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PCNs are not very popular. It is currently BMA policy to organise the withdrawal of practices from the PCN DES by next year. But whatever you think of them, there are good reasons to both stick with PCNs and want them to remain within the national contract.
While general practice is looking to get rid of PCNs, the rest of the system is trying to work out how they can get their hands on them. The Fuller Stocktake report was accompanied by a letter from all 42 Integrated Care System (ICS) Chief Executives that was little over one page long. The one thing they could all agree on, it seems, is a collective desire for the funding (and control) of PCNs to come via ICSs in future and not via the national contract.
The letter states: ‘National contractual arrangements, including for PCNs, have and will continue to provide essential foundations. But they can only take you so far. Getting to integrated primary care is all about local relationships, leadership, support, and system-led investment in transformation’.
What the system recognises is that there is significant funding wrapped up in PCNs. All of the additional funding for general practice since 2019 has come via PCNs, and by the end of next year will total £2.4bn, or £1.47M for a typical PCN. The system can see the nearly 20,000 extra bodies on the ground in terms of the ARRS staff and they want to get their hands on them.
For the system, PCNs are a route to developing neighbourhoods, where all the NHS, local authority and voluntary sector providers can work together to deliver ‘integrated’ care for local populations. They are ready funded building blocks they can use to try and make integration a reality.
For general practice, however, this is not the only role of PCNs. They play a role in ensuring that general practice is sustainable, as they have been the only source of additional investment in the service since 2019.
The risk of handing back the PCN contract (as per the BMA’s policy) is that it will simply mean giving up all the additional investment received via PCNs since 2019. While the BMA thinks that the funding would be reinvested into the core contract, a much more likely outcome is that the resources and staff would be transferred to the local system to form the basis of the new neighbourhood teams.
If funding, or (best case) any additional funding, for PCNs does transfer to local systems from 2024, what does this mean for general practice?
The upside will be that there will need to be some sweetener on the deal to shift the funding from national to local, so there would most likely be some short-term benefit. It would mean a move away from the nationally prescriptive PCN service specifications, which would most likely be replaced by more bespoke, localised, enhanced service style specifications. And it may even mean the overly-cumbersome investment and impact fund (IIF) would be replaced with a local, more focussed and more meaningful schemes.
The downside, however, would be the risk this would pose to whether PCN resources could stay linked to the sustainability of practices. Local systems do not seem very interested in this. Instead there may be a pull for ARRS staff to be centrally controlled. Leadership, ‘support’ and funding for PCNs (as they develop into ‘integrated neighbourhood teams’) may well come from a lead provider organisation rather than stay within general practice itself. Local funding would require local negotiation, which means the variation of both levels of investment and adequacy of funding would most likely be significant.
It is time to change the thinking on PCNs. General practice needs to be fighting to keep control of them, not playing into the system’s hands by offering to give them back early.
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.