For those who have been around a long time it is hard not to get cynical, as every couple of years there is a new scheme for general practice that is heralded as the big ‘new thing’ but then fizzles out, and disappears as quickly as it arrived.  Are we not headed the same way with PCNs, and so shouldn’t we be keeping our heads down and simply focussing on the day job?

Bear with me as I take a short trip through recent history.  Back in the early 1990s (voluntary) GP fundholding was introduced, but no sooner had it been embraced by more than half of the practices across the country than it became politically unpopular over concerns of a two-tier service, and it was quickly abolished by the incoming Labour government in 1998.  By this point some practices had become heavily invested in the scheme and its removal represented something of a kick in the teeth.

The Blair government replaced GP fundholding with primary care groups (PCGs).  Here groups of practices were to work together to provide the universal coverage that fundholding had not, with the idea of an indicative budget at each practice level.  However, by 2001 these PCGs were deemed too small and it was announced they were to be replaced by a smaller number of larger more powerful Primary Care Trusts (PCTs), who it was hoped would have more purchasing power.

Of course this meant practices were once again removed from any actual commissioning decisions, and so practice based commissioning was introduced in 2005.  This quickly came beset by implementation challenges, and was ultimately itself replaced (having never really taken off) by Clinical Commissioning Groups (CCGs) when the now infamous Health and Social Care Act was published in 2012.

The death knell for CCGs was sounded in 2016 when Sustainability and Transformation Plans were introduced, as the NHS started on its journey towards integration.  Even though they limped on until the latest Health and Social Care Act had been passed in 2022 they had already effectively been replaced by Integrated Care Boards.

It is not surprising, then, that against such a backdrop of continuous change that many practices are sceptical about Primary Care Networks (PCNs) and their chance of any long or even medium term sustainability.  PCNs were introduced as part of the 5 year GP contract in 2019, immediately after the publication of the NHS Long Term Plan in January of that year, and face an uncertain future as that particular contract draws to an end.

However, when it comes to PCNs there are some important differences.  One is that all the previous incarnations were attempts to place primary care at the centre of the purchasing arm of the internal market model.  PCNs, in contrast, are the first attempt to enable general practice to integrate with the wider system, in this new way of NHS working.

While there were always arguments about the scale required for effective commissioning, there is less debate about the scale needed for integration.  All seem to agree that integration has to start at the local neighbourhood level, and even if you consider Labour’s current shadow health policy they are promoting a ‘neighbourhood health service’.  The pseudo-primary care policy that is the Fuller Report recommends integrated ‘neighbourhood’ teams.

The concerns with PCNs seems to be less about their scale and more about the extent to which they have enabled wider integration.  The debate is also as much about the independent contractor status of general practice (something that never really featured during the purchaser provider era) as it is about PCNs, as this status is regarded as a blocker to integration.

Here is where we get into the real difference of the current situation.  Previously the changes were nothing to do with the core delivery of general practice, but attempts to harness practices as commissioners.  Now the changes are attempts to join up core general practice with the rest of the NHS.  It is not scale that policy makers want to change (the size of PCNs seem about right to them), but the function of general practice behind that scale.

This is important because while for the past 20 or so years a strategy of ‘watch and wait for the latest fad to pass’ has been largely successful, there are warning signs now that such a strategy for individual practices could result in some very unwelcome changes at practice level.