PCNs past, present, future: Looking beyond the DES

PCNs know the contract is coming to an end in March 2024 but are unclear what that means. With just over a year to go we look at the challenges past, present and future. Emma Wilkinson reports

The future is unwritten and in this case it’s the future PCN contract that’s unwritten. What will become of PCNs, how they will work with integrated care teams and the integrated care boards (ICBs) and wider systems is all yet to be worked out. But lest we see a ‘vacant chair in the corner’ and feel a heavy sense of humbug, PCNs must be able to look to and plan for the future to ensure the improvements they are making in their communities are sustained rather than lost.

The past year has seen PCNs face a head-spinning array of changes, from the introduction of the new PCN DES and enhanced access, and a complete overhaul of NHS structures with the introduction of ICBs and the Fuller Stocktake on the Next Steps for Integrating Primary Care. Add to that the incredible pressure on primary care even before winter hit, a revolving door of health ministers and the health select committee’s Future of General Practice report, and it’s no wonder PCNs are not in a position to scan the horizon and plan for the future.

Yet the current five-year contact is ending in little over a year (in March 2024) and while the Fuller Stocktake is seen as a way ahead, how PCNs will sit with integrated care teams is unclear. We look back at the key challenges in the past year, the present pressures and consider how PCNs can get themselves in the best position for the next 12 months.

PCN past: changes to the network DES

The network contract was updated in April, with a significant boost to funding through the additional roles reimbursement scheme (ARRS) and dramatic expansion in the impact and investment fund (IIF). The aspect that caused the biggest stir was the compulsory requirement for PCNs to provide enhanced access, which left clinical directors (CDs) carefully considering what they could realistically achieve.

Dr Sarit Ghosh, CD at Enfield Unity PCN, London, said teams were under huge pressure after the pandemic, then the vaccine campaigns and now with reactive care going through the roof.

He adds the IIF and locally commissioned services that PCNs are delivering are a lot of work. They are still training an ever-expanding workforce and trying to support practices, and with wider policy changes and integrated care system (ICS) strategy, ‘we have to be selective. If you tried to do everything you would probably fail.’

As a result, PCN CDs have taken a pragmatic approach to enhanced access, trying to prevent the additional appointments being swallowed up by yet more urgent care. But the new access requirements have been challenging for PCNs, which have burnt-out teams already working at
maximum capacity. Some have turned to alternative options, with 40 PCNs contacting the private digital GP provider Livi.

PCN present: winter pressures

In further sweeping changes to the network DES announced in September, £37m was reallocated to support practices to improve access over winter. It meant the deferral of three IIF indicators and the
scrapping of a fourth with the money instead coming to PCNs through a monthly support payment from October to March.

NHS England has confirmed that the support payment ‘must be used to purchase additional workforce and increase clinical capacity to support additional appointments and access for patients’ with PCNs committing this in writing to commissioners. Two new roles – GP assistants and digital and transformation (D&T) leads – have also been added to the ARRS.

But, says Dr Yasmin Razak, who recently stepped down as CD at Neohealth PCN in North Kensington, London, the winter DES is not new. It is simply releasing some of the IIF sooner.

‘I’m unsure if this will make any difference as it’s only about 70p a patient and NHS England is missing the real issues.’

She adds she would have liked to have seen other IIF incentives axed to free up GP time and
reduce system pressures because as targets they will bring little gain.

Professor Aruna Garcea, NHS Confederation Primary Care Network advisory group chair, says the funding that’s been released back to primary care is just a rebadging of the IIF. The amounts are minimal, considering what PCNs are facing. Also, there is hidden work in setting up respiratory hubs and redirecting ambulances. ‘I don’t think it will have a significantly robust impact on the winter threats and the workforce issues we’ve got,’ she says.

Alongside the changes to the IIF indicators, there was also a framework outlining how ICBs should support PCNs. It tasked ICBs to scope out ‘how any additional capital funding available later in the year for primary care could be used’ with a focus on areas with deprivation and recruitment challenges. This had to be done by 21 October.

The framework also covers areas where support would ‘help improve patient access and staff experience over the longer term, and build an ongoing quality improvement support process within primary care’. It would be paid for by ongoing system development funding (SDF) or other
transformation funding.

