Viewpoint: Are PCNs working - and where do they go from here?

In January 2019, GP practices in England were asked to form primary care networks (PCNs) serving 30-50,000 patients within shared geographical areas. Asking practices to work together at scale was a key policy of the 2019 NHS long-term plan.

While not obliged to join a PCN, practices were heavily incentivised by additional funding available. Deadlines were short. Some larger practices were able to form a PCN alone, but the vast majority of practices had to rapidly join up with others. Since July 2019, PCNs have increasingly become the focus for primary care development and investment, with new initiatives, such as the Investment and Impact Fund (IIF)¹, being organised and distributed through the networks.

What are the advantages of PCNs?

Working at scale allows the ability to offer population-based health services, employ a wider range of clinical staff and expertise to improve patient care. Patients prefer to be seen closer to home, and care is often more efficient in primary care, so developing community-level services and preventing onward referral to hospitals is both cost-effective and popular.

The rationale behind potential improvement in patient care from collaboration is based on economies of scale.² Collaboration including sharing best practice, integrating IT systems and exchange of information facilitates a learning environment and results in gained efficiencies. Positive impacts of large-scale practice collaborations, however, depend on their structure and implementation.³

The main advantage of PCNs is funding for extra staff. Given a well-recognised GP crisis⁴, with falling numbers of full-time equivalent GPs⁵ despite promises for 6,000 more by 2024, central policy has been funding allied healthcare professionals (AHPs). AHPs provide specialised services, freeing up GPs’ time and easing demands on primary care.

The range of staff that can be employed is dictated by the additional roles reimbursement scheme (ARRS), with most PCNs employing practice-based pharmacists, social prescribers, paramedics, physios, physician associates and mental health workers. Alongside the additional roles reimbursement scheme (ARRS)⁶ there has been pump priming money for development, education, and funding towards a clinical director.

What are the disadvantages of PCNs?

There are inflexibilities in the ARRS⁷ - such as restrictions on types of staff recruited, and the inability to roll over unspent budget into following years or spend it on anything apart from staff. This can be particularly challenging where budgets are devolved within PCNs in proportion to the list sizes of constituent practices.

Sharing staff can raise issues with allocating workload, using multiple IT systems, or understanding varying protocols. Like any new enterprise, legal agreements are required, funded by the practices, with much discussion about structures and voting rights. PCNs can become another layer of bureaucracy requiring regular meetings with associated preparation time and increased email traffic.

Working in groups and sharing staff can bring tensions. Many PCNs have seen clinical directors change, and practices come and go due to disputes. New staff require recruitment, training and supervision, which is not accounted for⁸ and is especially challenging with remote working.

Integrating into large teams can be difficult for staff, especially if working across multiple sites. Training reception staff to understand ARRS staff roles and appropriately signpost patients takes time. Some patients prefer to see ‘their GP’ over AHPs, and larger teams risk eroding continuity of care.⁹ Finding desk space and clinical rooms for expanding teams poses another major problem, with many practices already struggling to accommodate existing staff.¹⁰

What is the evidence on the impact of PCNs?

As for other organisational models of general practice, like super-partnerships and federations, research in this area is scarce. In 2021, there are around 1,250 PCNs across England.¹¹ Since their establishment, GPs’ discontentment with the accompanying GP contract that was implemented has been well-documented.¹²

However, an early evaluation indicates an overall positive effect on service provision - at least from an operational standpoint.¹³ PCNs were integrated rapidly, including swift recruitment of staff into ARRS roles and establishment of enhanced patient services.

However, how this translates to health outcomes or quality of care is uncertain. No conclusive qualitative or quantitative evidence on the topic exists to date.

What has been learned so far?

Despite a lack of evidence on the impact of PCNs on patient outcomes, several learning points have emerged. Firstly, PCNs provide a nationally aligned framework for co-working between GP practices. While the consistency of resulting outcomes is to be determined, this has resulted in a clearer direction for practices expanding their services at the community level.

Secondly, this framework is not overly prescriptive and does not prevent practices from having autonomy. Even in terms of operational aspects of PCNs, there is significant variety. For example, while initially devised as networks covering a population of 30-50,000 patients, in practice a lot of the established networks are either smaller or (more often) larger than this.¹⁴

What might the future hold?

The COVID-19 pandemic presented opportunities for PCNs to deliver population-based care at scale. Many PCNs spearheaded the vaccination rollout, with GP teams delivering around 75% of vaccines.¹⁵ Social prescribers have made an impact in supporting shielding patients. PCNs have developed home visiting and minor illness teams, first contact physios, mental health and pharmacy teams to ease GPs’ workload.

