The State of Primary Care: A PCN Evaluation

Primary care networks (PCNs) have been the biggest change in the primary care landscape in a decade. As set out in the 2019 NHS Long Term Plan, the goal was for PCNs to be a vehicle for investing in primary care and community services. As then detailed in the 2019/20 GP contract, practices were offered the opportunity to sign up to a Network Directed Enhanced Service (DES) requiring them to form networks of 30,000 to 50,000 patients.

Various funding streams were channelled through these new networks with the goal of bringing practices together to provide care for their local populations. While signing up to the scheme was voluntary, 98% of practices did so to make the most of the billions of pounds of additional funding delivered through several mechanisms, including a core payment per patient, additional funding for specific professional roles to support the general practice team and fees for providing enhanced care, the focus of which changed over time.

The first major task of PCNs came in the pandemic with the organisation of a highly successful mass Covid vaccination campaign. This galvanised PCNs around a single aim, speeding up the collective joint working. The pandemic also gave practices a push to move to online working. Since that time, general practice, just like the rest of the health service, has been struggling to recover, facing ever-increasing demand despite providing record numbers of appointments – four million more each month. In 2022, integrated care boards (ICBs) replaced the clinical commissioning groups (CCGs) with which primary care had developed a close working relationship and this too has caused a certain amount of flux.

Across PCNs, the biggest slice of funding has come through the Additional Roles Reimbursement Scheme (ARRS), which provides a resource for PCNs to hire pharmacists, physiotherapists, social prescribers and a long list of other roles, which has been added to over time, including most recently an enhanced practice nurse. More than 31,000 staff have been recruited into primary care with the vast majority coming through the ARRS, and this has sent shockwaves across the sector. The large shift in roles over a short period has created issues with staff shortages within community pharmacy and concerns over the role of the practice nurse. It has also prompted serious concerns among GPs about how the ARRS scheme may have undermined the GP role, leading to fears that salaried GPs cannot find jobs.

As an investigation by Pulse revealed recently, there has been much debate in particular about the role of the physician associate, how that is regulated and supervised, and what it has meant for patient care. The inflexibility of the ARRS scheme has also led to GPs reporting a lack of salaried and locum jobs with practices warning they cannot fund these roles as much as they would want to hire them. And despite the success that PCNs have had with the scheme, an investigation by Pulse PCN revealed that more than £45 million went unspent last year, with only a fraction reallocated. This relates to ongoing issues with finding suitably trained staff, lack of funding for the support and training of staff who are new to primary care and restrictions placed by NHS England on who can be recruited.

Enhanced access has been a clear focus for PCNs in the past couple of years. They are tasked with improving digital transformation to increase the options that patients have for contacting the practice and booking appointments with different members of the team. PCNs have also been responsible for providing extended hours in the evening and on Saturdays, coming up with individual plans about the sort of appointments that would best suit their population needs. Tackling health inequalities has been on the agenda since the start but has perhaps become less of a priority for those overwhelmed with demand. PCNs are also working within a wider context of a cost-of-living crisis and lengthy waiting lists for patients to access specialist care.

Since PCNs were set up, there have been dramatic changes to the wider system in which they operate. When the CCGs – created in 2013 to put the GP at the centre of planning for their local populations – were replaced by ICBS in 2022, PCNs raised concerns about getting lost in these larger structures where acute care may attract a bigger focus. There does seem to be some evidence that relationships between primary care and the wider commissioning structure may have become more disconnected, as well as concern that ICBs have not prioritised funding for primary care services, having been heavily focused on cutting secondary care waiting lists.

The State of Primary Care survey was answered by more than 1,700 healthcare professionals. This PCN evaluation focuses on how different professions rate and interact with PCNs and what impact they have on their profession.

About the survey

The State of Primary Care survey took place between April 29 and May 20 2024 across Pulse PCN and our parent and sister titles, Pulse, Healthcare Leader, Nursing in Practice, The Pharmacist, Management in Practice, Hospital Healthcare Europe and Hospital Pharmacy Europe.

There were 1,795 responses from health professionals. The majority – 72% or 1,294 – of respondents work in primary care in England. There were answers from across England with all 42 ICBs represented.

Of those who stated their profession (1,104) the majority were GPs at 37% (411). Nearly a quarter of these GPs (83) have a PCN role and a further 6% (65) of the total respondents are clinical directors (CDs) who are also predominately GPs.

PCN and practice managers were the next largest cohort of respondents at 21% (231) with 2% (21) of participants working as network managers.

Nurses were the third largest group to respond, representing 16% (179) of participants. The largest majority were general practice nurses at  11% (122) followed by community nurses at 3% (29) and nurses with an ARRS role at 2% (28).

Pharmacists made up 10% (114) of respondents, with the majority being pharmacists employed via ARRS 4% (44) followed by community pharmacists at 3% (31) and practice pharmacists at 2% (25).

As of April 2024, there are 1,279 PCNs in England. Data from NHS Digital shows 363 full-time equivalent CDs, eight in ten of whom are GPs, a number that has remained stable over the past year. The goal, as set out by the network DES in 2019, was for PCNs to build greater resilience and leverage the benefits of working at scale for practices. In its latest iteration, this remains a key aim for CDs who are tasked with forging closer links between practices as well as the broader health and care system and voluntary sector.

CDs are responsible for ensuring their PCN delivers the requirements set out in the network DES and allocating the funding, including that provided through the ARRS across the practices. A key addition to the list of roles that can be funded under the ARRS scheme this year has been the enhanced practice nurse. They are also accountable for deploying capacity and access support payments which have been introduced to improve patient experience and access to general practice. A fairly recent introduction to the lexicon for PCN CDs has been their work within integrated neighbourhood teams – first mentioned in the Fuller Stocktake report. They bring together multi-disciplinary professionals from different organisations across health and care services and CDs are tasked with helping to establish them and ensuring PCN  participation.