PCN CDs say they have not heard from their ICBs about the framework. ICBs took over from CCGs on July 1 so ICBs may have had little time to consult PCNs before the deadline. Or they may already have the necessary data or don’t want to overwhelm people with more engagement that they don’t feel will be useful, they added.

Issues that ICBs are being asked to consider include whether cloud-based telephony is in place, what business intelligence tools practices are using, what processes have become automated and whether estates and equipment are adequate.

Professor Garcea adds there is a risk that with extra system development funding, ICBs and PCNs will not have the time to come up with a co-ordinated solution to winter pressures. This needs to be
addressed for next year. ‘We need to get better at planning for winter together, the ICBs and PCNs.’
Dr Emma Rowley-Conwy, clinical lead of Streatham PCN, says she has not heard from the ICS about the framework. She presumes it will filter through but says PCNs do not have the time to engage with it.

For her area, cloud telephony is well ahead. Some of the local IT issues relate to factors outside the ICB remit, such as the lack of functionality in EMIS to support enhanced access implementation. ‘We need to secure ongoing funding for Accurx – licences and SMS. This is currently our most important universal tool to manage patient demand and recall, but the costs are high. Also, NHS England says that GP development fund monies cannot be used for licences. This presents a real challenge,’ she says.

PCN present: organisational and policy overhaul

While they grapple with funding changes, new roles and preparations for a difficult winter, PCNs have had to keep abreast of key reports, policy developments and the shift from clinical commissioning groups (CCGs) to ICBs. The implications are still not fully apparent nearly six months on.

This is such a big challenge for general practice that extra pots of money here and there are unlikely to make a difference, says Dr Ghosh. Long-term strategic thinking is needed, but that takes time and space.

In May, the Fuller Stocktake set out a vision for the development of integrated neighbourhood teams to drive improvement. Left as it is, primary care will become unsustainable in a ‘relatively short period’, said Dr Claire Fuller, the report’s author and chief executive of the Surrey
Heartlands ICS. It also called for a system-wide approach to managing integrated urgent care to guarantee same-day care for patients.

The Fuller Stocktake learned from good projects around the country, says Dr Ghosh, but moving to integrated neighbourhood teams is easier for some parts of the country than others. In London, there’s a lot of overlap. ‘Working in teams is absolutely the way to go but how do we do
that without disrupting relationships?’

Although ICBs are still in a nascent phase, all 42 chief executives signed a letter endorsing the Fuller Stocktake and recognising the importance of primary care. However, they are only just starting to
consider what their primary care strategy may be.

In October, the Health and Social Care Select Committee published its view on the future of general practice after a lengthy inquiry chaired by now Chancellor Jeremy Hunt. Key findings included ‘extreme concern’ about the decline of continuity of care, a call to return to individual patient lists and a call for NHS England to review PCN funding mechanisms to ensure they do not exacerbate health inequalities. It concluded that significant pressures in under-doctored, highly deprived areas are compounded by ‘unfair funding mechanisms’ that fail to account for deprivation. It was highly critical about the Government and NHS England’s failure to acknowledge the crisis in general practice.

Dr Razak welcomes the headlines in the committee’s report and says GPs had known about these issues for a long time. This should be the focus she believes, rather than the Fuller Stocktake. ‘The report looks at root causes of problems – to give primary care its strength back.

‘Moving acute primary care presentations to at-scale providers and out of the GP system will lead to a further loss of GP continuity, which we know improves outcomes. We need to build on the longitudinal relationship.’

In June, amidst the changes to the network DES and the Fuller Stocktake, doctors at the BMA’s annual meeting voted for practices to withdraw from PCNs by next year and for funding to be moved into the core contract. That followed a warning from the General Practitioners Committee (GPC) that the PCNs posed an ‘existential threat’ to the independent contractor model.

More recently, details have emerged of how this might happen. The BMA has set out plans for PCNs to evolve into ‘locally flexible neighbourhood teams’ where local practices can collaborate. At a meeting in October, the GPC suggested that a mass exodus from the PCN DES was not imminent and there would be no point at which PCNs would close down and make ARRS staff redundant. As part of its September winter support measures NHS England also encouraged PCNs to continue to recruit, and make full use of their ARRS entitlement ‘with the knowledge that support for these staff will continue’.

