Who leads a primary care network, and what authority do any of them actually hold?
(Part of the series: How Primary Care Networks work, why sometimes they don't, and lessons for neighbourhood working.)
This series takes primary care networks apart component by component, the way Ian Dunt does for Westminster, and asks what each part is actually for. Not to catalogue what has gone wrong, but to work out what neighbourhood working needs to do differently, before the same mistakes get built into the next structure.
Part one covered what a PCN is: not an organisation, but a contract signed by practices, with no legal personality of its own. This blog can be found here: https://www.thcprimarycare.co.uk/post/what-is-a-primary-care-network-what-is-its-history-and-why-is-it-so-hard-to-run
This instalment looks at the people the contract asks to lead it: the Clinical Director, the PCN manager, the practice managers, and the board they sit on together.
What the DES actually requires
The Network Contract Directed Enhanced Service, aka the DES, requires a PCN to appoint a Clinical Director.
The PCN members appoint their Clinical Director and decide the appointment process themselves.
According to the DES, the Clinical Director should be a practising clinician from within the member practices, able to undertake the responsibilities of the role and represent the network’s collective interests. Most likely a GP, though that has never been an absolute requirement. Pharmacists and nurses also hold the role in some networks.
The role was funded from the outset on a baseline equivalent of 0.25 whole time equivalent per 50,000 registered population. Roughly two sessions a week to lead a network of tens of thousands of patients. From 2026/27 that payment is no longer expressed on its own line, having been folded into a combined Core PCN Funding figure alongside the leadership and management payment.
The DES sets out high-level minimum responsibilities and states that the detailed requirements will vary according to the characteristics of the PCN, including its maturity and local context, and should be set out in the Network Agreement. It requires the Clinical Director to take a lead role in developing the PCN’s conflict of interest arrangements, which matters, because in many networks the Clinical Director is also a partner in one of the member practices, holding a personal financial stake in the business their leadership decisions affect.
How does one become a Clinical Director?
There are three types of Clinical Director.
Some are elected by the members of the network because they are liked, trusted, and respected, with no formal recruitment process.
Some do apply through a recruitment process.
Some accept the role because nobody else wanted it and, under pressure, begrudgingly say yes.
What authority does a Clinical Director actually hold?
This is an interesting question, and I’m sure it will spark lots of debate.
Externally, the Clinical Director carries real weight. They are a named signatory on the Network Agreement. They are usually the ICB’s first point of contact when something involving the network needs sorting.
There are peer meetings and forums that exist only for Clinical Directors, and other organisations often want direct access to them specifically. The role has status.
Internally, what a Clinical Director actually achieves depends heavily on the person in the post and the culture of the network.
Some lead through direct influence. Others through coaching and convening. Either can carry genuine weight with practices. But that internal influence is personal, not structural. It does not transfer to whoever holds the role next.
It’s all about relationships, positioning, politics, and history in determining how effective the Clinical Director is, but I feel confident saying:
If you have a weak CD, the network is merely a group of practices co-existing to access the funding.
If the CD is too strong, the practices may feel like it’s a dictatorship, which will result in a weak network.
A strong network requires a leader that knows when to push, pull and back off.
But when it comes to authority, if a practice will not comply with something the network has agreed on, the options are limited.
You meet with them. You try to understand their position. You look for a compromise. You point to the Network Agreement, which every practice signed and which is supposed to carry some weight (but doesn't really).
Beyond that, you have the ICB. But ICBs are often reluctant to get involved in what looks like an internal dispute between practices, even where one of them is breaching a contractual requirement. Beyond that again, the LMC, or an external mediator or facilitator, brought in to help the conversation along.
What is missing at every stage is the one thing a private sector board has. If someone will not adhere to what has been agreed, a private sector board can remove them. A PCN board could do this, but it’s a very messy, drawn-out divorce.
So what actually happens, in practice, is a lot of time and energy going into conversations, because there is no sanction that would end them.
Practices are the actual principals. They are the signatories to the DES, the prime contractors. The Clinical Director is appointed by them, on terms they decide. Where a board exists, it exists because the practices chose to have one, made up of clinical representatives and, in some networks, practice managers sent to sit alongside them. The board can be shaped or dissolved however the practices like.
So the board, where there is one, is the practices’ own instrument for holding the Clinical Director and the PCN manager to account.
In a typical PCN, Practices sit at the top, and the effectiveness of the Clinical Director and the manager is determined by the level of engagement of the practices.
The Contract value of the PCN DES and leadership resources
Under the 2026/27 Network Contract DES, a typical network of 50,000 patients receives roughly ÂŁ153,000 in Core PCN Funding, ÂŁ445,000 in Enhanced Access funding, and up to ÂŁ1.38 million through the Additional Roles Reimbursement Scheme. Call it close to ÂŁ2 million a year moving through a single network.
The ARRS figure is by far the largest, and its reimbursement is tied to the actual employment costs of specific roles.
A primary care network moving close to ÂŁ2 million a year is typically led by a Clinical Director working a quarter of a week, and, where the network is fortunate, a manager who may be full or part time. Some networks have a further layer of leadership underneath that. Many do not.
What about the PCN Manager?
The PCN manager, sometimes called the CEO, MD, Business Manager or COO depending on the network.
The manager is there to support the implementation of decisions the network has made, and where a network has one, they tend to be central to how anything actually gets done.
The manager can be seen as a welcome resource to work alongside practices or as a threat or nuisance.
The standing of the manager has to be earned through the same kind of relationship-building the Clinical Director has to do with practices, and public favour can be withdrawn instantly, leaving the manager out in the cold.
Unlike the clinical director, if this person vacates the position for whatever reason, they will continue as a GP in their practice.
The manager, on the other hand, is likely leaving the network completely.
What this means in practice
In many cases, PCNs have leadership roles carrying real responsibility and no formal mechanism behind them. This is not a criticism. It is an observation.
As networks move into neighbourhoods, while there is no national contract for neighbourhood working yet, single neighbourhoods and multiple neighbourhood providers could be managing additional seven-figure budgets, clinical services, and a significant workforce, built on the same informal foundations.
Holding practices properly to account will require a culture shift.
Governance structures on paper can look complex and compelling to provide reassurance, but who or what entity will enforce anything?
Next time, where the money actually sits once it arrives, and what it means to move that much money around a system in plain sight.
Part of the series
Want to understand more about Primary Care Networks? Read our blog, “What is a Primary Care Network, what is its history, and why is it so hard to run?” for an overview of how PCNs came about and the challenges involved in running them.
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.
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Sources
Network Contract DES 2026/27, NHS England, published 26 March 2026
Pulse PCN, “PCNs expected to better align with neighbourhood boundaries under new DES”, 31 March 2026
Ian Dunt, How Westminster Works… and Why It Doesn’t, 2023
Alex Thomas, The heart of the problem: A weak centre is undermining the UK government, Institute for Government, January 2021
Matthew Rice, To be, or not to be, a clinical director… but is that the question?, The King’s Fund, 2015
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