Successes and failures

In our survey, 97% of PCN CDs said they would continue with the network DES in 2024/25 with only 3% indicating they were unsure.

This likely reflects the reality that a large amount of primary care funding is delivered through PCNs and practices would not be able to function without it. One clinical director (CD), who wished to remain anonymous, says the work being directed to general practice at the current level of funding is economically unviable with practices at ‘immediate threat of collapse’.

When it comes to pointing to the positive aspects of their work, 69% said their PCN had been successful or very successful in improving joint working. Around 63% also said their PCN had been successful or very successful in improving care for patients while more than half, 57%, also rated themselves in these terms for improved patient access.

While there may have been some heated debate around the use of ARRS money in the profession more widely in recent times, this was an area in which PCN CDs rated success particularly highly in our survey. In all, almost nine in ten respondents rated themselves as successful or very successful in recruitment and retention of ARRS staff, with 48% putting themselves in the most positive category. But that is not to say all is rosy, with one CD specifically commenting that they could have done even more had there not been ‘so many strings attached’.

‘So much of the ARRS budget has been lost to primary care because it seems to have been almost designed to make it impossible to take full advantage,’ they note.

Dr Nicholas Jackson, CD of Selby Town PCN, said pharmacists, physiotherapists and mental health workers had been most valuable to them in supporting core general practice. ‘We have had equal, if not greater, success in delivering personalised care and population health and heath inequality work via roles such as care co-ordination, social prescribing, dietetics and health and well-being coaches.’ While the impact on workload is less obvious, this is part of investing in a more prevention-focused model ‘which we hope will bring rewards in the future’.

Among CDs responding to the survey, 30% said their PCN had been unsuccessful or very unsuccessful at freeing up GP time with 36% feeling neutral about this part of their work. This perhaps reflects the well-documented pressures seen in general practice overall. As has also been widely reported, the addition of new practice staff also comes with supervisory responsibilities for the GP members of the team.

While the results around digital transformation and improving health inequalities were also broadly positive more than one in five CDs did report a lack of success in these areas.

Dr Manraj Barhey, CD at Medics PCN, Luton, Bedfordshire, says PCNs provide a ‘really good opportunity to tackle health inequalities’.

‘We focus a lot on outcomes and they have been pretty phenomenal. There is a lot of hidden need out there,’ he says. Medics PCN has identified thousands of patients with conditions such as hypertension that were going undiagnosed or unmanaged as well as success in tackling very frequent attenders through non-clinical interventions.

ARRS

A more in-depth look at survey results around the additional roles scheme specifically shows a great deal of consensus that it has improved joint working between practices, with 84% agreeing or strongly agreeing with this view.

There was also a very positive outlook for ARRS having improved patient care and access. Yet the responses from CDs also show a bit of a mixed bag when it comes to the impact of the new staff on the GP and the rest of the team. Half of respondents said the ARRS scheme had increased workload for practice staff and 46%  said it had put more pressure on GPs and general practice nurses. The balance of opinion as to whether the hiring of ARRS staff had reduced GP workload was a relatively even split, with 50% believing it had but 42% saying it had not, and 8% unsure.

Dr Barhey said they had freed up tens of thousands of appointments that would have gone to GPs as well as case finding and prevention work. ‘We are a large PCN of 60,000 patients and we have 28 staff that we use to ensure we can offer capacity to practices.

‘For our practices and GPs, there has been a noticeable difference, and we are not as stretched’. He added that the impact that PCNs have made on access is considerable and ‘perhaps not recognised enough’ because of the pressures that primary care is under.

He is among those who would like to see far more freedom in how PCNs can use their ARRS money. ‘It should be: “Here is your budget, do what you like with it”. We need that flexibility.’

Dr Jackson adds that GPs still feel significantly overstretched because of the additional burden of supervision and there has also been an unintended effect of ARRS roles in ‘introducing duplication and inefficiency’ and multiple appointments that could have been all handled by a GP in one appointment.

In general though, the hiring of ARRS staff is viewed as having had a positive impact on GP practice staff and CDs were particularly upbeat about the impact of ARRS staff on their own GP practice, with 82% saying this had been positive or very positive, perhaps showing how well the newer members of staff had embedded within existing teams.

Eight in ten respondents also cited the ARRS scheme as having had a positive impact on their patients and 59% said these new members of staff had also had a positive impact on the GP profession.

Since the ARRS funding stream was introduced, PCNs have raised concerns that they can struggle to recruit the specific roles set out by the network DES. The list of eligible roles now includes clinical pharmacists, paramedics, first contact physiotherapists and social prescribers but also mental health practitioners, physician associates, general practice assistants and dieticians.

Pulse PCN has recently revealed that tens of millions of pounds available to PCNs through this scheme have been lost to primary care. PCNs have reported being unable to make full use of this money because they cannot recruit, or the funding is inadequate when they do find someone or the staff they need in their practice are not included in the scheme.

In the past year there does seem to have been some improvement on this front from previous reports where 65% of CDs have said they have struggled to fill ARRS roles. In the latest survey, 81% said they had been able to spend all the ARRS money available to them under the network DES, which may reflect the expansion of roles included in the scheme over time. In all, 16% of respondents said they had not been able to spend the ARRS money they were eligible for.

Yet some respondents said it had been a source of significant stress to spend the funding as the rules were complex and difficult to administer, while others noted they had got close to spending the money but had difficulty recruiting specific roles or had been unable to have their first choice of staff, for example, a paramedic.

Dr Sian Stanley, CD at Stort Valley and Villages PCN, Hertfordshire and Essex, said general practice is very efficient but has been hampered by ‘not being able to employ the people who could make a real difference to capacity and access because the ARRS scheme has been so restrictive’. 

When it comes to the ARRS staff most valued by CDs in helping support the PCNs’ practices and patients, our survey shows pharmacists coming out top, with 81% saying they had been most successful in this role. Physiotherapists, care coordinators, social prescribing link workers and paramedics were also all seen as successful in supporting practices and patients by at least half of respondents.

