Evolving times for PCNs

A suite of recent NHS England (NHSE) documents, primarily focused on the PCN Network Contract Directed Enhanced Service (PCN DES), sets out some important issues for practices’ consideration.

As I write there has been no published update to the GMS or APMS contracts or the PMS agreement and no amendments to the associated regulations and directions underpinning these.

Consequently, there is clear guidance and expectations on the development of PCNs over this next year but relatively little information about the legislative and contractual changes which may be applied to the core contracts. Despite this, it is evident that practices must continue to work closely and potentially provide services at scale within the PCN remit.

Four key themes have arisen from changes relating to PCNs:

1. Redefining the role and objectives of the PCN
2. Providing greater flexibility for future development, particularly with the workforce
3. Increased collaboration and integration between the member practices
4. Re-enforcing the requirement to work with other providers including the Integrated Neighbourhood Teams (INTs).

These themes are not new but have been reframed to represent the next stage for PCNs and they are the framework for general practice’s future development.

Roles and objectives

There have always been questions about the PCN’s role and purpose. The initial version represented a provider and quasi-commissioner role looking at local service development.

The pandemic focused most PCNs onto delivering services at scale. The subsequent recovery period continued this approach but many questions about the future of PCNs were being asked as the initial five-year term they were set up for was due to expire.

Clarification about PCN functions in DES Specification clause 8.1 has been well-received by many clinical directors and PCN management teams. There are four key functions:

a) co-ordinate, organise and deploy shared resources to support and improve resilience and care delivery at both PCN and practice level.

This ties in closely with other changes in the document about collaborative working. It allows for PCNs to reconsider how they utilise their resources to help their member practices. How much this is implemented will depend on member practices’ strategies and by the increased service requirements as commissioner intentions increasingly focus on the delivery of general practice at scale.

b) improve health outcomes for its patients through effective population health management and reducing health inequalities.

This has evolved and tools including the data analysis have greatly improved to help PCNs develop strategies and plans to address local health needs.

But there is a query about whether this function exceeds the remit of traditional practice. It requires the input and collaborative working with neighbouring parts of the health and social care system.

PCNs will need to demonstrate they are working on local projects to tackle these inequalities but it is likely to be measured against function (d – see below) and collaboration with INTs to bring large-scale change.

c) target resource and efforts in the most effective way to meet patient need, which includes delivering proactive care.

This confirms the PCN’s role as a service delivery provider or, at the very least, co-ordinator. The resources will include staffing, finances, equipment, data tools and technology. Sharing and allocation of these resources will need good governance systems.

That includes clear decision-making procedures, analysis of effectiveness and ensuring suitable arrangements are in place, including in the Network Agreement, and satisfactory sub-contracts to manage these resources appropriately.

There could be tension between this and function (a) if patient need and proactive care requires resourcing which could be used for other resilience projects.

The PCN management team will need to demonstrate how and when it wishes to prioritise one over the other in a transparent and supportive manner.

d) collaborate with non-GP providers to provide better care, as part of an integrated neighbourhood team.

PCNs have intended to expand membership beyond practices since formation but this has increasingly shifted to a commitment to work with others rather than expressly include them.

This is represented by the new express requirement to work with INTs but these are in their infancy and there is no formal guidance or governance about what they are and how to develop them. Several pilots are working on how they may be shaped.

But the principles of collaborative working are not new in the NHS and it would be suitable for PCNs to consider the terms. Will this require additional time or transfer of resources? Could it create a tension between allocating resources to core primary care from wider community services? How would the outcomes be measured and what would success look like?

Greater flexibility

The four functions are expanded upon in clauses 8.1.4 to 8.1.10 of the DES Specification. They can be interpreted as a move towards an outcome focused method of working with reduced level of prescription.

However, the DES Specification has been supplemented with the guidance document Part A: Clinical and support services which refers to best practice, coding requirements and other resources which should be used to interpret and implement Specification requirements.

This guidance is a definite change in direction and PCNs have increased flexibility about how they develop their services, such as the workforce.

