Leading questions: Health policy expert Nigel Edwards on PCNs and rural healthcare

Nigel Edwards, chair of the National Centre for Rural Health and Care (NCRHC), and former chief executive at the Nuffield Trust, speaks with senior reporter Jess Hacker about the progress of rural PCNs and their future in 2025.

Jess Hacker: What are the biggest problems facing rural GPs?

Nigel Edwards: General practice is under huge amounts of pressure in the UK. We’re seeing problems in general practice and primary care in rural areas particularly because of a recruitment issue. People are less willing to live and work in – and take on the responsibility of partnership-based models – in rural areas. That is quite challenging. As we’ve seen in the chief medical officers two recent reports, coastal areas also have problems of deprivation and ill health, which means that primary care in rural areas is being asked to do more than it would be in equivalent areas. So a disproportionate burden falls on falls on general practice, pharmacy and dentistry. On top of that, it costs more to provide services in rural areas, there are fewer opportunities for career progression for your staff, getting people to come and work is challenging as there might not be jobs locally for someone’s partner. Hospitals in these areas are also under pressure with similar recruitment issues which naturally means GPs often find themselves mopping up some of the fallout.

We are asking primary care to do more, and in some sense one of the props for a failing system, or a failing economy in some of these local areas. We are seeing a lot of economic contraction in rural areas, particularly younger people moving out, there are fewer jobs, and the level of deprivation is often quite well hidden. If one can’t get a job or has unhealthy behaviours as a consequence of deprivation or income, where do you find yourself? General practice is often a place of last resort for people with poor mental heath.

JH: As their five-year tenure comes to an end, have PCNs helped to address that hidden deprivation?

NE: PCNs are harder to make work across big geographies. I’ve been talking with one ICB that is having great success developing PCNs, sharing resources between practices and dealing with various workload pressures – but it’s notably not rural. The practices are close together and are able to provide more mutual support. A lot of rural areas have a market town where there might be one or two practices, so you can attempt that support, but it’s much harder. Bringing community nurses into these PCNs creates the added issue that they are now working across big geographies. It is harder to create a team if everyone is spread out.

You need a different model of PCN for places with a distributed population. The question that always comes up is: ‘Are we properly compensating rural health care for the additional costs of that distance travelled?’ And the answer is probably ‘no’.

PCNs can definitely help but it takes time to build those relationships and think about how you work. And likely more time in rural places.

JH: PCNs have been around for four years, has that been enough time in rural areas?

NE: Having a policy in place and saying a policy is in place is not the same thing. PCNs have been in place for four years in theory but in actuality, many of them only started to gear up and start moving considerably more recently than 2019. I think everyone is still learning how to make the most of these. I don’t have any data to suggest rural PCNs are behind city-based PCNs. There are likely to be other determinants to whether or not a PCN is going to be successful, including the support from the ICB and I doubt there’s a rural-urban split on that [aspect].

JH: Would shifting to integrated neighbourhood teams or some other replacement from 2025 be too soon for rural PCNs?

NE: I would be very nervous about losing the identity of the PCN, even if you’re expanding it to develop a wider neighbourhood team. That core of general practice and the associated staff that goes with it is very important and those relationships need to be sustained. If that is in place, then you can develop relationships with a wider team covering a neighbourhood or doing things beyond the provision of health care, like social care and wider prevention work. It should not be seen as the end of the PCN but how you plug the PCN into a wider team. You can’t integrate with everyone all the time – that’s one of the lessons from the literature. Where integration matters is where the highest volume of transactions is. It strikes me that, having invested time into developing these PCNs, they should not get lost.

JH: Given PCNs are well placed to tackle hyperlocal issues, would you rather see the PCN continue as-is?

NE: Being realistic about how long it takes to develop these ways of working, you will need a really solid base. One thing I think we are very bad at here [in the NHS] is allowing people to adjust to what they do given their local circumstances. Some areas will undoubtedly be able to move much more quickly and will already have those relationships [needed for an INT] in place, and it will just appear to be a minor extension of what they were doing. For other areas, that is not the case and it will take much longer and a lot more effort. It’s up to the ICBs and PCNs to work out what is right for their rural practices and their urban practices. That needs to be done with much more careful thought than just mandating it nationally and expecting the same pace.