Around 60% of CDs said they did want to see other roles including in the ARRS, with GPs and practice nurses being suggested most frequently.

One respondent who said doctors and nurses should be included added ‘this is what patients want’.

The clinical director role

There is experience among those doing the job, with the majority of our respondents – 38% – having been in the CD role since PCNs were formed, with 30% having had the job for four to five years.

A quarter also said they would like to stay in the role for five years or more but just over a quarter responding say this is a role they can only see themselves doing for one to three years.

The job takes time, with 28% of respondents spending 16 to 20 hours a week in the role. Another 38% of respondents said they spend more than 20 hours doing CD work. Only 16% spend up to ten hours which seems quite a shift from our 2021 report when this was the most common response.

Dr Barhey says his role as a CD has grown hugely, having gone from no staff employed by the PCN to 28 who need managing and training. ‘It is our job to set the strategic direction and the biggest problem has been having CDs who are trained in those leadership roles.’

It also appears from our survey responses that more appointments a week are being lost through CD activity. Our 2021 report found that CDs who reported losing appointments mostly set it at 16 to 20 per week, but in this survey, 10% selected 26 to 30 hours and 8% selected 41 to 45 hours, another indication that the role is increasingly taking up more time.

Dr Paul Evans, a GP in Gateshead without a PCN role, says their local experience is that over time, it has been increasingly difficult to attract CDs to the job. ‘There was a lot of initial enthusiasm, but while the workload has grown, the funding for the job has not. It has been taking up more time and impacting on the ability to do their practice job. It is a lot of work.’

The wider system

The survey does show a real mix of views among CDs about how PCNs are interacting with the wider system, including neighbourhood teams and ICBs. The vast majority (78%) are aware of what neighbouring PCNs are doing and 53% say their PCN is part of an integrated neighbourhood team.

Dr Alison Challens, CD of Chippenham, Corsham and Box PCN, Wiltshire, thinks the idea of integrated neighbourhood teams is good but needs to be adequately funded and she also commented that the development of them is ill-defined as ‘No one knows what an integrated neighbourhood team should be’.

While a majority do say there is good engagement with primary care and the ICB and they know who their representative is, 41% strongly disagree that this is better than it was with CCGs and 38% also feel strongly that ICBs will not ensure more funding is directed into primary care. CDs appear to have very split views on whether PCN same-day access hubs are a good idea, the future role of general practice and whether PCN funding should be moved into the core contract.

Funding

For 2024/25, funding into general practice increased by 2.23% or £259 million, which breaks down as £215 million for the core contract and £44 million for the DES. In all, 72% of CDs responding to our survey said the resources in the network DES were inadequate for the workload requirements. This is a similar response to our report in 2021. One respondent noted that finances were so tight there was nothing left for developing at-scale provision, while another noted that to run a good functional PCN is a huge undertaking that requires people who care to make it work.

Dr Challens said core funding of general practice also needs to increase – ‘it should be both, not either/or’.

‘There is less flexibility in the system so this reduces innovation due to lack of resources. We are having to reduce services to patients as we can no longer afford to provide them, we are being told that there is likely to be a further reduction in funding in real terms. Most PCNs are trying to ensure max funding and staff go to practices from the PCN as there is such a lack of funding and staff through core funding,’ she says.

The initial five-year PCN contract was subject to considerable changes throughout, in part due to the pressures incurred by the pandemic. It ended in March this year and NHS England put out a one-year version. This detailed several changes that CDs are largely positive about.

The two changes CDs were most positive about were releasing the capacity and access improvement payment (CAIP) at the start of the year rather than at the end and reducing the service specifications.

Most CDs do see a future for PCNs, with only 18% seeing scrapping them as a priority for the next government and 48% listing this as a very low priority. Much progress and hard work has been put into PCNs over the past few years not least being mobilised to deliver a nationwide Covid vaccination scheme. Far higher up the agenda for those leading PCNs is recruitment of more GPs and practice nurses, and better pay for all NHS staff. This is followed by reducing the elective care backlog, improving access to primary care for patients and better movement of patients between primary and secondary care.

Dr Jackson says: ‘I think it would be a tragedy to lose all the good work and staff we have put in place through PCN’s, but I understand the argument that more funding should be directed towards recruiting GPs and nurses.

‘I always describe it as like living in a house which is falling down – we need builders and scaffolders to come and repair it (and build an extension ideally) but all we can find in the Yellow Pages are landscape gardeners and trainee plumbers – skilled people doing a good job, but not really equipped to fix the problem.

Dr Stanley adds that to run a good, functional PCN is hard work and needs a huge skill set. ‘The successful ones have been led well but the work needed to make sure the needs are met of the participating practices is huge. I do want some acknowledgement that this has been a tough road and only made successful due to people like myself who cared enough to make it work.’

Five years after their introduction, GPs do not feel particularly positive about what PCNs have been able to achieve across several measures. Their concerns centre around funding for practices, the influx of new practice staff and a general feeling that pressures are increasing in primary care rather than being alleviated. Few of our respondents felt that PCNs had had a positive impact on their work, with most believing it had in fact destabilised general practice. Yet PCNs do seem to have forged greater connections between practices from the perspective of GPs. It is clear that pharmacists and physiotherapists are the roles that are the most welcome addition to the practice team.

It is perhaps unsurprising that GPs have strong views around funding given how squeezed practices have reported feeling. In all, 47% of our respondents strongly agree that PCN funding should be moved back into the core contract after 2024/25. Another 22% agreed but less vehemently. This supports the BMA position to end the network DES and fund practices through a core pot.

GPs are also sceptical that the ICBs that took over from CCGs in 2022 will ensure more funding is directed into primary care. Of our respondents, 64% strongly disagreed or disagreed this would be the case. A similar proportion also felt that engagement with commissioners had got worse since ICBs were introduced. Just under a quarter said they did not know if this had changed and less than 5% agreed that this had improved.

