There is a tension that sits at the heart of any PCN.  It is the mismatch between the practice expectation of a PCN (that it will support the practice and enable it to be sustainable at a time when GP practices are struggling), and the system expectation of it (that it will work as a force for integration at a local level and unite services around the needs of local populations).

This tension sits primarily on the shoulders of PCN Clinical Directors.  These individuals spend much of their time trying to engage their member practices in the PCN project, practices that are often asking the question of what the PCN has ever done for us.  At the same time the weight of system expectation is that they will form productive alliances with the local (sometimes failing) mental health trust to introduce mental health practitioners, or the local (under pressure) ambulance service to magic up new paramedics, or interface effectively with a whole regional infrastructure that drags the PCN social prescribers away from what the practices want from them.

What is the role of the PCN?  Is it to support member practices, and act as a vehicle for the introduction of additional roles that will sustain them in the absence of any more GPs?  Or is to tackle health inequalities and help ensure the needs of local communities that have often been overlooked finally start to be met?

The fundamental problem with the whole PCN agenda is that the answer to this question is not clear.  It feels like their introduction was a compromise, an attempt to try and do both of these things at once.  The problem is that it was sold to practices on the basis of their future sustainability (remember £1.8bn of the additional £2.8bn promised to general practice in the 2019 5 year contract was via PCNs), and at the same time sold to the system as providing the building blocks of the new integrated care system.

The problem with compromise is that it often means no one wins.  In social psychology studies of groups, compromise is considered lose-lose in a zero sum equation.  Both parties want 100%, but they both have to give something up to appease the other party.  As a result, neither party really gets all of what they want.  Typically it results in resentment and not really being happy.

This feels like where we are now.  General practice is not happy with the PCN DES, as was clearly signposted by the inclusion of resignation from it as part of the move towards industrial action.  At the same time the system is not happy with PCNs and the role they are playing in the developing integration landscape, or else why would they have been replaced by “neighbourhoods” in the recent White Paper?

This is all starting to feel like a missed opportunity.  There is no reason why PCNs cannot meet both agendas, and contribute to the sustainability of practices and enable meaningful local integration.  But what this requires is an explicit acknowledgement by all that PCNs are trying to do both of these things.  Their success should be measured by the extent to which it achieves both of these goals.

At present there is no marker of what PCNs have done for practices.  There is no reason not to make this explicit, and include it front and centre of what PCNs achieve.  At the same time the PCN DES measures that we do have are national markers (because it is a national contract) of the role of PCNs in integration.  But of course for them to be really effective in this role these measures need to be locally set – the challenges in Frimley are not the same as the challenges in Newham.

So instead of trying (badly) to do two different things for two different audiences, it would better for PCNs to be explicit about the dual goals to everyone, have appropriate separate measures for each, and be given the freedom to use the resources that are being made available to make both things happen.