One of the potential scenarios for next year is that the funding for the PCN DES will be shifted from the national contract and given to local Integrated Care Boards (ICBs) to commission locally.  What impact would this have?

I should start by saying I don’t know what is going to happen next year, although as I wrote last week we know more than we sometimes think we do.  I don’t have any inside track or knowledge beyond what anyone else has, but based on what we do know it is possible to hypothesise about what next year might bring.  So to be clear this is a thought experiment on what might happen, not a statement about what will happen.

We know the system is pushing for is greater local control of GP funding.  While there have been some ideas floated previously around QOF potentially being commissioned locally, it would seem to me that a much more likely target would be the PCN DES.  PCNs are the basic unit of integration for local systems, and as such it would actually be surprising if systems did not want more control over them.  PCN DES money is not technically core contract money (despite it now constituting more than a quarter of all funds coming into general practice), and so it may actually be easier to shift to local control than other parts of the contract.

What would happen if such a change was to occur?  The first thing we would see would be an increase in variation across the country.  The national contract brings a degree of standardisation which would be lost with such a shift.  We would most likely see some areas add additional local investment to the PCN DES pot to accelerate the local development of PCNs and the shift to neighbourhood working, while others would most likely view it as another source of funds that could be accessed to cut costs so that the system could get closer to its financial savings targets.

We would probably also see variation in how the PCN DES funding is treated.  Some ICBs would understand the funding to be primarily general practice funding, and be mindful of the role this funding plays in supporting the sustainability of general practice.  Others would see the funding as system funding for neighbourhoods, with general practice being only one part of what constitutes a neighbourhood.  One suspects in those areas it would not be long before the resources within the DES started to be shared across a wider group of providers.

Then there is the ‘infrastructure’ question posed by the Fuller Report.  The report stated that PCNs’ “lack of infrastructure and support has held them back from achieving more ambitious change”.  So where does this infrastructure come from?  According to the Fuller Report this would come from an at scale general practice provider or existing NHS Trust.  Would it be wholly unexpected, then, if ICBs then contracted the PCN DES money via one of these providers?

If you take into account the new provider selection regime, which is due to come in place in the new year (watch out for my forthcoming podcast with Ross Clark from Hempsons for more details on this), then actually making this happen would be relatively easy for ICBs.  Having PCNs being directly contracted by the local community or acute trust does provide the type of structural integration ‘solution’ that the NHS heavily favours.

It all feels like a high risk scenario for general practice.  While it may create local opportunities in some areas, it clearly comes with huge risks.  Of course it may not happen, but it is exactly because scenarios like this are not unrealistic that it is critical general practice in local areas work together to develop their local system voice and influence.  This way at least it is in a position to mitigate some of the bigger risks that such a change would cause.  Even if it does not happen next April the chances are high that this will come at some point, and so being prepared is essential.