I have talked a lot about needing to start with why and build relationships before you get into the discussion about what form your primary care network should take. But time is short, and form is also a decision that will need to be made.
First things first. £1.8bn of the promised £2.8bn coming in to general practice in the next five years is coming through networks. It is worth spending some time making sure these are set up correctly!
Technically practices sign up to networks by signing up to the Network Contract DES (guidance due out in March). Networks are not to be legal entities of themselves; the aim is explicitly not to create another layer of governance/bureaucracy. In signing up to the Network Contract DES practices have to identify, by 15th May, “the single practice or provider that will receive funding on behalf of the PCN” (p27).
The contract goes on to say, in paragraph 4.32, that “It is for each PCN to decide its delivery model for the Network Contract DES. It could be through a lead practice, GP federation, NHS provider or social enterprise partner”.
But which option to choose? How would a new network decide? It is worth spending some time examining the pros and cons of each of the options.
- Lead Practice
Summary: This model feels primarily designed for those practices already at the magic 30-50,000 population, who wish to become a network in their own right. The money stays close to general practice, but could be a fast-track to inter-practice disputes where more than one practice is part of the network.
| Pros | Cons |
| Allows a single practice to receive/manage all the network funding | Funding routed through one practice can lead to tensions between practices |
| Keeps the funding as close as possible to core general practice | Liability for expenditure (e.g. employment of new staff) sits with the host practice |
| Enables rapid decision making and minimal bureaucracy | Limited ability to influence as wider general practice within local integrated care arrangements, or to develop services beyond network boundaries |
Key questions to consider:
If the network has more than one practice: How will you ensure all practices have an equal say? How will you ensure transparency between practices? How will you prevent it feeling like a pre-cursor to a future merger with so much of the funding flowing through one practice?
How will you establish joint working arrangements with other networks? How will you create a strong local voice for general practice with other networks?
- GP Federation
Summary: This model feels primarily designed for those practices who already have a successful GP federation in place, who want to use the federation infrastructure to strengthen the ability to deliver against, and maximise the opportunities of, the Network Contract. It will require a clear accountability of the federation to the networks.
| Pros | Cons |
| Creates a GP owned host that will allow equity between practices in a network | Given the timescales, is likely only to work where GP federations already exist |
| Creates opportunities for at scale working beyond network boundaries, e.g. extended access funding is often already routed through federations, development of services to impact the Investment and Impact Fund | Federation may have priorities different to those of networks, e.g. delivery of existing contracts |
| Limited liability for the member practices of employing new staff if employed directly through the federation | May feel like the networks work for the federation rather than vice versa if not structured correctly |
| Potential enabler of strong collective voice for general practice in local integrated care working | Potential VAT issues if practices want to second existing practice staff into the federation |
Key questions to consider:
How will you make sure the federation is working for the networks, and not vice versa? Who controls the decision making in the federation? Do/will the networks have enough of a say? Is there a willingness among federation leaders to adapt the existing governance to meet the needs of networks?
- NHS Provider or Social Enterprise Partner
Summary: This model feels primarily designed for those practices already in some form of partnership arrangement with either the local hospital, the local community or mental health trust, or some other organisation. Without an existing relationship in place it is hard to see how the level of trust could be high enough for practices to be willing to entrust their funding to them.
| Pros | Cons |
| May be able to provide additional services for networks such as estates or HR support | Is only likely to work where a reasonably advanced existing agreement is in place between local practices and the host organisation |
| Large turnover organisations will be able to carry liability and any financial risk the networks want to undertake | The size and core business of the organisations may mean the networks and their activities are low priority for them |
| May enhance ability to recruit and support new staff groups e.g. physiotherapists, pharmacists, where host organisation already employs these staff groups | Voice of the networks may get confused with that of host organisation in system/integrated care discussions |
| May be able to offer synergies with own service offerings, e.g. integrating community and primary care teams | Distance of the funding from practices |
Key questions to consider:
What influence will the network have on the host organisation? How will it be able to control how network funding is used? Does the relationship rely on certain individuals, who may only be around for a few more years? How can networks ensure they can retain a distinct identity from the host organisation?
Conclusion
It very much looks like different solutions will be appropriate for different areas, and that there is no obvious “best” solution that applies to all. For single practice networks, or those already in a federation or who have a pre-existing relationship with another organisation, the challenge is probably mainly about adapting their existing arrangements to meet the network requirements. But the greatest challenge may lie with those nascent networks who are formed of a group of practices, with no federation or obvious organisational link. For them, the best way forward appears far less clear.
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