The publication of the PCN DES specification for 2026/27 includes an opportunity for ICBs to introduce what is termed a “local variation agreement”.  What does this mean and what are the implications for general practice?

Essentially the change allows ICBs to alter the PCN DES locally.  It has to be agreed by NHS England, but one assumes there is a willingness nationally for this to happen or else they would not have been introduced.

The document states that the change is limited to sections 7, 8 and 10.1-10.5.  But when you understand that these sections encompass the ARRS roles, the core service requirements of PCNs and the network financial entitlements it pretty much means the whole lot can be changed.

There will inevitably be some nervousness about this change within general practice.  While individual practices are small and relatively weak compared to NHS England or even an ICB, their strength has always historically come from acting collectively as one.  The national GP contract is the biggest symbol of this, and by negotiating it collectively their position is far stronger.

The shift to enabling ICBs to essentially create their own version of the PCN DES, which constitutes a large percentage of GP practice income, potentially undermines this position.

However, the benefits could well outweigh the risks.  For a start NHS England is no longer negotiating the contract with general practice, and is instead simply imposing it year on year instead.  We will have to wait and see whether the new round of collective action is able to influence this.

There are also significant safeguards in place for practices when it comes to any local variation.  First of all, the ICB has to evidence each practice has agreed to participate in the Local Variation Agreement (4.10.6).  The PCN DES part B guidance makes it clear that ICBs have to ensure that “the total investment available to the participating PCN(s) is greater than that provided under the relevant Network Contract DES Specification entitlements” (B.2.1).  On top of that, the ICB has to engage with the local LMC in making any changes (in contrast to NHSE who do not believe they have to engage with the GPC at all).

The other question that the change raises is what its relationship to the forthcoming Single Neighbourhood Provider (SNP) contract will be.  NHS England states that this is separate from the SNP contract, which we know a consultation is planned on later in the year.  But there does seem to be considerable overlap between the two considering the SNP contract once it arrives is expected to incorporate the PCN DES.

For general practice the option of an upgraded PCN DES with more resources attached as opposed to a whole new SNP contract feels much more attractive.  This is because the PCN DES is a contract for general practice and is held by practices.  The big risk with the SNP contract is that it could be held by organisations outside of general practice, and as a result move resources away.

So more resources, retaining control within general practice, and in a deal that all practices have to be happy with seems like a lot of upside.  Indeed, if general practice can make this work maybe we can get to a position where the SNP contract is not even needed (and there have been a lot of delays when it comes to any guidance or documentation linked to neighbourhoods to date), which might end up being the best result of all.

As the shift to neighbourhood working accelerates there is an important question that is emerging: where does the legitimacy of those talking on behalf of general practice come from, both with the GP practices themselves, and with the leaders of the other organisations across the partnership?

Practices and PCNs ideally want a say in which individual or individuals should take on these roles.  But as many of these roles are (or at least were) funded by ICBs, it often ends up being a direct appointment by them.  This lack of an obvious link back to practices and PCNs can create problems when it comes to legitimacy, which then in turn can make it difficult for these leaders to be effective.

For partner organisations the legitimacy of these leaders comes from their ability to convert conversations and agreements that are made into tangible action, rather than a clearly defined route back to practices.  They are far less interested in the process by which leaders came into post than effective services being put in place when agreements are reached.  The most common complaint from acute and even community trusts is that they invest time with GP leaders and nothing tangible happens as a result.  Instead, what they more commonly experience is a list of issues and complaints about their own services.

I recently spoke to Dr Sian Stanley on the podcast about this very issue.  She is very clear that legitimacy comes from delivery, not from representation.  If she as a general practice leader is able to work within the new provider partnerships developing within the changing NHS landscape and turn those conversations into the practical delivery of new services and new ways of working then her legitimacy will come from that.

This works with the practices, because they are happy with the tangible changes in service delivery, the opportunities to work within these services should they want them, and the financial returns these generate for the practice.

And it works for the partner organisations, who can see the result of their own investment of time and energy into partnership working in actual service delivery.

