Can PCNs save the GP partnership model?

GPs have long prized the autonomy afforded to them by the partnership model, but have now been warned that reversing its decline - and avoiding becoming a salaried profession - is also down to them.

Primary care networks (Photo: Mike Kemp/Getty Images)
Primary care networks (Photo: Mike Kemp/Getty Images)

NHS England's national director for strategy and innovation Ian Dodge set out five priorities for primary care networks (PCNs) in a document published just days before they became operational on 1 July.

Top of the list was that by 2023/24 they would have 'stabilised the GP partnership model'. The document added that 'it is now down to PCNs to decide their own long-term future: take responsibility for securing a new generation of partners or by default (rather than choice) become salaried to other NHS providers'.

To be clear about the scale of this task, over the three-and-a-quarter years following former health secretary Jeremy Hunt's 2015 failed pledge to add 5,000 full-time equivalent GPs to the GP workforce, the number of GP partners in England fell by more than 3,000 - a staggering 12% drop.

GP partners

Where once partnership roles were the aim of almost all GPs, doctors have increasingly chosen to step away from them in recent years to escape unmanageable workload. Many have chosen to retire early, others have opted for salaried or locum work.

So can PCNs - barely a day old - reasonably be expected to reverse this decline within just five short years?

The BMA's GP committee (GPC) believes that they can have a positive influence - although it is clear that saving the partnership model will not hinge on the efforts of PCNs alone, particularly after years of underfunding of general practice.

GPC executive committee member Dr Krishna Kasaraneni says: 'With over 99% of practices now choosing to join and form PCNs this model of working provides an opportunity for practices to support one another while maintaining their independence.

GMS contract

'Practices can use this to shape their future by working together to strengthen the partnership model of general practice. PCNs provide a viable alternative, based on the existing GMS contract, and are the vehicles for general practice to come together and therefore resist vertical integration by being forced into salaried employment for an NHS provider.'

Wessex LMCs chair Dr Nigel Watson's review of GP partnerships, published at the start of 2019, set out seven key recommendations to revive the model. It warned that reducing personal financial risk for GPs, boosting GP numbers and increasing community staff to support general practice were vital.

A strong voice for GPs 'at system level' was also key, the review found, and PCNs should 'operate in a way that makes constituent practices more sustainable and enables partners to address workload'.

PCNs are backed by £1.8bn in funding - more than half of the £2.8bn package attached to the five-year GP contract deal unveiled earlier this year - and are expected to recruit 'an army' of 20,000 staff including physios, pharmacists and others to work alongside and support primary care.

Long-term plan

Dr Watson says it is clear that 'if we carry on as we are and do nothing, the trend is that general practice is losing partners and that the independent contractor model doesn't have a long-term future'.

He admits it remains to be seen whether PCNs have enough levers at their disposal to save the GP partnership model - but is convinced they can address some factors behind the loss of partners, particularly alongside other measures such as reducing costs through state-backed indemnity, and plans to ease premises liabilities for GPs.

'If we want to recruit partners we have to make general practice a better place to work,' he says. 'PCNs should not be seen as the sole reason the partnership model will succeed or fall - but it can be a major factor. If practices use this investment wisely they can address workload - but it depends on general practice owning it, and CCGs and STPs backing and investing in it, rather than just talking and then spending more on hospitals as they have in the past.'

For some GPs, however, expecting PCNs to save the partnership model is unrealistic. Londonwide LMCs chief executive Dr Michelle Drage says: 'The additional investment via the network contract provides useful support, but it is a false premise to suggest that the survival of the partnership model is now the responsibility of PCNs and their member practices.'

Bureaucracy

She adds: 'There is much more that the DHSC can do to alleviate the bureaucratic burden on partners, reduce financial uncertainty, support struggling practices and encourage proportionate regulation.'

Dr Watson admits that unless the wider government takes steps to resolve problems caused by punitive pension taxes that have forced many GPs to reduce their working hours and even take early retirement, PCNs may not have enough sway to save partnerships.

Perhaps the strongest argument that may help to persuade the government and NHS England to make sure that partnerships continue, however, is that the alternative would be unaffordable.

Dr Drage says: 'If independent contractors were to be swallowed up by larger providers, the government would rapidly realise that it has lost a service which provides unprecedented quality of care for patients and value for money to taxpayers.'

The GP partnership review makes clear that the existing model of UK general practice 'has been credited as a major reason for the NHS being one of the most cost-effective models of healthcare, outperforming many countries in the Western world which spend significantly more'.

Dr Watson says simply: 'I don't think they can afford a salaried service.'

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