New contract puts a strain on clinical directors

The new contract contains additions which may affect the relationship between practices and PCNs and with funding becoming so tight next year, will tensions between the two escalate, or will practices turn to PCNs for support?

Some new text has been added to the PCN DES this year. In the introduction it states that, ‘A key aim for introducing PCNs was to build greater resilience and leverage the benefits of working at scale for practices’ [1.3]. This was something NHS England put little if any emphasis on in the initial five years of the PCN DES, but it is a definite addition this year, one assumes because they are now keen to paint PCN funding as investment into the core service in light of the clearly underfunded contract.

The PCN DES elaborates further. It states one of the key functions of the PCN is to, ‘co-ordinate, organise and deploy shared resources to support and improve resilience and care delivery at both PCN and practice level. This could also include the PCN delivering practice-level contractual requirements such as vaccinations, screening and health checks, provision of personally administered items, QOF and IIF-related activity during core hours’ [8.1.1].

But many PCNs do not have the kind of relationship with their practices that would enable this kind of working. Independence, and the ability to act independently, is something most practices strive hard to protect. Clear lines have often been drawn between the remit of the PCN and the remit of the practices. Talking about the PCN getting involved in core practice work such as QOF crosses these lines, and is something many practices will not countenance.

Instead the financial pressure on practices is creating a new tension. Where previously practices would choose to have limited engagement with the PCN, now they are much keener to ensure that they are securing their ‘share’ of the PCN resources. So, practices want their own pharmacists or paramedics or GP Assistants, making the job of the PCN clinical director [CD] much harder in terms of being able to both meet the PCN requirements and keep practices happy.

The new contract also contains more of an expectation of PCNs ‘managing’ their practices. PCN CDs have to assess the performance of each of their practices against the key components of Modern General Practice Access in order to be able to claim the local capacity and access improvement payment, and are responsible for determining whether the improvements have been achieved. 

It is not hard to predict that this is going to be a source of tension between PCNs and practices in some areas. If the CD gets it wrong (should the commissioner choose to carry out a ‘post-payment validation’) then any money received has to be repaid, but pressure on CDs to claim the money from practices is likely to be high.

But internal tension between practices within a PCN is not going to help the practices.  The reality is that the only real support available for practices at present is from other practices, and it is most likely to come via the PCN. Right now no support can be expected from the government or NHS England or even in most places the local system.

With finances being so tight it does make sense for practices in a PCN to sit down and work out what it is better to be done individually by practices, and what would be better to be done together. It makes sense to review the ARRS roles and ensure that the balance between collective delivery and individual practice support is right. It makes sense for PCNs to create a financial plan that details how it will invest in developing the ability to deliver collectively and what funding will go to practices. It even makes sense for practices across the PCN to understand where their respective strengths and weaknesses lie, so that they can make the most of the strengths of each and provide support to each other where it is needed.

But just because it makes sense does not mean it will happen. It needs strong relationships to be in place and an underpinning level of trust. Some PCNs already do all of these things because they have this in place, but in others where trust is low and relationships are strained it is hard to exploit these opportunities. 

PCNs present an opportunity for practices to be able to work together to manage the tough financial environment, but the risk is that the financial pressures on practices this year will lead to an increasing strain on the relationship between practices and PCNs. 

Ben Gowland is director and principal consultant at Ockham Healthcare, a think tank and consultancy. He was an NHS chief executive for eight years and has also been a director of Croydon Health Services NHS Trust. He established Nene Commissioning, first as a PBC organisation and then as one of the largest CCGs.