A key issue for ICBs and PCNs this year has been the implementation of same-day access hubs. This model is based on PCNs, or groups of PCNs, coming together to ‘deliver a single point of triage for same-day, low complexity’ appointments leaving GP practices with the longer-term complex cases. It was a concept first mooted in the 2022 Fuller Stocktake, a landmark review of primary care, which recommended that urgent on-the-day appointments be dealt with by a single care team based across a larger population. But there has been a backlash to this idea from GPs, including in North West London where the ICB had to step back from a mandatory imposition of the model. The opposition of GPs can be seen in our survey results with 21% agreeing but 58% disagreeing or strongly disagreeing they were a good idea.

Dr Paul Evans, a GP in Gateshead, is among those who believe strongly that this model will be ‘utterly disastrous’ and could lead to even more money being removed from the core GP contract. ‘It would fundamentally change the job and break the relationship with patients. It will also make training new GPs nigh on impossible.’

Practices are certainly under a great deal of pressure trying to meet ever-rising demand and with the long waiting lists for elective care having a knock-on impact. This is reflected in the finding that 69% feel that PCNs have been unsuccessful or very unsuccessful at freeing up GP time. Neither is there much support for the idea that PCNs have improved care for patients or access. In all, just 16% of GP respondents believe PCNs have boosted access and 14% think they have improved care.

There is a more even divide among GPs on whether PCNs have had success in recruiting and retaining ARRS roles – a quarter have a negative view and 32% report some success in this area with another quarter somewhere in the middle.

Professor Azeem Majeed, a GP in South London and professor of primary care and public health at Imperial College London, says more flexibility for practices would make the ARRS scheme more attractive. ‘Some practices might want to place posts within a PCN or a GP federation. Others may want to invest more in posts within their own practices. There should also be flexibility in the roles that are funded – for example, allowing ARRS funding to be used on GP and nurse posts,’ he adds.

Dr Neil Banik, a GP in Kent, agrees. ‘Some ARRS roles have proved to be particularly valuable like physiotherapy, dieticians, mental health. Especially valuable have been the pharmacists and pharmacy technicians embedded in practices. Others have not been helpful but adding advanced nurse practitioners and GPs would be a big help if NHSE agrees’.

Overall, 62% of GP respondents disagree or strongly disagree that PCNs have had a positive impact on their work and 55% believe that the introduction of PCNs has destabilised general practice.

Dr Evans notes that after five years PCNs should have been able to demonstrate that the influx of additional staff has reduced GP workload as promised. ‘We were told that the job would become more manageable, and this has not been true.’ Partly this is because those staff were given additional tasks through increasing requirements placed on PCNs. ‘There has been more work coming with them as a condition of their employment which has meant a lot of administrative work and supervision requirements.’

GPs with a PCN role

For those GPs who have a role within the PCN, perhaps on the PCN board or as a clinical lead in a particular area, there are also widely held views that PCN funding should be moved back into the core contract after 2024/25. Of these respondents, 70% agreed or strongly agreed this should happen. A quarter thought ICB plans for same-day access hubs were a good idea but 54% did not.

This group also had concerns about the interaction with ICBs with 64% disagreeing with the statement ‘my ICB is highly engaged with primary care’ and a large majority saying engagement with primary care had got worse since ICBs replaced CCGs.

Dr Steven Rossi, a GP and practice lead at North East Derbyshire PCN, says ICBs are ‘distant’, leaving PCNs feeling they have little influence on policy decisions. ‘The creation of PCNs could have been positive but has resulted in increasing diversion of monies from the practice unit.’

GPs with a PCN role were slightly more positive about PCNs having freed up GP time but still 58% thought they had not been successful in this regard. More than a quarter thought PCNs had improved patient care and 35% were positive about PCNs having improved patient access. However, a larger majority cited that PCNs had been unsuccessful in this regard. Just over half believed PCNs to have been successful in recruiting and retaining ARRS roles, the survey found.

Dr Zoe Archer, a GP and PCN care home lead in St Leonards-on-Sea in East Sussex, says in her experience the first contact physiotherapists and pharmacists have been a great support and have reduced GP workload. Care coordinators have also been a great help, she adds. But she appreciates that ‘everyone has their own interpretation of the contract so each PCN is different and it is hard to compare’.

The future

Whatever concerns are apparent among all GPs about funding streams into primary care and relationships with ICBs, a majority of those who have a role within a network do want to see the continuation of PCNs. In all, 42% of respondents did not want to see them scrapped. Yet the profession is divided with 37% responding that they did not want to see PCNs continue.

Dr Evans says despite wanting funding to move back into the core, he can see a future for PCNs as long as it is light touch and genuinely voluntary for practices to take part. ‘The PCN format does need to be more relaxed and high trust. There should be a pot of money for networks of practices to spend on projects from a long list of options depending on their population.’

Dr Archer says the creation of PCNs has identified local leaders who want to and are able to make a difference. ‘Individual practices are overwhelmed and struggle to get projects off the ground due to time restraints, despite their diligence and dedication. With a central team, studies and pilots can be looked at and actually get beyond the idea stage.’

She gives the example of a proactive paramedic home visiting team that improves the care of their elderly and frail patients as well as working to improve asthma care in children in the most deprived areas.

‘Overall, I believe PCNs have been a positive for local areas. Like with most things, the longer they are established, the more successful they will be.’

The adoption of clinical pharmacists in primary care has been one of the most welcomed and popular addition to the team from GPs. The latest figures published in June show there are now 5,308 full time equivalent pharmacists hired through ARRS funding. It equates to 22% of the total ARRS staff employed by PCNs to date.

