There is a storm brewing in general practice.  Not unusually it relates to access, and more specifically extended access.  The ramifications are significant for PCNs more widely and the ability of general practice to be effective within local Integrated Care Systems.

What exactly then is the problem?

Right from the inception of PCNs it was announced that the funding for extended access would shift from the CCGs to the PCNs.  Originally this was planned for a year ago, but then this was delayed for unspecified covid-related reasons to April 2022.  It does look like it will happen this time round, especially because CCGs themselves will no longer exist at that point.

The current situation is that either local practices via a federation or an external provider deliver extended access.  This is not the same as out of hours, but covers 6.30–8pm on week days and 8am to 8pm at weekends.  Out of hours providers cover the 8pm to 8am period.

The issues can be broadly broken down as follows:

• Where an external provider delivers the service there is often unhappiness with the quality of service provided, and many local GPs have a sense that a better service could be put in place, particularly given the amount of money on offer.

• Extended access is funded at £6 per head of population. Given the requirements placed on the service, this feels generous to many GPs when compared to the core funding they receive.  We do not know whether this will be the funding level transferred to PCNs, or whether the service requirements will remain the same, but some practices believe it would make financial sense for extended access to be directly delivered by the practices in their PCN.

• Many practices are at breaking point already. Regardless of the finances, there are many practices who are vehemently opposed to taking on extended access at a practice level.  The issue for these practices is that their staff cannot cope with the workload they have, and to then ask them to cover extended hours is untenable.  Those with longer memories view it as a step back to the pre-2004 days when GP practices were responsible for their own out of hours cover, and are passionately opposed to any such movement.

• Federations use extended access funding to carry out far more than extended access. The relatively generous funding to date for extended access means that many GP federations have been able to build an infrastructure to support the delivery of at-scale general practice based on the extended access contract.  This has often included support for PCNs, delivery of vaccination services, delivery of resilience programmes (etc).  If the extended access contract is moved away from the federation by the PCNs then the whole at scale delivery capability for general practice that sits within the federation is put at risk.

The issue is hugely divisive because there are those practices who are adamant in their refusal to take it on, and practices and PCNs who are very keen.  Areas without a federation are already starting to feel forced into having to deliver this service, whereas areas with a federation are having to weigh up the impact on the federation as well as the impact on the PCN and its practices of any decisions they make.

The whole issue is unsurprisingly leading to increasing tension and animosity within general practice, just when it needs to be creating a united front.  The ongoing delays in the guidance from NHS England (it was due last year, then this summer, now it is due this autumn) are exacerbating the situation because without clarity on the requirements and the funding no one is in a position to make a final decision.

It is a controversial issue that is likely to become more divisive in the short term.  It falls to local general practice leaders to help navigate a way through this that works best for local practices and their populations, and not allow it become something that prevents general practice working together and having the united voice it so urgently needs within the emerging Integrated Care Systems.