determine what organisational forms are best suited to them. Provided there is a single ‘nominated payee’ for funding, practices can choose their own models for how that funding flows within the network and their governance arrangements (for example, whether to have a board, how to make sure practices are represented adequately and can hold both the network and each other to account). Five potential options are set out in the BMA’s PCN handbook. All have different implications for VAT and employment liabilities (for the new staff), and the degree to which practices may or may not be happy to trust a lead practice, federation or third-party organisation to manage the PCN funding on their behalf.

While the freedom to determine what works best locally makes sense, these decisions will have been challenging to make in the limited time available, not least because they have important implications for individual practices. In its guidance, the BMA states that ‘in all cases it is essential to take your own legal and financial advice on the potential legal and tax implications’. Mandating that networks form at such speed risks pushing them to make decisions based on what is most possible, or easy to do, rather than allowing time to consider how to best structure themselves to meet the needs of their populations.

For some parts of the country, in particular those with primary care homes or the early MCP vanguard sites, networks are already the norm in primary care. Some will already have strong cross-practice relationships, trust and understanding – all necessary foundations for successful collaboration. But in others, existing collaborations may not match the PCN requirements to be geographically contiguous or within the specified population size, and their service models may not match the requirements of the new network DES. Existing relationships may be strained as a result.

For areas without existing network structures, in the absence of organisational or leadership development support from NHS England, establishing PCNs will have been more challenging. PCNs with data-sharing agreements in place ready to deliver the extended hours requirements of the network specification on 1 July 2019 will receive £1.50 per head of core PCN funding backdated to 1 April 2019. This is a significant incentive to be ready ‘on time’, but areas with the strongest existing network structures are most likely to capitalise on the offer, while others that face the longest road to network formation might receive less funding for the start of the journey.

Getting organisational forms right will be necessary, but not sufficient, to produce high-functioning PCNs. Lessons from the Health Foundation’s improvement programmes have included the importance of teams having the time and skills to design, implement and sustain new ways of working. NHS England has been keen to leave the choice of which professionals to employ, and their remits, up to individual networks, but without careful implementation the benefits of expanded clinical teams are not guaranteed. The speed of implementation means that NHS England has not yet made any comprehensive organisational development support available to networks, and there is  no leadership development offer for clinical directors (who may have been selected from a relatively small pool of available and willing GPs within a network). These resources are in development, but are large omissions that need to be rectified quickly.

PCNs are being developed within a context of wider changes in NHS structures. Sustainability and Transformation Partnerships (STPs), themselves relatively new, are rapidly evolving into ICSs, and the wider architecture of the NHS is shifting quickly. These overlapping initiatives, which must eventually work seamlessly together if their ambition is to be realised, add to the complexity of implementation.


Although the majority of practices stand to benefit financially from network participation, there are concerns that this will not universally be the case. PCNs will self-determine the distribution of network funds across member practices, making it hard to generalise about the implications for individual practices. Possible risks include:

  • The removal of other sources of income for practices. To cover the cost of providing core PCN funding (which must come from CCG core allocation) CCGs may remove other payments available to practices (for example, some locally incentivised schemes). If income available to individual practices from enhanced services is reduced in order for CCGs to afford to pay networks, it is possible that funding to individual practices may fall.
  • Payment for the clinical director role is being made on a whole-of-England average – but GP salaries vary by locality. PCNs in areas with high salary costs may find themselves out of pocket in reimbursing clinical director time, particularly if they face a ‘double whammy’ of needing to employ additional GP cover to fill clinical sessions vacated by the clinical director.
  • Under the ARRS, NHS England has promised to meet 70% of the costs of employing most additional staff, but networks will be expected to meet the remaining 30%. This may be more feasible for some networks than others, and therefore ability to unlock the potential benefits of additional staff may vary between networks depending on their underlying financial positions. Financial liability for the new roles, for example in the case of redundancy, will also sit with the practices in the network.

Workforce and workload

Increasing the skills mix in primary care is intended to relieve pressure on GPs. Although NHS England recognises that more GPs need to be recruited and has put plans in place to accelerate this, progress is slow. There is an additional risk that PCNs might decrease the amount of GP time available for direct patient-facing activity.

Clinical directors are being funded at 0.25 WTE (on the basis of an average network size of 50,000). If this would otherwise have been patient-facing time for the clinical director, then the loss to a practice of over 1 day of consulting time each week is not insignificant. New staff such as pharmacists and physiotherapists will also need to be supervised by GPs. This is both a contractual obligation and a requirement for patient safety, but supervision, particularly with new staff, is an additional draw on GP time. Perversely, areas with the fewest GPs – where there may be greatest reliance on allied health professionals – will require proportionately more of the GPs’ scarce time to be spent on supervision.

