The general consensus appears to have fallen on integrated care systems and primary care networks as the way forward. CCGs have been instructed to encourage every practice to be part of a primary care network, which are to cover populations of (roughly) 30-50,000, and as a result a plethora of these new entities are now developing.

Here is a question: where should the funding for the management of these primary care networks come from?

We may not be convinced that another layer of management in the NHS is what is needed, but if the mantra of the day is primary care networks, and the point of them is to enable core general practice to partner effectively with other providers within an integrated care system, then some management function is going to be required.

What are the options?

1.Use the management margin gained from the delivery of additional services.

Traditionally this is how GP federations have made themselves sustainable. In some places this is the assumed mechanism for developing the management funds for these new organisations. The problem is that the networks are expected to represent the delivery of core general practice, not simply the delivery of the (small) range of new services they may provide. This method creates an incongruence between what the network does and the voice it is supposed to have. It also serves to inflate the management costs they have to charge for any service delivery, which is likely (at some point) to make them uncompetitive.

2.“Investment” by GP practices.

In this model GP practices chip in anything up to £2 per head of practice population. This ensures the network function has a clear sense of ownership from its member practices, and that it speaks on their behalf. The challenge comes here with the underfunding of general practice in recent years. Establishing the networks becomes another drain on GP practice resources, at a time when many practices simply do not have the spare financial capacity. As a result, many practices will choose to pass when the opportunity to directly fund the new networks comes along.

3.GP Transformation Funds.

The GPFV is investing a considerable amount of funding to enable “transformation” in/of general practice. Some STP areas are using the transformation funds to support the establishment of GP networks with appropriate management. This is a sensible starting point, but really is deferring the question of where recurrent funding will come from, rather than answering it (i.e. what happens when the non-recurrent transformation funding runs out?).

4.Additional Funds for the GP contract.

Essentially, a model could be introduced whereby additional funding is given to every practice through their contract, for them to use to fund the management resource required for primary care networks. A similar approach was used in practice based commissioning days when practices in many areas received an enhanced service for practice based commissioning, although then they could choose to use it themselves or pool it to create a shared function.

The benefit of this approach is it ensures GPs retain ownership of the management function because even if it is “pass-through” funding, it comes from the practice. This creates the accountability between the network and the practices that is required for them to be successful. The downside is that local disputes and disagreements make local arrangements hard to pin down and sustain over a period of time – just look at the blood, sweat and tears it took to tie down CCG configurations.

5.Transfer of some CCG management allowance

The final option (that I can think of) is the transfer of some of the management funding that sits within CCGs to these new networks. CCGs as member organisations at some stage in the move away from the commissioner/provider split are going to cease to exist, and the natural replacement for groups of practices looking to work together to improve population health (although this time as providers) is going to be primary care networks, so it seems a relatively logical move. It may also serve to stop the shedding of the huge amount of GP leadership talent that CCGs have uncovered.

This would be a recurrent resource, but the downside would not only be the lack of ownership from practices that this move may generate, but also a reinforcement of an unease held by some GPs that primary care networks are the next iteration of PCGs/PCTs/CCGs.

It will be interesting to see where this ends up. It is important that general practice fights hard against the result defaulting to option 1, which in the end will serve no-one, and put unrealistic pressures on network leaders. I suspect we will find ourselves in some form of amalgam of option 3 (to get things started) and option 4 or 5 – but with the proviso that additional recurrent funds build on and develop whatever was established in the start-up phase to prevent huge backwards steps.