Yet this mass move of pharmacists into primary care has not been without controversy and has been blamed for a drain of staff out of community pharmacy. In May, the Health and Social Care Select Committee called for a review after noting the knock-on impact on staffing in the community pharmacy sector. Between 2019 and 2022, it was estimated that almost half of the money spent on ARRS roles related to clinical pharmacy recruitment.

The National Pharmacy Association agrees that many community pharmacies are experiencing real difficulties recruiting and retaining staff because of the migration of staff into general practice, including in towns and cities where this had never been a problem.

A spokesperson said they recommend ‘a robust local impact assessment prior to any further recruitment into GP or PCN sites under the ARRS programme. It should calculate the impact on other parts of the local NHS, including pharmacy contractors, and their ability to deliver patient care objectives, prior to any further recruitment under ARRS.’

They added that ‘forward thinking’ ICBs might even consider an ARRS scheme for local pharmacies ‘to enable services such as structured medicines reviews in convenient community locations’.

This large shift of staff in a relatively short space of time is reflected in our survey responses. Among community pharmacists, 45% of respondents said the introduction of the ARRS pharmacist had destabilised the profession and a third said it had created tensions between community pharmacists and GP practice pharmacists. Around 35% agreed that the introduction of ARRS roles had resulted in pharmacy closures and 70% said too many had moved from community pharmacy into general practice, creating a workforce shortage.

Likewise, responses from general practice pharmacists not in an ARRS role showed concern about the impact of the changes. In this group, 42% felt the introduction of the PCN pharmacist had destabilised their profession and half said it had created tensions.

Liam O’Sullivan, a community pharmacist in Southampton, said he has seen many of his colleagues move into PCN roles. It has also meant those working in community pharmacy having less opportunity to gain prescribing qualifications, he adds. With newer pharmacists now coming out of university with independent prescribing skills, this is causing concern.

‘I am unable to get GP support for a prescribing qualification. I have other colleagues who are travelling far to get supervision requirements. The Government needs to really push support for current community pharmacists who are eager to qualify before newly qualified pharmacists can “jump the queue” despite having less experience.’

But he also noted that some PCN pharmacists have had difficulty getting support for training. ‘If even employing pharmacists under ARRS is not enough incentive to invest the proper time in mentoring, I’m not sure what the answer is.’

The role of ARRS pharmacist

It is of note that PCN pharmacists responding to our survey do feel generally positive about their work and place within the team. In all, almost two-thirds said they were satisfied in their job.

Three-quarters of respondents said they had a formal induction into their role and 68% said they have a dedicated workspace for their job. In addition, 76% said they have had time for protected learning or ongoing training. A large percentage – 88% – also said they had been supported in their PCN role and the vast majority see patients as part of their role.

But there appears to be more negative responses around pay and career progression among our respondents. Only 38% said their pay was adequate for the job they were doing and 56% answered no when asked if there had been good career progression in their PCN role.

Robin Conibere, lead PCN pharmacist at the Beacon Medical Group in Plymouth, Devon, says the fact the pharmacists are the largest group of healthcare professionals employed through the ARRS scheme ‘demonstrates the value they bring to PCNs and the patients and communities that they serve’.

‘GP colleagues value the work we do and the contribution we make in terms of improving safety, optimising use of medicines and ultimately improving outcomes,’ he adds.

While there may be concerns about pharmacists’ movement from community to PCN roles, he believes this is, in fact, an asset, as PCN pharmacists can champion their colleagues’ work in supporting patients and improving access.

Most of our respondents worked across several practices, if not all across the PCN, and had been in the role for between one and three years.

The main focus for 40% of those responding who were in a PCN pharmacist role was carrying out medication reviews followed by phone or video calls with patients. Running face-to-face clinics with patients seemed to be a medium priority, the survey responses suggested.

When it comes to looking to the future, there did appear to be some uncertainty, with less than half of respondents believing they had job security. Overall, PCN pharmacists were positive about what the PCN had been able to achieve. The responses showed that 62% believed that the PCN had successfully freed up GPs time and 71% said patient care had improved through the work of the PCN. While this group were more evenly split on their views of whether PCNs had addressed health inequalities, they did veer more towards believing PCNs had been successful here and half said PCNs had improved joint working.

It was noted by one respondent, who did not want to be named, that the role of pharmacists in primary care had ‘strengthened the profession’ and provided opportunities but PCNs differed in how well they functioned.

O’Sullivan is one of those who believes that, on the whole, the more joined-up approach fostered by PCNs has improved service provision.

‘It has meant easier communication with PCN surgeries’, he says as well as simplifying the rollout of flu and Covid vaccination, Pharmacy First, and blood pressure screening services.

The limiting factor is ‘funding for GPs and community pharmacies in general’.

Conibere adds: ‘Future iterations of primary care contracting need to consider how we invest in these roles to ensure opportunity for career progression to retain and grow these valued and trusted professionals.’

The introduction of newer members of the primary care team under funding through ARRS has had unintended consequences for general practice nurses. A valued part of the workforce with GPs having long asked to be able to recruit more of them using ARRS money, nursing leaders have raised concerns that they are at risk of being sidelined.

ARRS funding, first introduced in 2019, enables PCNs to pay for nursing associates and advanced nurse practitioners. To date, it has not covered general practice nurses (GPNs), but an enhanced level practice nurse role was added to the scheme in March 2024/25. Funding for this position was capped at one per PCN or two if a PCN had more than 100,000 patients.

A report published earlier this year by the Queen’s Nursing Institute said the ARRS changes implemented in recent years had led to a devaluing of the GPN role and that, in some cases, they were being substituted by other cheaper staff. GPNs have also reported that ARRS roles have increased their workload and meant they were expected to provide supervision and training, in some cases for lower pay.

Callum Metcalfe-O’Shea, professional lead for long-term conditions and primary care at the Royal College of Nursing, said the knock-on effect of undervaluing GPNs increases pressures across the system.

