PCNs roles in the future NHS

Uncertainty around the role of PCNs is a constant theme for clinical directors as short-term contracts mean developing services and hiring staff feels risky despite central funding and assurances.

Today’s announcement that NHS England is to be abolished is unlikely to ease any of these concerns.

Details around how NHS England’s functions will be brought back into the Department of Health and Social Care are still being worked out. Added to this, ICBs have been tasked to cut their workforce by 50%, which equates to around 12,500 staff across the health system.

While the upper echelons of the NHS are reeling today – where does this leave PCNs?

It seems neighbourhoods are in the ascendance – this word has been touted around by this government since it launched its manifesto for the 2024 election in June last year.

It is not a new term, PCNs were set up on a ‘neighbourhood footprint’ of 30,000 to 50,000 and the Fuller Stocktake discussed care across neighbourhoods.

There were initial suggestions that PCNs may morph into neighbourhoods as integrated neighbourhood teams, with their preexisting multidisciplinary teams working across neighbourhood-level population areas.

However, the Neighbourhood Health Guidelines published by NHS England last month mentioned PCNs once, stating that  forming a neighbourhood health service would ‘build on’ existing cross-team working such as PCNs, that the role of establishing these bodies was placed at ICBs’ feet.

This guidance seems to suggest that a Neighbourhood health service will operate on a larger scale than a PCN. This has led some to believe that PCNs will just be components of neighbourhoods, which will presumably assert some control or oversight of PCNs when in place.

In a Pulse PCN roundtable due out next month, six clinical directors discussed this topic and mentioned significant concerns around the role of PCNs in the neighbourhood health agenda.

Dr Shanika Sharma, clinical director of West One PCN, East London, said: ‘My biggest concern is that integrated neighbourhood teams (INTs) are going to pose a risk to dismantle what we’ve worked to hard to build over the past few years with PCNs and the infrastructure we’ve created, and also health inequalities as well.’

Dr Sian Stanley, clinical director at Stort Valley and Villages PCN in Hertfordshire added that it was PCNs that had made the biggest difference to integrated working in recent years.

She said: ‘It’s the PCN resource, that shared resource and working at scale, that has probably had the single biggest impact into integrated neighbourhood working than anything else.

‘What it’s done is taken some of my very traditional partners who’ve got a very traditional view of what primary care is – about seeing your doctor, your doctor imparts wisdom, you go off and listen to your doctor. Instead of that we’ve flattened hierarchies, got people understanding the social needs of our population. That has only happened as a result of PCNs.’

Dr Binodh Chathanath, clinical director at Bexhill PCN in Sussex, added that he believes PCNs will start to disappear in the future.

‘I think PCNs would start dissolving in our area because we are looking at more integrated care team (ICT) work,’ he said.

Part of his concerns are around the Additional Roles Reimbursement Scheme (ARRS) fund and calls for it to be added into core funding.

‘I think PCNs will start to slowly disappear in our area because there’s a big push for the ARRS funding to be used at practice level which I think is counterproductive to the PCN agenda and vision about networking and coming together.’

Significance of ARRS

Despite uncertainty around the future of PCNs within the system, the employment mechanism for PCNs, the ARRS, has so far continued to receive endorsement from the government as it continues to expand its scope. Although there are questions over whether the ARRS pot will remain ringfenced under System Development Funding (SDF), or be added into core allocations.

In the contract changes for 2025/26, revealed by the BMA on 28 February, the restrictions on how many GPs can be claimed under the scheme was lifted, alongside an increase in the amount of money that can be claimed for them. Practice nurses were also added to the list of reimbursable roles.

Though there are some concerns that the addition of GPs to ARRS is a ‘Trojan Hose to a salaried model’, the contract changes have given greater local discretion and flexibility to PCNs.

In a webinar on the recent contract changes on 3 March, NHS England’s primary care director Dr Amanda Doyle emphasised the significance of the ARRS changes for PCNs in the upcoming contract, saying that it was a ‘single pot’ that PCNs could ‘use for anyone’.

‘You don’t have to have any GPs, or you can have as many GPs as you can recruit and you’ve got money for,’ she said. ‘Same with nurses, it’s completely and utterly flexible and up to you how many of what sort of staff you use that money for.’

Katie Collin, partner at specialist medical accountancy firm Ramsay Brown LLP, said this move could result in PCNs employing more staff. 

She said: ‘Now that PCNs have the freedom to use ARRS funding to hire practice nurses, as well as GPs on slightly higher salaries, we could see them employing more and more of a practice’s workforce. Theoretically speaking, they could even employ the entirety of a surgery’s direct patient care staff.’

She added that this was ‘unlikely to happen’ in practice due to the qualifying conditions for ARRS salaries, such as GPs having to be within two years of obtaining their CCT.

‘ARRS budget is only valid for GPs whose salaries sit below the £82,418 mark, for example – that’s only £10,000 above the minimum GP salary, and well below the £110,000 maximum. With all that said, you can see how difficult it would be for PCNs to hire experienced practitioners through ARRS alone,’ she added.

‘While we could see PCNs employing more practice staff over the next contract cycle, it’s fairly unlikely they’ll become responsible for a practice’s entire crew. The relaxation of some ARRS rules is a welcome development, but the remaining conditions still pose significant hurdles to PCNs across the country.’

Limits of a one-year contract

But despite the increase in flexibility and funding for PCNs, there is still a level of uncertainty that comes with a one-year contract. 

PCN pharmacists recently reported concerns over the instability of being employed on 12-month contracts which is often due to a ‘reticence and a nervousness’ of PCNs taking someone on full time, according to the Pharmacists Defence Organisation.

In the contract webinar on 3 March, Dr Doyle said this was a question she got ‘every year’ as people ‘get caught up’ in the funding being a one-year deal.

When asked about the future of PCNs, Dr Doyle said: ‘We get a one-year budget every year for the entirety of the service. It doesn’t mean we don’t intend it to continue, it’s just that we don’t know how much money will be available in future years or what we can commit to.

‘We’re very clear that there are lots of services that benefit from being delivered at a bigger than single practice scale.

‘There are lots of services, whether that’s long-term condition management or urgent on the day care or targeted work around cohorts of patients, vulnerable patients, frail patients, people with learning disabilities, that actually having a specific service on an individual practice basis is quite difficult.’

She added that there was ‘no intention to not continue to support PCNs’ and that ‘there’s no threat in any of this to working on the PCN scale.’

A similar commitment was made by NHS England’s group director for primary care, Alex Morton in a webinar in January, who said: ‘The future of PCNs is secure for 25/26 with additional funding being implemented through ARRS.’

PCNs have also been the vehicle chosen to pilot demand and capacity changes for general practice, with a programme running across three years in seven ICBs to try and understand whether interventions can make a difference to capacity in primary care.

However, without a longer-term funding commitment for PCNs, coupled with today’s news that NHS England will be abolished and ICBs have to make 50% cuts to staff, questions will keep being posed over the future of the system as it stands. The details in the new Network DES in the upcoming contract may give an indication of this for the next financial year, but it is the 10-year health plan that will be crucial for understanding just how neighbourhoods will be organised and what role PCNs will play in years to come.

Additional reporting by Anna Colivicchi.