A problem that PCN leaders will often raise is how they can hold their member practices to account.  With all the delivery requirements that are now placed on PCNs there is an inevitable trickle down to delivery requirements on practices within the PCN (e.g. IIF requirements), but what can a PCN leader do if a practice simply is not pulling their weight?

It is a difficult issue.  IIF targets are such that it can easily be that if one practice does not get anywhere close to the target then the whole PCN can miss the target, despite the hard work to achieve it of all of the other practices.  No funding will be forthcoming despite potentially the majority of practices doing the required work.

It is an issue that sits at the heart of why PCNs are so unpopular in some quarters.  The NHS does not want to do business with 7000+ individual practices and instead wants to transact with 1200+ PCNs, but this in turn means it is the PCNs who have manage across their member practices.  This causes internal disputes and division across the profession, by setting it against itself.

There are a number of responses to the issue that have been taken that I wouldn’t recommend.

Some PCNs have tried to explore the idea of financial penalties for practices.  The idea is that if one practice ends up costing the other practices money because their poor performance has resulted in funds not being received, then they have to reimburse the other practices out of their own pocket.  The idea here is that rather than the practice simply not receiving any money for doing no work they actually incur a financial penalty (justified because the other practices have done the work for no reward), which in turn will act as an extra incentive for them to perform.

It is not hard to predict how such a system would be both hard to implement and lead to a serious breakdown in trust across the PCN.  And more fundamentally general practice should not be allowing the introduction of PCNs to set the practices against each other.

Other PCNs have taken even more drastic action.  Some practices have identified that they cannot rely on the other practices in the PCN to perform and so have petitioned to be able to set up their own separate PCN.  We have seen a number of PCN reconfigurations across the country where this issue is at least close to the centre of what is going on (although it is never that explicit).

But PCN reconfigurations themselves are always painful.  They generally end up being even more acrimonious than when financial penalties are introduced!  It is hard to believe this is the best action for practices in a PCN.

What action, then, can PCNs take?

The starting point has to be first and foremost the mindset that the main support general practice has in this new environment of Integrated Care Systems and a not-negotiating NHS England is general practice itself.  A primary role of PCNs must be to support its member practices, not penalise them.  There is precious little support available for practices outside of general practice itself.

What really helps here is a PCN vision, i.e. where the practices in the PCN have come together and agreed exactly what they are trying to do through the PCN, including the role it is to play in supporting practice sustainability.  Having this agreement is very helpful as a reference point in discussions about individual practice performance.

The starting mindset should be how do we help all of the practices in our PCN to deliver.  If one practice has identified ways of effective delivery how are we facilitating them being able to share this with other practices, and supporting those practices when they are struggling.  We are bad in general practice at learning from and supporting each other, and PCNs actually present an opportunity to put this right.

It may be that a practice cannot deliver one of the PCN requirements.  Then the PCN can agree whether a different practice might deliver this for them (and potentially receive any associated funding as well) or agree an alternative solution.  The key here is developing the trust required across the practices to be able to first of all share that a particular aspect of delivery is a challenge, and then to be able to have a sensible conversation as to how to tackle this together.

The job of PCNs is not to hold practices to account.  Rather it is for the group of practices that make up the PCN to ensure that they work together to maximise the benefit that the PCN brings to each of the member practices and their patients.  It is this mindset that can enable PCNs to work for practices not against them.