‘We recognise the vital role of General Practice Nurses to the healthcare system and their importance in delivering safety critical care in our communities. But our 35,000 GPN members are undervalued, underpaid and undermined, working under conditions that fail to match their skills or experience. GPNs are now considering leaving the profession altogether, leaving practices increasingly short-staffed. This leaves patients enduring longer delays in accessing treatment, putting their health at risk and heaping more pressure on hospitals.

‘Some practices are turning to ARRS roles to increase clinical support, which allows PCNs to fund additional roles each year, but this must be an additional role – not one that is overused. ARRS roles should never replace the role of a substantive GPN employed in practice.

‘There have been longstanding challenges recruiting practice nurses and whilst we welcome the introduction of nursing roles through ARRS, we need the next government to deliver consistent support for all GPNs.’

For nurses who work with but not in a PCN, our survey shows more positive than negative views for the impact of PCNs on improving care for patients, tackling health inequalities and improving joint working. Patient access is viewed as a particular benefit here. While there appears to be a range of views, 44% of nurses working in general practice or the community think PCNs have been successful or very successful in this regard. As has been shown with other staff groups in our survey, a smaller 31% agree that PCNs have had success with freeing up GP time.

Yet the figures show a certain amount of disconnect between nurses not in an ARRS role and PCNs, with around a quarter saying they do not know the impact that networks have had on recruitment and retention of ARRS roles or digital transformation. One respondent who wished to remain anonymous believes practice nurses are not being listened to and are being given more work that no one else wants to do. ‘Practices nurses have become invisible. We are not informed of any changes until management literally says, “You will be doing this”.’

GPs and PCNs have often called for general practice nurses to be included as a role in the ARRS, with a clearly defined skillset that could impact patient care. This call was repeated among respondents to our survey. The results also show that nurses not in an ARRS role also feel strongly about this. In all, 66% of GPNs said they should be included within ARRS roles, with just 11% replying no. More than half of community nurses also agreed this would be a positive move but a large proportion here also said they did not know.

The latest network DES saw a potentially significant change to the ARRS criteria, with PCNs able to recruit an enhanced practice nurse. Of general practice and community nurses combined, 50% saw this as a positive or very positive move. However, another 39% had fairly neutral views about the change, which may reflect a lack of information about what it might mean for practices or PCNs in reality. Some commented that they wished to reserve judgment, while others noted that there may be limited impact given it equated to only one nurse per PCN.

‘The enhanced role will be unachievable for most, we need more practice nurses,’ one noted, while another said ‘there is a lack of definition about what this role is’. More than one respondent said it may further increase the divide between general practice nurses and those in ARRS roles.

Research has raised a potential issue of workforce ‘tensions’ in general with the addition of ARRS roles with registered nurses losing the opportunity to gain specialist experience and feeling devalued in their role. Around one in five nurse respondents were considering applying for the enhanced nurse role but a majority of 60% answered no to this question. Some commented that they do not have the required qualifications to apply.

In all, 40% of nurses in primary care who are not in an ARRS role said they would like to see the continuation of PCNs. However, a slightly larger proportion (42%) did not have a view, which again may reflect a disconnect between nurses and the wider PCN. One commenter noted that there have been too many big changes in primary care and it is ‘better to work to improve what we have got’. Another said the continued development of ARRS roles would support general practice and patients.

Nurses who work in primary care were mostly unsure if PCNs should continue.

Nurses with an ARRS role

Under ARRS, PCNs have hired 467 trainee nursing associates, 457 nursing associates and 430 advanced nurse practitioners according to the latest data.

Nurses who work in an ARRS role are more positive about the impact of PCNs than their colleagues working in general practice and the community.

This group of nurses rate PCNs as having improved the lot of patients with 56% saying they had been very successful at improving care and 38% saying they were very successful at increasing patient access. This mirrors nurses more widely. However, conversely, the majority of nurses in an ARRS role do believe that PCNs have freed up GP time, with 59% stating they had been successful or very successful in this regard.

The job role

The majority of nurses, 58%, who work in a PCN are satisfied with their job roles.

While half of nurses working for PCNs noted that they had a formal introduction to their role and that there is good career progression, just a third thought the pay was adequate.

The vast majority rated training and support highly, but just 42% said they had a dedicated workspace for their PCN role.

A quarter of ARRS-employed nurses work across all practices in their PCN and a quarter are based in one, but the majority – 42% – work across a few PCN practices.

The success of a PCN has often been linked to the employment of a network manager. Where the relationship between CD and PCN manager is strong, the PCNs tend to function better, according to experts.

PCN managers generally feel that their PCN has had a successful impact across a range of factors despite there being work left to do. Our survey suggests that PCN managers also feel supported in their role by the wider teams they are working with.

Among respondents working in PCN management roles, there does appear to be a fairly healthy level of job satisfaction – in fact, 80% told us they were satisfied or very satisfied with their role.

That is not to say there aren’t frustrations, including around keeping everyone happy and motivated. One commenter noted: ‘I enjoy my job but there is a battle to get practices (GP partners) to let the network build and utilise ARRS funding to increase capacity collaboratively.’ Another pointed out that the job was satisfying but it comes with ‘constant anxiety’ about the certainty of PCN funding.

Similarly, a large majority of respondents (90%) said they feel supported and valued by the CDs they were working with. This feeling extends to others within the PCN with 70% feeling valued by other practice managers and 60% saying they feel supported by other practice staff and GPs. In fact, very few answered in the negative to this question. Overall, most of those in the PCN manager role 90% feel their job has had a direct positive impact on the successful working and running of their PCN and 65% have the same feeling when it comes to improved joint working and patient care.

The results show that 60% believe their PCN has increased patient access and the same proportion say the PCN has improved care for patients. No one who responded said that PCNs had been very unsuccessful at this. As has been shown with most other staff groups, including CDs and GPs themselves, there is less support for the view that PCNs have freed up staff time. Only 40% of the managers we asked said this was the case.

