Dr Johnny Marshall, an advocate of practice-based commissioning (PBC) as NAPC chair in the early 2000s, said he believed PBC had failed to create a lasting impact because GPs had little say in how resources were allocated. As a result, it had 'lacked teeth' to deliver real change.
He also warned that NHS England needed to avoid a top-down approach to the development of PCNs if it wanted to replicate the best of the NAPC's primary care home model, on which networks are broadly based.
Launched by Labour in 2005, PBC gave GPs, nurses and other primary care professionals influence over how NHS money was spent in their local areas - encouraging them to work in partnership with neighbouring practices.
However, the initiative was abandoned a few years later after doctors complained about high levels of bureaucracy, which they said prevented them from getting business cases through in a timely manner.
Dr Marshall said: ‘In 2009, we had mapped out what we needed to move towards was provider organisations that had a responsibility for the health of a population.
‘They needed to have the insight from a commissioner perspective about all the different things that you could do to effect that change, so they could work with other partners. But PBC didn't really have any teeth because you couldn’t move anything in your area and effect change.'
Achieving change
He said that PCNs had to be able 'to move resources around… that’s what didn’t happen under practice-based commissioning and that’s why some CCGs have struggled to achieve change, due to the financial constraints that they are working with.
‘If we don’t enable that to happen within an integrated care system, we will not be able to effect this change.'
Clinical directors are expected to work with clinicians, other networks and their ICS/STP to develop new ways of working that address local needs. However, it is yet to be seen how much clout PCN leaders will have when discussing and negotiating the delivery of local services.
Dr Marshall said that specific attention should be paid to how budgets are organised under the new plans.
‘There’s been a big focus on getting populations of below 50k patients and on integrated working, but we know within the NHS that ultimately, where the money goes is where the effort and attention goes,' he said.
'It's not about pouring more into PCNs in isolation. [It’s about saying] this is our collective resource, how do we start to realign how we use the finances. It's about how we move it into a different place within our local health and care system and how it adds value.’
Avoid top-down approach
Dr Marshall also said that if networks were to succeed NHS England needed to give them the space to come up with their own ideas and drive their own development. He said that the ‘greatest and most positive’ changes he had seen through the NAPC's primary care home model had sprung from a bottom-up approach adopted by groups of practices.
Dr Marshall said it was important that this was not lost now that the model had effectively been scaled up and rolled out across the country.
‘There’s always a little bit of a danger where a great idea that has enjoyed success suddenly becomes national policy. Much of [the work around primary care homes] is based on a bottom-up, driven by the practices and the other parts of the primary care family that really understand the needs of their population and how to meet them.
‘The danger is when you have a big central policy change, it often comes with certain levels of bureaucracy that are just innate in the system. No one intends for them to get in the way but they can create a great big wind that could blow out the flame.
‘We need to guard against that and make sure the energy, support and policy supports a bottom-up approach because I genuinely believe that’s the way to go.'