The impact in West Essex has been tangible, with general practice playing a leading role in the running of the urgent treatment centre and developing further services to change the model of care, all of which are generating a return for the local practices.

But this is in stark contrast to many parts of the country where place-based partnerships and system working feels more like a lot of meetings and a drain on leadership time than an enabler of actual change.

The really important take away for general practice, then, is to consider whether they have the right people representing them in system discussions.  The right people are those GP leaders who can make change happen, who can set up new services from scratch and who have a track record of delivery.  Often they are the people who set up shared assessment and treatment sites during covid, or got the immunisation sites up and running, or who have set up system wide delivery models through federations or other such organisations.

The point is they will have a track record of delivery and of setting up services at-scale.  People who will be able to deliver within the emerging integrated care system will already have experience of doing it.  These are the people general practice needs to be in leadership positions within the new system, because these are the ones who have the best chance of making the left shift a reality.

Equally, what won’t work for general practice is having leaders in place who understand the role as attending meetings, and of giving a general practice point of view, rather than of making change happen.  Sooner or later the system will get frustrated with these individuals and the most likely result will be general practice being bypassed when changes are made.

The neighbourhood system presents real opportunities for general practice to re-shape the system of care and to strengthen the role of general practice and community services within that.  But the first step to grasping this opportunity is ensuring that it has the right leaders in place.

There was a fascinating session at the PCN Plus Conference in which colleagues from West Essex presented how they are working together.  This included leaders from the acute trust, community services, social care, general practice and the ICB.  What they presented really challenged my thinking about who should become an integrated health organisation (IHO).

Plenty of people working in or with general practice, including myself, bring a healthy scepticism to the notion that an acute trust could or should be identified as an IHO.  Just the idea of the acute trust holding the funding for general practice is enough to bring most people in the sector out in cold sweats.

This is not without good reason.  There is little or no track record of acute trusts investing into general practice and community services.  Those of us with long enough memories remember that community trusts had to be separated from acute trusts only 20 years ago because of the stripping of community resources to fund acute services.

But there is an argument that it would make sense.  If you take any local health community with an acute trust at its centre at least half of the total funding is going to the hospital.  They have the deepest pockets, and are the ones most able to make any shift occur.

The problem is we don’t trust them to do this.  We know the financial pressures acute trusts are under, and expect any widening of their income to be used to ease this pressure – to the detriment of all other providers.

So it was hugely refreshing to hear Thom Lafferty, the CEO of Princess Alexandra Hospital, talk about the need for a shift of resources to primary and community care.  He was clear that the solution to the pressures his hospital is under will only come from a change in the way the whole health community operates, and that this requires a shift of resources out of his acute.

The GP leaders had clearly bought into this.  The GP leaders came across as extremely astute and well informed, and so this isn’t a case of the wool being pulled over their eyes.  Trust has clearly been built, and there were concrete examples of how the Trust is actively trying to support general practice, such as providing estates.

What was even more interesting was the CEO sharing how he was coming under pressure from NHS England because of the challenges they are experiencing with acute operational targets.  When he explained to them that his plan to address these was founded on working across the whole health community (in line with NHS England’s own strategy!) it didn’t sound like this was what NHS England wanted to hear.

This raises a really interesting question.  Which are the best organisations to become IHOs?  Do we want it to be the trusts that have their finances, waiting lists and waiting times under control?  Because won’t they want to protect what they have, and be the ones most likely to continue the historic shift of resources from community to acute care?

Wouldn’t it be better for it to be those acute trusts with performance challenges who genuinely believe the only way out of their current predicament is a change in the way the whole system operates (like Princess Alexandra)?  Surely the key point is not one of operational grip, but rather of a genuine, bought-into strategy to change the way things work by investing in out of hospital care.

From being extremely sceptical about the IHO model, I do now think there is possibility that it could work, and for the benefit of both the whole system and general practice.  At present the potential risks still seem to me to outweigh the potential benefits, but the key will be whether NHS England will let those places like West Essex where the whole system wants to do things differently become IHOs, or whether it insists on focussing on those organisations without financial or operational challenges which feels like a recipe for disaster.  I for one will be watching with interest to see how the story in West Essex unfolds.