One of the key aims of PCNs when they were conceived was to improve health inequalities by interventions targeted to the specific needs of their populations. They have been incentivised directly for work in this area. Among PCN managers, there is some agreement that PCNs have been able to have impact here, with 55% believing they have success or have been very successful in this area. While there is a similar level of support for how well PCNs have been able to take on digital transformation after the inclusion of the digital transformation lead in the 2023/24 network DES, one in five believe this has not been a success story with just 10% rating this as very unsuccessful.

The real positive story, at least from the perspective of practice managers, has been the recruitment and retention of ARRS roles. This is supported by the figures in one sense which do show a mass movement of a variety of roles into primary care since PCNs were established. But it cannot be ignored that there has also been money that has gone unspent because PCNs were unable to use all that had been allocated. Among managers, 70% believe that PCNs have been very successful in the ARRS drive with another 20% saying there has been some success. No one rated this in the negative.

Seema Gater, digital and business manager at Whitfield PCN, says the idea behind PCNs was to alleviate the workload of general practice, but she adds, ‘I don’t think this has been universally achieved’.

In her experience, there is still a sense of ‘us vs them’ from general practice staff in some surgeries, creating an uncomfortable working environment for the ARRS staff.

‘This situation has improved with targeted inductions for new ARRS staff and extensive shadowing of traditional primary care roles. We have been striving to integrate the ARRS staff as an extension of the practice team, but there is still work to do here.’

Pay for PCN managers’ roles appears to be more of an issue than the job itself. When asked about this, only 40% said the role was adequately reimbursed.

The latest version of the PCN Network contract rolls the PCN leadership and management payment into core funding and our survey asked network managers about the impact they thought this might have. The majority – 60% – thought it could mean lower pay.

Robyn Clark, director of IGPM and managing partner at Kingswood Medical Practice, Bristol, said: ‘Like with practice manager pay, there is some disparity between PCNs on the level of remuneration for the role. There is also some disparity between what the role entails and we hear from our PCN manager members quite the variety of different tasks and duties that each PCN manager is expected to complete.

‘Some PCNs have utilised the funding for the digital and transformation lead role under the ARRS scheme to pay for their PCN managers, with some maximising the full available budget and others not. There has been concern from some of our members that the rolling in of the leadership and management payment into core funding might lead to a disinvestment in PCN manager time, with practices feeling the financial pinch more than ever this year and potentially looking to use this money to top up practice coffers. It’s difficult for us to comment on pay levels as they differ so vastly between PCNs.’

Interestingly, 60% of PCN managers who responded to the survey had not previously worked as practice managers but had come from other management roles, mainly in the NHS.

A quarter of PCN managers who responded are also practice managers. Among this group, it seems common to work part-time in both roles to accommodate them.

Practice managers

Among practice managers more widely, there is slightly less positivity about the impact PCNs have had, with 49% rating them as successful in improving care for patients and 52% rating them successful in increasing patient access. Half of practice managers said recruitment and retention of ARRS roles had been a success. A practice manager from West Yorkshire commented that ‘Money is being spent but the rest of the practices have no idea where, decisions all made by CD, nothing is shared including accounts or finances, staff retention is very poor, quality very poor.’

PCN finances is an issue that has been recently flagged by experts from the Association of Independent Specialist Medical Accountants (AISMA) who urged practices to double-check their income to ensure they weren’t missing out. This was also backed up by PCN CDs who branded it as ‘incredibly difficult’ to navigate PCN finances.

Another respondent pointed out, ‘How can PCNs be graded on freeing up GP time when activity has increased by 25% at least?’

The introduction of this new breed of manager into primary care has had some impact on the practice manager role with 35% noting it as positive, 28% disagreeing and 34% remaining neutral on the matter. Most do not think it has made their job harder. While the role does not appear to further collaboration outside the PCN, a majority of 57% agree it has further collaboration between practice managers within the PCN.

Robyn Clark said: ‘I think what these figures demonstrate is less about the role of the PCN manager and more about PCNs as a whole. There are many PCNs in the country that work well together and have done some really innovative and collaborative work, but there are also many PCNs that have been unable to achieve the same for a variety of reasons. Likewise, the role of the PCN manager may have been well integrated with practices in areas where the PCN is working well, but perhaps less so in areas where this has not been the case.’

For practice managers as a whole, there are also questions about the future of PCNs, with a third saying they should be scrapped and a quarter saying they were unsure. Only 40% said they should continue.

Since PCNs were introduced five years ago there have been a list of fundamental issues they have been asked to address. Some of this has been in place since the start, including tackling health inequalities and introducing a wider team to support practices through ARRS.

During COVID, they quickly shifted to delivering a highly successful mass vaccination campaign. Other priorities have been introduced since the pandemic, most notably the concept of integrated neighbourhood teams, first introduced in the Fuller Stocktake in 2022 and still in their infancy in many places.

While access has always been something for PCNs to address, the focus on this has also intensified in the past couple of years, including through digital transformation. Fuller noted in her report that inadequate access to urgent care is having a direct impact on GPs’ ability to provide continuity to those patients who need it most. Primary care teams are stretched beyond capacity delivering record numbers of appointments. With the move from CCGs to ICBs two years ago, there is an opportunity for a ‘radical overhaul’, the report said. PCNs need to evolve to develop integrated neighbourhood teams bringing together health and social care professionals as well as the voluntary sector across a footprint of 30,000 to 50,000 patients. Same-day access hubs for providing urgent on-the-day acute care across a PCN have been proposed to help free up GPs for more complex ongoing care.

More recently the announcement of an ICB run pilot across 20 or so PCN sites sees them at the centre of evidence gathering for understanding the difference between demand and capacity.

ICBs

Across all those we surveyed, there are mixed feelings about the move to integrated care systems and PCNs that has happened since 2019. The largest proportion of respondents, 31%, felt neutral about it, with a quarter feeling positive or very positive. In all, 15% felt very negative and 23% felt negative about the changes.

