What is a network?  According to that modern day fount of all knowledge, Wikipedia, it is, “a set of human contacts known to an individual, with whom that individual would expect to interact at intervals to support a given set of activities. In other words, a personal network is a group of caring, dedicated people who are committed to maintain a relationship with a person in order to support a given set of activities.”

The key point here is that networks are based primarily on relationships.  So while Primary Care Networks (PCNs) may have originated through a contractual route, that shouldn’t be what defines them.  Rather the connectivity, interactions and mutual support of relationships are their lifeblood, and what will determine the impact they can have.

So far Primary Care Networks have, in the majority of cases, been made up of groups of GP practices.  Practices within a network have been building the relationships between themselves to build trust and enable joint working across practices.

But in the Network Contract DES Specification for 2019/20 it said, “There is no requirement for the Network Agreement that is signed by 30^th June 2019 to include collaboration between practices and other providers, but this will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated to reflect the new Network Contract DES Specification.” (p11, 3.6).

If we leave the cloud having over next year’s Network Contract DES specification aside for a moment, then the logic of this requirement is sound.  If PCNs are based on relationships, then to make the maximum impact they need to include all those who can contribute to the cause.

But of course there is another way of looking at this.  The reason why practices were uncomfortable signing the network agreement in the first place was the potential impact on the practice’s autonomy.  Practices didn’t want to be told how they would have to operate by the other members of the PCN.  But at least all the other members of the PCN were GP practices, and so there was a level of shared interest.  Widening the membership to include non-GP practice organisations reduces practice autonomy further (less influence on PCN decision making), with less certainty that decisions made will be made in the best interest of my particular practice.

So there are two factors at play here: impact and trust.  For PCNs to have the maximum impact they need a broader set of relationships.  But without trust practices are going to be reluctant to include new members into the PCN family.

Networks must start with a common purpose (clarity on what we are trying to achieve).  Identifying who can help deliver this purpose and widening the membership to include them is the way to move forward.  Let the shared purpose determine the terms of any agreements that need to be made, but prioritise person to person relationships, because it is only when we trust each other that we can work effectively together to make change happen.

The mistake is going to be starting with the network agreements, ahead of building relationships and trust.

PCNs have the opportunity to establish a new way of working for the NHS.  Instead of the traditional top down, bureaucracy heavy, organisation centric way of working, PCNs can model a new style based on trust, relationships and commitment to a common cause.  Whatever the PCN DES specification ends up saying for next year about extending the membership, how PCNs extend their membership is going to be at least as important as who with.

The biggest challenge the publication of the PCN DES specifications for next year has created is not so much the detail contained within the documents but the loss of enthusiasm amongst GPs for the whole PCN project.

Before Christmas there was hope that PCNs could mark a new dawn for general practice.  But that bubble was burst when the specifications demonstrated the lack of any national ambition to use PCNs to support the ailing profession.

Wherever the national negotiations end up, it is hard to believe they will restore the hope and energy that existed last year.  But PCNs don’t go from being a good thing to a bad thing overnight, and so it is worth taking some time to reflect on the opportunities PCNs create, regardless of national specifications.

A good place to start is the time before PCNs existed (remember that?).  There were two main trends in general practice, both a response to the pressures the service has been facing.  The first was the introduction of new roles, not to replace GPs but to manage those parts of the (growing) demand that their skills made them best placed to take on.  The second was the move to bigger practices and operating at scale, to develop the resilience of practices and to enable them to embrace any opportunities that develop.

PCNs continue both these trends.  The majority of the funding for PCNs is for the introduction of new roles, and PCNs bring practices together and provide the opportunity for the benefits of scale to be delivered across practices.

The big new opportunity the introduction of PCNs has created is working in partnership with other providers.  One of the rationales for PCNs was to enable the gap between primary care and the rest of the system to be closed, and to bring (in particular) general practice and community services closer together.

For GP practices PCNs create the opportunity to better meet the needs of the local population.  Practices can clarify what part of the local demand they are best placed to meet, and what part of the demand is best met by partners, by collaborations and by network wide services.  Where gaps in service provision exist PCNs can work with local partner organisations to fill these gaps.