Previous restrictions on staff numbers recruited through the Additional Roles Reimbursement Scheme (ARRS) have been replaced with only the new enhanced nurse role having a limit. This allows PCNs to restructure services based on the workforce available and their priorities.

They will need to consider how this impacts the existing teams and current employment terms. It is likely to lead to changes to some PCN recruitment strategies.

Clause 7.3.2-A and B include a procedure by which PCNs may now submit business cases to their ICBs to expand the ARRS to other non- GP and non-nurse team members. They must relate to direct patient care and comply with the following:

• be additional to the roles already working within the practices
• be demonstrably different from the other ARRS roles
• have a clear scope of practice and training requirement
• fit with local care pathways and not duplicate existing provision, and
• reimbursement must be at a rate commensurate with its scope of practice.

ICBs may consider the impact of the role and if it is suitable in the wider context of the health economy. This provides a mechanism for practices to be creative and develop Multi-Disciplinary Teams to target local issues.

Increased collaboration

The latest Specification extends the Capacity and Access Programme to incentivise the concept of Modern General Practice Access. This requires the PCN to provide evidence it has better telephony, simpler online requests, and faster care navigation, assessment and response. PCNs need to consider how they manage this. Options range from simply monitoring and reporting PCN practices’ progress through to fully redesigning access support systems and creating centralised support.

The Specification also refers to shared vaccination and immunisation clinics. Many practices do this for Covid vaccines but this option allows all vaccinations to be delivered likewise. NHSE has produced seasonal Collaboration Agreements to help define the legal relationship between practices. Many of these have been signed as blank templates rather than fully completed. This creates a significant risk between practices because the legal relationship, including the governance, liabilities and operational specifications, are not appropriately documented.

With any collaborative model the practices must ensure these are addressed in appropriate agreements to avoid uncertainty.

NHSE has added a requirement that any practice using a collaborative model for vaccination clinics should add a new Schedule 8 to their Network Agreement and agree a variation which adds additional clauses to the document’s mandatory terms.

This should not be seen as a replacement for a formal collaboration agreement tailored to meet practice needs.

Practices have an exciting opportunity to redesign their services and help create increased resilience but many GPs are concerned it may affect their ability to control core service delivery and their practices’ support teams.

Careful planning is needed and final arrangements need to protect participating practices’ interests and ensure the quality of patients’ services.

Working with providers including INTs

Clause 8.1.8 requires PCNs to contribute to the delivery of multi-disciplinary proactive care for complex patients at greatest risk of deterioration and hospital admission. This ‘must be done as part of INTs’.

So PCNs should consider how they will do this, who the partners are within the INT, and what the relationship will be.

Parties are allowed to define what the INT will be and how the different elements will contribute. This should then be the basis to implement a suitable legal structure to formalise the relationship.

It may include collaborative working agreements and/or sub-contracting arrangements but, however they are formed, they must ensure the parties understand their duties and have suitable protections built into them.

Clause 8.1.10 extends the requirement to ensure PCNs work with other PCNs, local community service providers, mental health providers, community pharmacists and other health and social care providers.

NHSE announced funding in May to allow PCNs a community pharmacy primary care network engagement role aimed at helping PCNs integrate with community pharmacists. As pharmacists increasingly take on some traditional general practice roles this is an essential first step in developing relationships between these providers.

Similar roles could be developed for optometry, dental and other providers in future and could help implement the strategies developed in conjunction with clinical directors.

Each of these four themes support the core message that PCNs are part of the long-term strategy for primary care. The key recurring theme appears to be the need to develop greater integration both in services delivered by practices and with other services.

These changes provide a clearer understanding of the future of PCNs, although it remains subject to a one-year contract and so decisions made after the election may impact the current proposed model.

First published in AISMA’s Summer 2024 edition.

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Robert McCartney is an associate in our primary care team. If you have any questions about the issues discussed in this article, or need legal advice on any aspect of your GP practice, contact us today.