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.