There are also unanswered questions about how realistic the PCN workforce plan is. NHS England is confident that 20,000 additional allied health professionals will be available in time, but there are no data available in the public domain to allow us to model or verify these projections. NHS England has not stated how many of each type ofprofessional is expected, but the scale of the increases required will be large. In September 2018, there were only 55 physiotherapists, 99 physician associates and 428 paramedics working in general practice in England.

Increasing the primary care workforce means more then just increasing headcount. Appropriate workspace must be found to accommodate the new workforce, and this is likely to be a challenge in some GP surgeries. It is not yet clear whether additional funding will be made available to ensure that practice premises are fit for their expanded purpose, but is likely to be needed.


The inclusion of a PCN service specification on inequality is a welcome signal that networks will be a core part of the increased efforts to tackle health inequalities, as set out in The NHS long term plan. But aspects of the way PCNs are currently designed risks exacerbating existing inequalities in the provision of primary care.

The Carr-Hill formula – used to weight funding for GP practices – has been criticised for not sufficiently taking the effects of deprivation into account. Despite promises from NHS England and the BMA to address this, the new GP contract has not done so. As a result, the weighted component of per capita funding for PCNs is based on a formula that may systematically under-fund practices with the most need. Furthermore, some PCN payments are not weighted at all, such as the annual uplift of £1.50 per patient from CCGs for networks and funding for extended hours.

There is a commitment that in future PCNs will be able to unlock extra funding from an Investment and Impact Fund – essentially a savings scheme accessible to networks able to achieve specific targets. Examples of what these targets might be include reductions in A&E attendances and delayed discharges, but these are likely to be systematically easier to achieve in some populations. There might be ways to mitigate this (by offering more money per unit of achievement in deprived areas, for example) but this will require action from policymakers.

It is already clear that the workforce crisis in general practice is disproportionately affecting deprived areas. Between 2008 and 2017, the number of GPs working in areas containing the most deprived quintile of the population fell by 511, while 134 additional GPs were recruited to the areas containing the most affluent quintile. The ability of PCNs to deliver the services that will eventually be required of them is contingent on the successful recruitment of allied health professionals. NHS England is confident that there will be enough staff, and that this can be achieved without pulling staff away from secondary care. But even assuming that the promised 20,000 additional staff will be available to PCNs, there are no mechanisms to level the playing field for recruitment. We calculate that the number of pharmacists working in general practice is already lower in more deprived areas. Although some professionals will choose to work in areas of greater need (and often greater workload) there’s a risk of perpetuating a situation in which PCNs serving the most deprived populations (with the greatest health needs) are least able to recruit. Funding through the ARRS is only unlocked when staff are in post: if networks in deprived areas are systematically less able to recruit, there will be a corresponding reduction in network funding. Where a PCN doesn’t use its full ARRS allowance to recruit into posts, the money will be retained by the CCG. This risks creating a perverse incentive for CCGs – themselves under significant financial pressure – to favour under-recruitment into PCNs.

Although the intention of PCNs is that working at increased scale will increase practice resilience, there is no evidence to suggest that this will necessarily or universally be the case. The number of practices closing has risen rapidly in recent years and the most affected areas have strikingly similar profiles. Areas with older populations and older GPs (often rural and coastal locations where attracting new staff has been particularly difficult) have borne the brunt of practice closures, often leading to increased pressure on remaining local practices. Geographically grouping practices might allow PCNs to offer more attractive and diverse job roles and to reduce workload by streamlining back-office functions. But where the entire geography of a PCN is an area of high deprivation, increasing inter-dependence between neighbouring practices that are already vulnerable risks a domino effect, where the failure of a single practice drags others down with it.

In networks with only small pockets of deprivation within more affluent areas, or where a very small area has a defined need (such as a practice specifically providing care to homeless people), a single practice serving that group may find itself and its specific needs isolated within a larger network of practices.

Evaluation and monitoring

CCGs (or NHS England local teams, where there are CCGs without delegated primary care commissioning) are responsible for overseeing the Network Contract DES registration process and assuring that PCNs deliver against the requirements of the DES. A Primary Care Network Dashboard is being developed to support this and should be introduced from April 2020.

This monitoring should set a baseline for delivery against contractual requirements, and should provide some accountability and transparency on what the new investment has produced in terms of services delivered and, ideally, outcomes. But comprehensive evaluation of PCNs is also needed. NHS England is working on an evaluation framework, and this must include metrics to capture process as well as performance, recognising the difficulty of evaluating a complex intervention within a complex system. The opportunity to design PCNs with evaluation in mind, and to commence evaluation at the outset, has already been missed.

The formation of PCNs also raises questions regarding the regulation of  general practice. The Care Quality Commission has been considering how to approach the regulation of larger providers of general practice, and the current model of inspecting and regulating general practice based on assessment of individual practices may need adjusting to reflect monitoring and regulation of services being delivered at network level, as well as the extent to which practice engagement in network activity is viewed as a marker of quality.

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