An article appeared in the Health Services Journal last week (here, although paywalled) which reported that Hertfordshire and West Essex ICB are replacing the APMS contract with a private provider with a GMS contract to be held by the local PCN.  What are the implications of such a move for general practice?

This is definitely a change in the direction of primary care commissioning.  While we do not know the extent to which this may become common practice amongst commissioners (and it could of course be a one off), it represents quite a significant U-turn from how such events have recently been handled.  Previously they would have either re-tendered the APMS contract or dispersed the list.

It does seem that tendering APMS contracts may no longer be much of an option for commissioners.  There is so little funding in the core contract that the historic providers of APMS contracts are now moving away, for example Centene is reportedly in the process of trying to offload its chain of nearly 60 Operose Health surgeries (formerly AT Medics).  Equally, in this new world of integrated care systems the emphasis is on GP practices working together in PCNs, and many PCNs with APMS providers as members have found it hard to engage them fully in the work of the PCN.  Hertfordshire and West Essex ICB cited the short term nature of APMS contracts, and the challenge this poses to PCN development, as one of the reasons for their action.

In the past some commissioners have sought help from local federations with the running of practices, but these have been almost exclusively APMS contracts.  The difference here is that the commissioner is awarding a GMS contract, i.e. one that exists in perpetuity, to the PCN.

Whilst responsibility for the practice does shift to the other practices in the PCN, it is not the same as dispersing the list.  In a dispersal practices have to take on their share of the patients on the dispersed list, but in this scenario the responsibility (and accountability) comes via their membership/ownership of the PCN.  It does make PCN resources (both clinical and managerial) more directly accessible to the struggling practice which may help, but of course this will equally be a distraction from the core PCN work plus from the PCN support to the other practices.

We have seen practices merging and becoming coterminous with their PCNs, making the PCN work simply an extension of the core GMS work.  But this approach of a PCN taking on a core GMS contract to me is more surprising and unexpected.

Not everyone shares my surprise, however.  Healthcare policy expert Nigel Edwards said “surely it was always the intention”.  Is it inevitable?  Does the current policy environment of integration mean that where we are heading is PCN-shaped or PCN-run practices?  Should we be expecting this to be just the start rather than a one-off anomaly?

PCNs up and down the country vary considerably in their state of maturity.  Some have now reached the point where taking on a practice is a viable option, although many (the majority?) are probably still some way off this.  But the system has been piling responsibility onto PCNs regardless of their ability to take it on, so readiness may not act as any kind of barrier to a roll out of this approach.

But equally commissioners vary.  At the same time as this ICS is awarding a GMS contract to a PCN, another is offering contracts on a ‘branch-only’ basis.  So I don’t think we have reached the point where this now represents the new system approach to commissioning contracts.

It is an interesting development, and one it is worth keeping an eye on to see whether it is a one-off or whether other systems follow suit.  It does seem extremely likely that any new resources for general practice will continue to come via PCNs, and that practices’ dependence on their PCNs will continue to grow.  Whether this then means that ultimately practices end up operating collectively as PCN units, as either a single contract or a collection of contracts held at PCN level, I don’t think is quite as clear cut.  But if we take nothing else away from this is should be that practices operating together as PCNs represents a cornerstone of the new NHS architecture, and it is one that is not going away any time soon.