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.