Those negative responses are likely to be tied up with the finding that 69% of staff across professions said the changes had increased their workload. While half disagreed that the changes had increased the ability of primary care to influence commissioning decisions.

The results showed some support for the success of PCNs in improving collaboration between GP practices, with 39% backing this idea compared with 31% believing this had not happened. When it came to improving the collaboration between primary and secondary care services, only 17% said PCNs had been able to do this. In terms of maintaining continuity between primary and secondary care, just 16% of respondents rated it as effective, with GPs the group most critical of this.

Responses from PCN CDs suggest that just over half were already part of an integrated neighbourhood team, yet there was a disconnect here with GPs, of whom only 25% said this was in place. Among CDs, there was limited support for the same-day access hub model with only a third agreeing on this point. By contrast, 42% disagreed or disagreed strongly with this approach. Support was even lower among GPs, 21% of whom agreed with same-day access hubs and 58% disagreeing.

Dr Zoe Archer, a GP and PCN care home lead in St Leonards-on-Sea, East Sussex, notes that communication and engagement between practices can be challenging. ‘We are a large PCN with nine surgeries and around 100k patients. We hold engagement meetings, but it is difficult to get information through to everyone. This will hopefully improve.’

The survey results do raise questions about whether ICBs are engaging effectively with primary care. GPs had often been at the heart of CCG commissioning and had built up relationships over many years. Two years in, the move to ICBs does seem to have disrupted this connection. PCN CDs have more positive views on this with 46% saying their ICB is highly engaged with primary care and the vast majority aware of who represents them. But 54% disagreed this was better than with CCGs. The engagement that some have seen has not translated into a belief that ICBs will direct more funding into primary care with only a quarter agreeing this will be the case. Among GPs, only 11% agreed the ICB was highly engaged with primary care and two-thirds believed engagement had got worse since ICBs came in. GPs are particularly sceptical that ICBs will direct more funding their way, with only 5% agreeing with this statement. One GP in the East of England who wished to be anonymous noted: ‘Our ICB is clueless about and hostile to primary care, totally focused on secondary care.’

GPs who have a PCN role are more positive about the relationship with new commissioning structures with 37% stating they are highly engaged and 32% believing this has improved since CCGs. These responses may well reflect the direct experience of those in leadership roles while GPs still feel a certain amount of disconnect.

Seema Gater, business and digital manager at Whitfield PCN, adds that it feels ICBs are not overly concerned with what is happening at the grassroots level. Getting their engagement and recognition can feel like searching for a golden ticket. The CCG was more accessible for discussing issues and visiting practices, which improved relationships.

Access

The network DES also tasks PCNs with providing enhanced access which aims to standardise services across the country, make greater use of the ARRS roles in provision and boost capacity. It also involves digital transformation providing more routes for the patient to access primary care and a broader set of services. Since 2022, PCNs have had to deliver 6.30pm-8pm weekday appointments and 9am-5pm Saturday slots. Each PCN had to assess how they would do this for the demands of their population and what services or skill mix and appointment types would be most appropriate to offer.

While overall, the view of how successful PCNs have been in increasing access is positive, it does vary between staff groups. Those in ARRS roles are most likely to believe PCNs have had success in increasing access with 63% responding with a positive view. More than half of practice managers and CDs also think PCNs have been successful or very successful on patient access. This then drops to 44% of nurses, 34% of GPs with a PCN role and 16% of GPs overall.

The impact of the ARRS scheme is positive when responses of all professions are combined. The impact on patients comes out on top with 52% rating it positively, followed by 48% rating it as a positive for the practice and 39% for practice staff.

Part of enhanced access was making the most of the ARRS roles that have been introduced by PCNs. There is a variety of opinions on which have been most successful with pharmacists, first-contact physiotherapists and care co-ordinators rated most highly in our survey.

Five years after the introduction of PCNs, there are key decisions to be made. Joint working of practices at scale has realised some benefits, as can be seen with the delivery of the COVID vaccination programme, some of the new staff roles that have been introduced and extended and enhanced access coordinated by PCN teams. But there is a reckoning to be had. Funding of core general practice must be addressed with practices warning they are becoming unviable. The vast majority of our GP respondents want to see funding moved back into core general practice while CDs are fairly evenly split on this question. They very specifically want more flexibility on the roles they are able to hire. The sector has been working under intense pressure for too long, and despite the promise that PCNs would free up GP time, this has not happened in any meaningful way.

ARRS is the biggest slice of funding available to PCNs and has led to a mass shift of more than 30,000 staff into primary care. This has had profound implications in a number of ways. While some staff have proved particularly popular, most notably the clinical pharmacist, the mass migration of the profession into this new role had had serious implications for community pharmacy, which is now facing staffing shortages. Physician associates currently make up a relatively small proportion of the ARRS-funded workforce but have caused a great deal of debate about scope and supervision. General practice nurses have raised concerns that their role is being undervalued as a result of ARRS and they are being tasked with supervising staff who are being paid more than them with less experience.

For the next Government, our survey results suggest the priority must not be more re-organisation but to listen to the deep concerns of those working in primary care and to take steps to put general practice on a sustainable and secure footing.

Better pay and improving ambulance response times came up high on our respondents’ lists of priorities. Those working with and in PCNs do not want to see more AI-driven care or the driving forward of integrated neighbourhood teams. Most would also not put scrapping PCNs at the top of the to-do list. Instead, the vast majority want more recruitment of general practice nurses and GPs, a reduction in the elective care backlog, which has a large knock-on impact on demand for general practice, and improved movement between primary and secondary care.

There is clearly also a need for ICBs to do more work on engaging with primary care. Our survey showed a real sense that connections with NHS commissioners have become remote for those working in general practice. The emphasis must be on listening to those who know and understand the needs of their populations the best as well as ensuring that all available funding is used to support the record levels of care they are delivering every day.