What is a primary care network, what is its history, and why is it so hard to run?

(Part of the series: How Primary Care Networks work, why sometimes they don't, and lessons for neighbourhood working.)

Part one: Where primary care networks came from, what they were built to solve, and what a PCN actually is.

Background

Inspired by Ian Dunt's book How Westminster Works... and Why It Doesn't, I wanted to share some thoughts and reflections on how primary care networks work, why they sometimes don't, and the lessons for neighbourhood working as we move forward.

Neighbourhood working is one of the hottest topics in the NHS right now, and for good reason.

It is a central feature of the 10 Year Health Plan, the government's blueprint for moving care out of hospital and closer to home, and every ICB, every practice and every network is now working out what it means for them.

Before we move forward, I believe it's important to look back and understand where primary care networks came from, as they are the latest in a long line of attempts to organise general practice at scale, and my research shows this goes back to 1999, but the problems they were meant to solve were already being written about in 1988.

What a primary care network is

On the surface, it seems straightforward. A primary care network is a group of general practices, organised by geography, working together with other key stakeholders to provide services to a combined population, rather than each practice working only to its own registered list.

Networks went live in July 2019. There are roughly 1,250 of them, covering almost every practice in England.

The geographical grouping of practices within a network sometimes makes sense. Sometimes it does not.

Where PCNs came from

1999: Primary Care Groups. Following the 1997 white paper, The New NHS: Modern, Dependable, practices were placed into geographically defined groups, GP-led, with a board and a chair, sitting as sub-committees of health authorities. The footprint was bigger, around 100,000 patients. Everything else is familiar. Your practices. Your patch. A clinical leader. An expectation that you work together on the health of a population.

Primary Care Groups did not stay. Most became Primary Care Trusts within two or three years, which meant the grouping was absorbed into a statutory organisation. Collaboration stopped being something practices did and became something done to them.

2005: Practice-Based Commissioning. Practices grouped into consortia and were given indicative budgets, with savings notionally available to reinvest in services. The theory was that the people who understood patients would make better commissioning decisions than the people who understood contracts.

In practice, the budgets were indicative rather than real, so nobody could commit to anything. The leadership was unpaid or barely paid, so it sat on top of a full clinical day. The administrative burden landed on practices with no infrastructure to carry it. And the savings, where they were made, were rarely released.

The King's Fund reviewed it in 2008, and the University of Manchester reported in 2009. Both found implementation slow and the barriers persistent. It was then superseded by Clinical Commissioning Groups.

2013: The Prime Minister's Challenge Fund. Money for practices working together at scale, on extended access. Time-limited and competitively awarded.

2015: The Primary Care Home. Developed by the National Association of Primary Care, wrapping multidisciplinary teams around a registered population of 30,000 to 50,000, the same footprint PCNs would later adopt. It was voluntary and sites applied.

What primary care networks were built to solve

In January 2019, the NHS Long Term Plan set out an ambition that general practice, on its own, could not deliver. Population health management. Proactive care. Multidisciplinary teams wrapped around the people most likely to end up in hospital.

The average GP practice serves around 10,000 patients. That is the right size for relationships and continuity, but seemingly the wrong size to deliver services at scale.

The NHS wanted a unit that was bigger than a practice and smaller than a place. Big enough to justify an investment in workforce. Small enough that people still knew each other. It landed on 30,000 to 50,000 patients and the term primary care network.

The Challenge Fund and the Primary Care Home were both absorbed into a national contract, and the PCN Directed Enhanced Service, known as the PCN DES, made it a near-universal expectation rather than something you opted into. ( But some practices have opted out).

Neighbourhoods are now being built on top of that structure, and around it, drawing in community services, social care and the voluntary sector that sit outside general practice.

It's important to say that a neighbourhood is wider than a PCN. It sits within the network's footprint, but calls for collaboration across a far broader set of partners.

Important distinctions

A PCN is not an organisation. It is a contract.

Specifically, it is the Network Contract Directed Enhanced Service, a schedule attached to the core GP contract. Practices sign up to it. The signatories are the practices. The prime contractors are the practices.

The PCN itself has no legal personality. It cannot employ anyone. It cannot hold a contract. It cannot be sued, and it cannot sue. It cannot be registered with the Care Quality Commission, because CQC registers legal entities and a PCN is not one.

Even where a PCN sets up a limited company to run its business, the PCN itself is still not an entity. The company is the entity, created by the practices to hold what the PCN legally cannot.

It is an agreement between practices to act together, given a name, a budget, and a set of expectations.

Why does the money always sit with a lead practice or a company?

Because it has to sit somewhere, and the PCN cannot hold it.

Why do ARRS employment arrangements vary so much, and why are they so often difficult?

Because the network the roles are funded through cannot employ anybody. The money that funds the role and the organisation that employs the person are not the same thing, and neither is necessarily the organisation the person works in day-to-day.

Some networks devolve the ARRS funding to a practice, and the practice hires the staff.

Some keep the roles at PCN level, even though there is no PCN to hold them.

Those staff then work across several practices in the network, getting used to different organisational cultures and different policies in each one, while being employed by another organisation entirely.

Why does so much depend on relationships between practices?

A PCN board doesn't really operate with any authority over the members.

Unless the ICB provides strict contract management ( some do, and some do not), the PCN can interpret the asks of the PCN DES.

If a practice decides not to engage in network activity, even though they will receive network funds directly or indirectly, there is very little anyone can do beyond asking again.

Some practices are asked to leave their network or want to leave, but often the ICB will try to keep networks together even if the working relationship has significantly deteriorated.

So... a lot of energy is invested in trying to find common ground that parties can negotiate and then agree on.

What this means in practice

For many people, running a primary care network is extremely challenging.

You are working across multiple independent businesses that have come together, and in some cases been pushed together, to deliver a national mandate. Finances are restricted. Demand outstrips capacity. There is a lack of estate. Power and politics are at play, and you could easily spend every day in meetings...

However, many successful networks take an innovative approach, work at scale, and deliver what their practices could not deliver alone.

Some will say the difference between thriving networks and those experiencing challenges purely comes down to relationships. This is something this series will look to explore, and in the next instalment we will cover: Who leads a primary care network, and what authority do they actually hold?

About the Author

Tara Humphrey has supported over 300 primary care networks across England, providing interim PCN management, training, events and facilitation.

Tara also holds an MBA in Leadership and Management in Healthcare and has written over 300 blogs and hosted the Business of Healthcare Podcast, which has published over 370 episodes.

Facilitation Support

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Blog Sources

• The New NHS: Modern, Dependable, 1997, and the establishment of Primary Care Groups from April 1999

• Practice-Based Commissioning guidance, 2005

• Natasha Curry, Nick Goodwin, Chris Naylor and Ruth Robertson, Practice-Based Commissioning: reinvigorate, replace or abandon?, The King's Fund, 2008

• Anna Coleman, Kath Checkland, Stephen Harrison and Barbara Dowswell, Practice-Based Commissioning: theory, implementation and outcome, National Primary Care Research and Development Centre, University of Manchester, 2009

• Prime Minister's Challenge Fund, 2013

• National Association of Primary Care, the Primary Care Home, 2015

• NHS Long Term Plan, January 2019

• Network Contract Directed Enhanced Service specification