Future opportunities may include further vaccine rollouts, tackling health inequalities¹⁶, introducing long-COVID clinics, providing community specialist services and improved cancer diagnosis. One challenge will be seizing these opportunities while operating within a changing NHS landscape, and PCNs establishing their role as a ‘building block’ of integrated care systems (ICSs).¹⁷

We can see the potential for PCNs to provide population-based healthcare at scale, improve patient services, bring extra AHPs into general practice and reduce existing pressures on GPs. We hope to see evolving evidence emerge regarding the benefits and opportunities for PCNs and would urge the government to scrutinise healthcare policy in the same way as we scrutinise new medicines or treatments before rolling them out.

• Dr Simon Hodes is a GP partner at Bridgewater Surgeries, Watford, and a trainer, appraiser and LMC rep. Also at Cleveland Clinic London @DrSimonHodes
• Lana Kovacevic is a doctoral researcher at the NIHR Imperial Patient Safety Translational Research Centre (PSTRC), part of the Institute of Global Health Innovation at Imperial College London

The views expressed are the authors' own.

References

1. NHS England. (n.d.). Investment and Impact Fund. https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/iif/
2. Rosen, R., Kumpunen, S., Curry, N., Davies, A., Pettigrew, L., & Kossarova, L. (2016). Is bigger better? Lessons for large-scale general practice. Nuffield Trust. https://www.nuffieldtrust.org.uk/research/is-bigger-better-lessons-for-large-scale-general-practice
3. Pettigrew, L.M., Kumpunen, S., Rosen, R., Posaner, R., & Mays, N. (2019). Lessons for ‘large-scale’ general practice provider organisations in England from other inter-organisational healthcare collaborations. Health Policy, 123(1), 51-61. https://doi.org/10.1016/j.healthpol.2018.10.017
4. Hodes, S., Hussain, S., Jha, N., Toberty, L., & Welch, E. (2021). If general practice fails, The NHS fails. The BMJ Opinion. https://blogs.bmj.com/bmj/2021/05/14/if-general-practice-fails-the-nhs-fails/
5. BMA. (2021). Pressures in general practice. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice   
6. Wessex Local Medical Committees. (n.d.). PCN Workforce – ARRS. https://www.wessexlmcs.com/pcnworkforcearrs  
7. Hodes, S. (2020). Viewpoint: How NHS England can give the ARRS a much-needed kick. GP Online. https://www.gponline.com/viewpoint-nhs-england-give-arrs-much-needed-kick/article/1696844
8. Vaughan, V., Ghosh, S., Nazir, S., Patel, S., Ganguli, P., & Alabi, M. (2021). Pulse PCN roundtable: The Additional Roles Reimbursement Scheme. Pulse. https://www.pulsetoday.co.uk/special/pulse-pcn/pulse-pcn-roundtable-the-additional-roles-reimbursement-scheme/
9. Hodes, S., Lewis, S., Eliad, B., & Richards, J. (2021). Continuity of care during covid-19: needed now more than ever? The BMJ Opinion. https://blogs.bmj.com/bmj/2021/06/25/continuity-of-care-during-covid-19-needed-now-more-than-ever/
10. Haynes, L. (2021). GP premises need major investment to let PCNs recruit, warns BMA. GP Online. https://www.gponline.com/gp-premises-need-major-investment-let-pcns-recruit-warns-bma/article/1708204
11. Smith, J.A., Checkland, K., Sidhu, M., Hammond, J., & Parkinson, S. (2021). Primary care networks: are they fit for the future? British Journal of General Practice, 71(704), 106-107. https://doi.org/10.3399/bjgp21X714665
12. Iacobucci, G. (2020). Primary care networks: NHS England under pressure to rein in its ambitions. BMJ, 368, m230. https://doi.org/10.1136/bmj.m230 
13. Smith, J.A., Parkinson, S., Harshfield, A., & Sidhu, M. (2020). Early evidence on the development of primary care networks in England: a rapid evaluation study. RAND. https://www.rand.org/pubs/external_publications/EP68311.html
14. Morciano, M., Checkland, K., Hammond, J., Lau, Y., & Sutton, M. (2020). Variability in size and characteristics of primary care networks in England: observational study. British Journal of General Practice, 70(701), e899-e905. https://doi.org/10.3399/bjgp20X713441
15. Hodes, S., & Majeed, A. (2021). Building a sustainable infrastructure for covid-19 vaccinations long term. BMJ, 373, n1578. https://doi.org/10.1136/bmj.n1578
16. Suleman, M., Sonthalia, S., Webb, C., Tinson, A., Kane, M., Bunbury, S., Finch, D., & Bibby, J. (2021). Unequal pandemic, fairer recovery: The COVID-19 impact inquiry report. The Health Foundation. https://www.health.org.uk/publications/reports/unequal-pandemic-fairer-recovery
17. Charles, A. (2019). A two-way street: primary care networks and integrated care systems. The King’s Fund. https://www.kingsfund.org.uk/blog/2019/05/primary-care-networks-integrated-care-systems