PCN future

This has been a remarkable period of flux and adaptation for PCNs, and it is difficult to know what their focus will be over the remainder of the contract and how can they can prepare for what comes next. A report published on 4 November by the NHS Confederation, Primary Care Networks: Three Years On, called for NHS England to guarentee they will exist beyond 2024 to aid long-term planning.

It says that NHS England must work urgently to remedy the ‘unstable operating environment’
PCNs were launched into and allow networks to plan beyond the uncertainty surrounding their own futures. It also asked NHS England to refrain from adding further service specifications to next year’s Network DES. PCN CDs will have to make tricky decisions and navigate opposing views, says Ben Gowland, director and principal consultant at Ockham Healthcare, a think-tank and consultancy that works with PCNs.

‘PCNs are wondering, will practices withdraw? Then the Fuller Stocktake says primary care will evolve into neighbourhood teams, so what does “evolve” mean, and is it the end of PCNs?’ he says. ‘We know the five-year deal is in place but not what will happen after 2024.’

He does note that in areas where integrated neighbourhood teams already operate, for example Suffolk, PCNs still operate, but voluntary, community and social care teams work alongside primary care. Some PCNs are starting to think about the wider strategy and how to avoid losing the funding that brings into general practice. But for the most part, PCNs are just focusing on core operational demands, he says.

Most PCNs are just doing the job, he says. ‘The IIF is demanding, as is the ARRS, and working in teams. And practices are starting to see value in additional roles. Their focus for the next 18 months should be two-fold: first, use ARRS funding to get the skill mix and roles they want before any contract changes; second, co-ordinate locally to work with other PCNs, the LMC and federations to ensure collective input to the ICS.

‘It does feel that funding and influence will come from the ICS rather than nationally after the end of the five years. So the ability to influence the system becomes important. That’s key over the next 16 months.’

But CDs are also having to accommodate different opinions among practices – whether to be proactive and propose solutions or whether to wait and see what ICSs devise. There are marked divisions, he adds.

‘Some GPs are under such pressure that the idea of leaving that to another team is appealing. But there is an equally vocal cohort that is adamant that continuity of care is about seeing the same person for an urgent need because the relationship builds over time. PCN CDs are left asking, “how do I manage that”?’

Professor Garcea notes this year has been a rollercoaster for PCNs but they now need ‘split-screen’ thinking. As well as doing the day job, they should think about how to work successfully with ICSs. ‘We’re on this train and it’s continually moving and we need to know what’s going to happen after 2024. As a GP community we should use where CDs are strategically placed to impact on our patients and the system. At-scale working has already started in different parts of the country to deliver local and resilient solutions to help general practice. Now we need to get that right, get the joint working that needs to happen. A CD has to focus on relationships [locally] and that has to be a priority.’

Tara Humphrey, managing director at THC Primary Care, which provides project and network management and training to PCNs, says uncertainty about change is stopping progress in some networks.

‘Nothing is for ever. We’ve seen that with the latest Government. I don’t think we should live in fear because there’s a lot of work to be done between now and the end of the contract,’ she advises.

‘I think that whatever the contract looks like beyond 2024, the infrastructure will stay unless something falls out of the sky. When there’s lots of change and you don’t know what to do, you do nothing because you’re frightened of making the wrong steps,’ she adds. But for PCNs, she says, it needs to be business as usual because there is enough demand in the system to warrant the work.

‘There is a spectrum of where PCNs are. But whoever they are, the one thing they can control is getting into the best situation from a business point of view – culture, network agreement, finances, HR, workforce planning and IT – to be ready for the next evolution,’ she says. ‘While some will always have one eye on the strategic landscape, that speculation is not always helpful and can mean you lose focus.’

She says workload pressures are hard to manage but a PCN does not have to do everything themselves. In her work, she meets CDs who want to learn and are daunted but still hopeful. ‘You have to able to transform into the next thing and you’ve got to be in a good place to do that.’

PCNs have shown resilience in the face of adversity, both past and present. Now the end of the contract is looming, casting its shadow over the coming year, and they must shore up their achievements and start on the next phase – building a larger team and links with ICBs and the wider system’s needs to ensure everyone is blessed with headroom, autonomy and support.