Primary Care Network submission day has arrived!  3½ months have passed since Primary Care Networks were formally announced as part of the new GP contract for 2019.  What have we learnt in the intervening period?  I would suggest there are (at least) 8 key lessons.

1. PCNs represent the biggest change for general practice in a generation. While PCNs may have started life as only one part of the package that was the 2019/20 GP contract, it has become clear they represent a much more fundamental change for general practice.  Funding flows into the profession are set to shift from being primarily at an individual practice level, to being primarily at a PCN level.  The fates of GP practices within a PCN are set to become inextricably intertwined.
2. 15^th May was an ambitious deadline for PCN submissions. The initial expectation was practices would have their network agreements in place by today, but as the complexity of that particular task became clear the deadline for the full agreement was relaxed to the end of June.  Practices choosing whom to get into bed with has taken most of the last few months (and some may still not be there yet!), and the challenge of defining the nature of the agreement between them still lies ahead.
3. The lawyers are coming. What wasn’t clear at the outset was how defined the nature of the network agreements between the practices needed to be.  NHS England has produced a “legally binding” mandatory network agreement for all practices to sign up to, but the meat of this agreement has been left to schedules that need to be developed and agreed locally, which will inevitably require lawyers.  It will be hard to keep the focus on trust and building relationships, which is widely agreed to be the most important foundation for a successful network, once the lawyers are in.
4. Focus has shifted away from the sustainability of core general practice. In the context of the new GP contract, PCNs were heralded as the mechanism for enabling new funding and resources to flow into general practice.  But on top of the legal fees, each new role requires practices to dip into their pockets to finance the unfunded elements, and the funding for extended hours has been cut.  The talk surrounding PCNs has quickly moved towards “system integration” and equally quickly away from the sustainability of PCN member practices.
5. The gap in funding for new roles is high risk. As practices have picked through the funding of the new roles, they have found that the headline 70% is an optimistic assessment of the national contribution.  This contribution is fixed regardless of the local market for the roles, or the package the network ultimately has to offer.  Financial liability for the new roles, for example in the case of redundancy, also sits with the practices in the network.  Whether all networks take up the offer of the new roles remains to be seen, but it appears increasingly likely at least some will not.
6. PCNs represent a shift in system GP leadership. CCGs always had the problem that they represented their population not their practices, despite being membership organisations.  The introduction of PCNs coincides with a 20% cut to the management costs of CCGs and a likely move to a wave of mergers, making CCGs yet more distant from local areas.  At the same time PCNs will each hold seats on the integrated care system boards, as the means of providing “full engagement with primary care” (Long term Plan 1.52).  There is a clear shift of power in motion from CCG GP leaders to PCN Clinical Directors.
7. The role of Federations is uncertain. Federations were conspicuous by their absence from the Long Term Plan and the new GP contract, and it is clear that PCNs are flavour of the month.  It remains to be seen the extent to which PCNs will work together effectively through federations, or whether each PCN will plough its own furrow.
8. Expectations of PCNs at practice and system level are very different. There are grand plans for PCNs in the Long Term Plan, as the focus of developing place-based care and integrating services around local communities.  But the challenges facing front line GP practices have not gone away, as the recent Panorama programme highlighted.  Practices need PCNs to first support and enable their sustainability, whereas the system expects them to first prioritise delivery of their own plans.  How that tension plays out remains to be seen.

We are still at the very outset of PCNs.  Establishing them may have been the easy step, compared to some of the questions that remain unanswered and the challenges that lie ahead.