The challenges NHS England must address if PCNs are to succeed

PCNs are off to a positive start, but there are risks in the reform programme ahead that could hamper NHS England's ambitions to better integrate services, says King's Fund chief executive Richard Murray.

King's Fund chief executive Richard Murray (Photo: King's Fund)
King's Fund chief executive Richard Murray (Photo: King's Fund)

Primary care networks (PCNs) are central to general practice, primary care and the NHS long-term plan. The first key test for these new PCNs was whether – in a matter of months – GPs would sign up to join and whether they would do so to the design principles NHS England agreed with the BMA and RCGP

The answer is: yes, by a positively North Korean general election margin. Over 99% of practices have signed up to create just under 1,300 networks. This must have represented a huge effort at local level by GPs, CCGs and LMCs and is worth taking a moment to digest.

Alongside this, some elements of the new GP contract are becoming clearer, including some of the important details over exactly what practices are supposed to do to get paid (the first draft modules of the revised QOF).

In addition, given the often dismal and sometimes disgraceful (lack of) progress in delivering decent services to people with a learning disability, it's nice to see the new learning disability elements fast-tracked, not slow-tracked. More details were also provided on how the funding guarantee (the extra £4.5bn promised by 2023/24), will be monitored.

Digital providers and premises

This of course leaves some major elements of the policy framework for general practice still in development. There are steps forward in two key areas: first, a consultation on the commissioning and funding for digital providers (like GP at Hand), and second, a review of GP premises policy.

The former is clearly key to mainstreaming digital approaches within general practice and to ensure, among other things, that such offers don’t increase inequalities. On the latter, given the NHS wants to pay for an additional 22,000 extra staff through PCNs, we clearly need to have the right buildings from which to deliver this expanded team-based model of general practice.

Historically, the NHS has relied on GP practices owning and investing in their own premises, but this model is already creaking at the seams even before importing another 22,000 staff. As NHS England says, this premises review is only a ‘staging post’ on the road to finding a permanent solution, but at least the problem has been recognised and we have the promise of a plan for a plan.

Integrating community services

One of the objectives of PCNs is to support the development of a more seamless connection to other community services – these should be two parts of the same jigsaw. Yet for many years, community health services have too often been a missing part of every jigsaw.

To take this forward, NHS England has created a new community health services programme, led by Matthew Winn (CEO of Cambridgeshire Community Services NHS Trust). This will work with the community network of trusts (a joint initiative between NHS Confederation and NHS Providers) but importantly, also clocks the Association of Directors of Adult Social Services, the Local Government Association, national primary care organisations and the voluntary, community and social enterprise (VCSE) sector.

It would have been possible to fall at the first hurdle by taking an overly NHS trust perspective of community services, so reaching out to local government, primary care and the VCSE is an encouraging sign, assuming it transpires into genuine partnership working.

NHS England will also aim to make the contracting of community health services ‘fit’ with that for PCNs (the jigsaw analogy is perhaps apt). It also comes with a sting in the tail for providers of community services, as there will also be a requirement within the NHS standard contract to reconfigure their services onto primary care network footprints.

This all adds up to a lot of change to community services and getting the implementation right will be hard, not least as many PCNs are likely to have been defined on the basis of what works for general practice, rather than what works for community health services.

Workforce shortages

Lastly, The King’s Fund has been arguing that overcoming existing and projected workforce shortages is key to the long-term plan or indeed, maintaining existing services. Both for general practice and community services, NHS England recognises the current shortages and that improved services cannot be delivered without confronting this challenge. Hence there is a new push on both GPs and on community staff as well.

Clearly there is a link to the final NHS People Plan and some of the task ahead will be to ensure the People Plan gives primary and community services the same depth of attention as the acute sector. But wherever possible, NHS England should move now on workforce issues (and to give credit where credit’s due, it does seem some workforce proposals will start now), not least given the fact that the People Plan is unlikely to see the light of day before 2020.

On the optimistic side, taken together this demonstrates both pace and a signal that NHS England is facing up to the thorniest of issues in primary and community services: workforce, as well as digital, the estate and the integration of the two.

Challenges ahead

NHS England – and GPs – can also put an emphatic tick in the first box on delivery (creating PCNs that cover England). But the challenges remain deep, notably on the workforce and the complexity of introducing new team-based working into a stressed general practice to name but two. The depth of commitment of individual GP practices to a new way of working with their neighbours will also be tested as PCNs move into delivery mode.

So despite this good start, there are real and present risks in this reform programme. I’ll pick out two in particular: getting the pace wrong and overburdening PCNs and making (apparently) theoretically sensible commitments that may prove hard to implement in practice (aligning all community services with networks may be one).

But as we have said before, given the state of general practice and the health challenges facing the English population, the risk of doing nothing is far greater and the time for half measures long since passed.

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