In a world where we didn’t have PCNs what would general practice be doing?  Probably working towards the development of something that looks very much like PCNs…

So the problem is not primary care networks themselves.  PCNs enable general practice to respond effectively to the pressures they face and to better meet the demands they are under.  The issue lies with the PCN DES specifications which seem to be attempting to shift PCNs away from supporting general practice and into the generation of additional work that will make the current problems worse.

But that doesn’t make PCNs themselves a bad thing.  They remain the best hope for general practice for the future.  What has been revealed as the ‘bad thing’ is the level of control the national contract has over PCNs.  Leaving the destiny of PCNs in national hands already looks like a recipe for disaster.  So now may be a good time for practices and local systems to think carefully about exactly how they want to make PCNs work for them, and to exert more local control to restore the confidence of practices that PCNs can still be the path to a bright new future.

There is a huge furore at present in general practice as a result of the publication of the draft PCN DES specification for 2020/21.  There are hugely detailed requirements on PCNs without any additional resource, and a clear expectation that the new workforce outlined in the 5 year GP contract last year is for additional work rather than to help meet the existing pressures in general practice.  Unsurprising, then, that general practice has reacted how it has.

But the implications of the draft specification go beyond general practice.  It is material to whether the shift away from the commissioner/provider split and towards integrated care, as outlined in the Long Term Plan, will succeed.

For integration to have an impact it needs local innovation, driven at a local level, based on trusting local relationships.  But as Integrated Care Systems (ICSs) and Integrated Care Partnerships (ICPs) try to meet testing national deadlines, their focus has shifted to governance, and the traditional NHS focus on accountability, control and decision making.

We have moved the deck chairs around enough times to know already that this will make no difference.  The one opportunity for it ‘to be different this time’ is PCNs.  Their 30-50,000 size enables real localism, borne out of an understanding of what is needed and what will work in each area, with person to person relationships as the enabler of making real change happen quickly.

The job of the architects of the new system really is to create the space, time and freedom for these local relationships to develop, for local problem solving to begin, and for local solutions to be developed.  So, for example, if a group of practices has a problem with the way district nursing is being delivered, instead of them raising that with the CCG to raise with the community trust in a contract meeting, who in turn will raise internally, and very little will happen, we move to a system where the practice leaders meet the district nurse leaders (who they already know) and work out what they can do differently to offer a better service to patients.  A system like this is one where things could start to be different.

The biggest problem with the PCN DES specification is the signal it gives that this will not be allowed to happen.  This is for three reasons.  The first is that if the centre dictates what PCNs should do in anything like the level of detail that is in the draft specifications, local innovation will not be able to flourish.  The mindset of central control has to be given up if integrated care is going to work, because the best solution in one area will not be the same in another, and each area needs the freedom to work out what will work best for them.

The second reason is that it has to be up to local areas to determine how they will use their workforce, and not nationally dictated.  The individual ‘return on investment’ mindset of any new funding, and a requirement for additionality even when core services are floundering, is fundamentally flawed.  We know we are 5-6,000 GPs short.  The new PCN-funded workforce can help both support general practice to thrive and be an enabler for local system working, but it has to be for local areas to decide how this workforce should be deployed across priorities (including core work), not via a nationally dictated contract.  Defining the “additionality” that new roles must deliver misses the point that existing (potentially more important) requirements cannot currently be met, and each local area has to be free to determine how to deploy the new roles to get the most out of them.

The third reason is that it takes time for local relationships to develop.  In year one we have had a primary focus on practice to practice relationships.  In year two we do need to widen that focus to the relationships across the wider group of providers within each network.  Time is needed for trust to develop, and over-burdening local areas with the level of delivery requirements contained in the draft specification at this stage runs a high risk of making relationships worse not better.  We need patience as we build a platform for future success.

My plea is for system leaders to recognise that the underpinning approach encapsulated within the PCN DES specification is one that will prevent the success of the new systems they are trying to create, and that it is not simply a general practice only contractual dispute.  If PCNs are really going to be the engine of integrated care, this contract needs to be an enabler not a dictator of local change.  Getting this contract right is everyone’s responsibility, and it would be great to see local leaders vocalising their own concerns about the issues the draft specification raises.