Last January, when the five-year GP contract framework was published, The King’s Fund was one of many commentators who warned of two real and present risks to the success of PCNs. First, that the volume of tasks and the timelines for delivery were too ambitions; second that while some of the tasks looked sensible in theory they would be hugely complex to implement in practice.
These concerns existed in part because of the multiple aims that had been set out for primary care networks: they would stabilise general practice, act as the link between general practice and the wider system and to be a key vehicle for delivering many of the commitments in the long-term plan.
At the core of the contract framework are seven national service specifications and in late December, NHS England released the first five of these for consultation. To say that the draft specifications landed badly is somewhat of an understatement. My email, WhatsApp and social media was full of GPs expressing enormous concern. Even those normally measured GPs among my contacts who have been engaged in primary care collaborations for years were suggesting they might pull out of the PCN contract altogether.
Where did it all go wrong?
NHS England has now said that it will 'significantly rework' the plans. But, how did it all go so wrong? I think there are a few reasons.
First, while there’s not much to criticise about the overall objectives of the specifications (though I would argue that a focus on mental health is a major omission), they require significant input from GPs at a time when there’s a workload and workforce crisis.
The consultation says that the new roles will provide 'more than sufficient capacity to deliver the requirements across all five services with significant capacity remaining for these additional roles to provide wider support to GP workforce pressures'. There might be a spreadsheet lurking at NHS England that can show the workings behind this statement, but if it does, it hasn’t been made public and it certainly doesn’t reflect the current pressures on general practice.
Second, it raises serious questions as to whether the funding available to PCNs adequately addresses the full resource requirements needed to deliver the specifications.
Practices are expected to contribute from their core income to supplement the new roles and this is likely to equate to more than 30% of the total cost of the new staff because of on-costs, training, supervision and the need to recruit staff at the top of pay bands because of the level of independence and expertise required.
Other funds, like the participation payment may not fully cover the costs of practice participation in networks, which includes providing practice manager support, GP backfill to take on clinical leadership roles, support for multidisciplinary teams and the supervision of new staff. This is on top of to the additional workload for general practitioners generated by the service specifications.
Third, the timescales are unrealistic - they assume that PCNs are already fully developed, that the new roles are in place and that there is active participation in PCNs from organisations outside general practice.
The reality is that many PCNs are still in the very early stages of development and there just hasn’t been enough time for PCNs and their complex networks of local partners to build the relationships that will be needed to deliver these specifications this year. And even if it was enough money these timescales assumes the new staff are there to be recruited, and that the organisational development challenge of establishing effective new teams is quickly solved.
How to get PCNs back on track
Fourth while recognising that the specifications reflect the ambitions of the NHS long-term plan, they are incredibly prescriptive and don’t allow the kind of innovation, flexibility and creativity that has been the hallmark of successful primary care collaborations to date.
PCNs need to embrace priorities that meet the particular needs of their local population, whether that’s improving mental health services, addressing deprivation or delivering better joined-up care.
A better balance needs to be struck – a realistic alternative might be to see the specifications as a menu of options for delivery, depending on local need, with the possibility for PCNs, working within local systems, to develop and deliver their own equivalent programmes and priorities, taking into account local population need.
To get PCNs back on track, the focus must be first on networks addressing the workload and capacity crisis in general practice by allowing enough time to get in new staff and embrace new ways of working. Without this, the specifications will not be deliverable without having a detrimental impact on core general practice – the government’s manifesto commitment to 50m extra appointments in general practice would also be in peril.
- Beccy Baird is senior fellow, policy at the King's Fund