PCNs to be contractually required to risk-stratify patients for continuity of care

Primary care networks (PCNs) will have as a ‘core requirement’ from 1 April to identify patients to prioritise for continuity of care, NHS England has said.

The updated Network Contract DES for 2026/27, published yesterday, also contains new clinical requirements with regards to vaccinations and cancer diagnoses.

On care continuity, the DES said PCNs will need to ‘identify and code the target cohort, develop a personalised care and support plan, deliver co-ordinated multi-professional interventions and provide a clear plan for continuity of care’.

An explanatory note from NHS England added that the move was aimed at ’embedding continuity as a core expectation and supporting the development of future continuity models’.

The updated DES said PCNs should refer to proactive care guidance to identify cohorts, adding that ‘depending on local capacity to implement proactive care, further prioritisation may be needed based on risk of deterioration’.

To code patients to be prioritised for continuity of care, PCNs should ‘utilise analysis of local data sets (as developed by ICS analytical teams where applicable), evidence-based risk prediction tools such as the electronic frailty index, the EFI2 (when published), clinical validation tools and local knowledge’, the specification said.

On vaccination, the DES now includes a new requirement to ensure care home residents are identified and offered seasonal and routine vaccinations. NHS England explained that ‘while PCNs are not required to deliver the vaccinations themselves, they must have arrangements in place to ensure residents are offered vaccination’.

The DES said: ‘A PCN must also review each resident’s overall vaccination status as part of personalised care planning, and where a resident is eligible for a routine vaccination, the PCN must work with the patient’s registered practice to ensure they are offered vaccination at the earliest opportunity.’

NHS England previously told Pulse that PCNs are ‘collectively responsible’ and that ‘if none of its member practices has capacity’ could make arrangements for another provider to vaccinate these patients under an appropriate arrangement, for example via a subcontracting arrangement or a vaccination agency agreement.

Meanwhile, new requirements to improve cancer referrals, early diagnosis and screening uptake will see PCNs having to review ‘the quality of cancer referral practice against the recommendations of NICE Guideline 12, focusing on timely referral to support improved cancer survival’.

‘This should include building on current safety netting practice, including using electronic safety netting tools where appropriate to monitor patients with symptoms which could indicate cancer,’ the DES said.

A survey published last week found that ‘too much focus’ on digital and online services is affecting continuity of care in general practice according to the public.

And the BMA has previously warned that Government-mandated online access requirements mean GPs ‘sit in front of a screen for hours and hours’, resulting in fewer face-to-face appointments for patients.