There is an almost palpable dissonance that sits between the Primary Care Networks (PCNs) as constituted in the PCN DES, and how they are perceived in the minds of CCG leaders and those responsible for developing integrated care systems.

On the one hand the GP contract portrays the DES as a framework for practices to work together and to secure investment into general practice over the coming years.  The system, meanwhile, seems to think of PCNs as the building blocks of the local integrated care system, with a membership and remit expanding far beyond core general practice.

So who is right? Are PCNs a contractual construct of joint working between practices, operating solely within the framework of the national GP contract, or are they something more, owned more widely across the system and with an accountability beyond the terms of the GP contract?

This question is one general practice would do well to take time to consider, because the implications are far reaching.

A good place to start is the Long Term Plan for the NHS, published just before the new GP contract.  In chapter 1 of this document, which sets the direction for the NHS for the next 5 years, it sets out five major changes to the NHS service model, the very first of which is “we will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community services” (Long Term Plan p12).

How will this be achieved?  Through PCNs. Through the investment of £4.5bn in “expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices… Most CCGs have local contracts for enhanced services and these will normally be added to the network contract… The result will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care” (Long Term Plan 1.9-1.10 pp 14-15).

There are some important points to note here.  First is that, in case anyone is in any doubt, the primary purpose of PCNs is the integration of primary care with the rest of the system.  The contract has been used as a necessary mechanism for setting them up.  How else can you integrate independent contractors?

Second, is that the promised £4.5bn in the Long Term Plan is considerably higher than the £1.8bn promised in the GP contract to support the formation of PCNs.  This is because the majority of investment in PCNs will not be through the core GP contract.  The funding that comes from other sources (which, by the way, represents a huge opportunity for general practice) will, inevitably, bring with it an accountability outside of the core contract, and into the wider system.

The other place to look is the PCN Network Contract DES, which notes the key features of the DES are set out in the Long Term Plan (and so references the points above without explicitly stating them).  It says the DES is subject to annual review and development, and that the focus in 2019/20 is “to support the establishment of PCNs and the recruitment of the new workforce, with the bulk of the service requirements coming in from April 2020 onwards” (Network Contact DES Specification p5).

So this year (the easy one) is about practices working together, and essentially getting ready for what is to come from 2020 onwards.  That is when the shift will accelerate away from core general practice.  The Network Contract DES guidance states, “PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care. To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.” (p16-17).

One of the service specifications coming in 2020/21 is the innocuous-sounding anticipatory care, “The Anticipatory Care Service will need to be delivered by a fully integrated primary and community health team. To support this, from July 2019 community providers are being asked to configure their teams on PCN footprints. The requirements will be developed across the country by ICSs, and commissioned by CCGs from their PCNs. NHS England will develop the national requirements for the essential contribution required under the Network Contract DES.” (p18).  Within one of seven DES service specifications the NHS has effectively announced the full integration of primary and community care!

Back to the original question – are PCNs about contractual joint working between practices, or about integrating all services within a local community?  While today the answer is largely the former, it is clear from 2020 onwards the answer is very much the latter.  There is no real dissonance (other than between the expectations of pace setting system leaders and the reality of where their local networks are).  PCNs are on a journey.  The start of this journey (and where we are today) is joint working between practices, but very quickly this will evolve into joint working between that group of practices and the rest of the local health and social care economy.  This is the DES practices have signed up to, and these are the changes that are on their way.