PCNs began life in The NHS long term plan in January 2019. NHS England and Improvement recognised that community and primary care had insufficient resources to meet rising patient need. All GP practices were expected to form geographical networks covering populations of approximately 30,000-50,000 patients by 1 July 2019, if they were to take advantage of additional funding attached to the new GP contract.
This direction to work at scale aimed to address sustainability issues in general practice – both funding and workforce shortages – and to support more integration through collaboration with secondary care, social care and the voluntary sector. It represents the biggest reform to general practice in decades and led to the creation of 1,250 PCNs, which now range from mature partnerships based on pre-existing collaboration to embryonic relationships across new geographic footprints. This was supported by a ringfenced uplift of £4.5bn (3.8% per year) for primary and community services by the end of the long term plan period (2023/24), meaning that funding for these sectors will grow faster than the overall NHS budget. While the new GP contract specified some detail, it remains unclear how this uplift will be allocated between GPs and community providers.
This was an important policy and operational development for trusts and not-for-profit organisations providing NHS community health services, as there was a clear onus on wide-reaching partnerships with PCNs including primary care, community services, community pharmacy, optometrists, dental providers, ambulance trusts, social care providers, voluntary sector organisations and local government.
All GP practices were expected to form geographical networks covering populations of approximately 30,000-50,000 patients by 1 July 2019, if they were to take advantage of additional funding attached to the new GP contract.
In July 2019, the Community Network published a briefing which explored the implications of the PCN roll out for NHS community health services and suggested ways for trusts and community service providers to engage effectively with PCNs. Much of this briefing remains relevant today, given the challenges facing both sectors and variation in how effectively PCNs are operating.
In summary, NHS community health services supported the PCN objectives of better integration and population health outcomes at neighbourhood level, as well as more flexible workforce models. They were particularly excited by the possibility of offering staff 'passport' arrangements across primary and community care to help create innovative career paths that would attract people to join and stay in the wider community workforce. They also saw an opportunity to support PCNs as strategic partners in helping to drive neighbourhood integration. Many felt they could offer practical support, including for governance arrangements, employment and back office functions. In the briefing, we highlighted case studies of trusts’ support offers to PCNs, including infrastructure resource and strategic development from Sussex Community NHS Foundation Trust.
However, community service providers were also concerned about several risks and challenges of PCN development that were documented in the briefing, as follows:
- As the PCN map was drawn on particular geographies, existing collaboration between primary and community care was disrupted. In some areas, this meant that pre-existing partnerships between locality teams and GP practices took a step backwards. In other areas where there had been historically little engagement between primary and community care, it took time to reconfigure locality teams and develop relationships with new PCN clinical directors.
- The national approach to channel additional funding for care in the community through PCNs has raised concerns around their capacity to deliver the new service specifications as well as stabilise general practice within the funding envelope available. Community providers feel that the focus in recent months on contractual negotiations has shifted the conversation away from finding the right model of care to drive effective neighbourhood integration. Primary and community care providers should be supported to develop the right model of care, collaborative culture and behaviours, which should then be supported by the funding and contract.
- There are also risks around the requirements on PCNs to expand their workforce to populate multidisciplinary teams, including clinical pharmacists, first contact physiotherapists and community paramedics. Well-intentioned recruitment by primary care colleagues could destabilise the local labour market and existing recruitment strategies, as they would be competing for the same limited local talent pool as secondary care providers. For example, ambulance trusts are grappling with shortages of paramedics, which could be exacerbated when recruitment for community paramedics for PCNs begins in 2021. PCNs are not bound by Agenda for Change remuneration requirements, so could pay staff higher wages and disadvantage other services. It is therefore crucial that recruitment of healthcare professionals is done in collaboration with system partners, with system-wide strategic intent, and based on a shared local vision.
Commitments within the ambitious agenda set out for PCNs in The NHS long term plan included an expectation they will deliver seven national service specifications. Five of the seven were intended to start by April 2020: structured medication reviews, enhanced health in care homes (with community services), anticipatory care (with community services), personalised care and early cancer diagnosis. The other two were intended to start by April 2021: cardiovascular disease case-finding and locally agreed action to tackle inequalities.
While the PCN service specifications were fit for purpose at the time of writing,[…] some community providers feel that defaulting back to the PCN delivery model risks failing to sustain care home support most effectively.
Initial excitement at the scale of ambition gave way to controversy at the high delivery expectations included in the draft Network Contract Direct Enhanced Service (DES) and concerns about insufficient resources allocated. Following negotiations between NHS England and the British Medical Association’s general practice committee, the updated DES contract included delivery of three (rather than five) pared back service specifications from April 2020 and more funding for additional roles to support the government’s new commitment of delivering 50 million more GP appointments by 2024. On 12 June 2020, 98% of practices signed the PCN contract for next year.
In response to COVID-19, NHS England and Improvement postponed some elements of the DES contract (structured medication review and medicines optimisation until October 2020) but PCNs were expected to begin work on the early cancer diagnosis specification as planned and, from 1 May, deliver elements of the enhanced health in care homes specification. However, community service providers had reservations about the way the enhanced health in care homes framework was brought forward in May. While the PCN service specifications were fit for purpose at the time of writing, COVID-19 has accelerated different models of support to care homes from community and acute providers, and some community providers feel that defaulting back to the PCN delivery model risks failing to sustain care home support most effectively. The emphasis should instead be on developing the right system-wide support model, underpinned by the contract and funding mechanism.