As of April 2024, there are 1,279 PCNs in England. Data from NHS Digital shows 363 full-time equivalent CDs, eight in ten of whom are GPs, a number that has remained stable over the past year. The goal, as set out by the network DES in 2019, was for PCNs to build greater resilience and leverage the benefits of working at scale for practices. In its latest iteration, this remains a key aim for CDs who are tasked with forging closer links between practices as well as the broader health and care system and voluntary sector.
CDs are responsible for ensuring their PCN delivers the requirements set out in the network DES and allocating the funding, including that provided through the ARRS across the practices. A key addition to the list of roles that can be funded under the ARRS scheme this year has been the enhanced practice nurse. They are also accountable for deploying capacity and access support payments which have been introduced to improve patient experience and access to general practice. A fairly recent introduction to the lexicon for PCN CDs has been their work within integrated neighbourhood teams – first mentioned in the Fuller Stocktake report. They bring together multi-disciplinary professionals from different organisations across health and care services and CDs are tasked with helping to establish them and ensuring PCN participation.
Successes and failures
In our survey, 97% of PCN CDs said they would continue with the network DES in 2024/25 with only 3% indicating they were unsure.
This likely reflects the reality that a large amount of primary care funding is delivered through PCNs and practices would not be able to function without it. One clinical director (CD), who wished to remain anonymous, says the work being directed to general practice at the current level of funding is economically unviable with practices at ‘immediate threat of collapse’.
When it comes to pointing to the positive aspects of their work, 69% said their PCN had been successful or very successful in improving joint working. Around 63% also said their PCN had been successful or very successful in improving care for patients while more than half, 57%, also rated themselves in these terms for improved patient access.
While there may have been some heated debate around the use of ARRS money in the profession more widely in recent times, this was an area in which PCN CDs rated success particularly highly in our survey. In all, almost nine in ten respondents rated themselves as successful or very successful in recruitment and retention of ARRS staff, with 48% putting themselves in the most positive category. But that is not to say all is rosy, with one CD specifically commenting that they could have done even more had there not been ‘so many strings attached’.
‘So much of the ARRS budget has been lost to primary care because it seems to have been almost designed to make it impossible to take full advantage,’ they note.
Dr Nicholas Jackson, CD of Selby Town PCN, said pharmacists, physiotherapists and mental health workers had been most valuable to them in supporting core general practice. ‘We have had equal, if not greater, success in delivering personalised care and population health and heath inequality work via roles such as care co-ordination, social prescribing, dietetics and health and well-being coaches.’ While the impact on workload is less obvious, this is part of investing in a more prevention-focused model ‘which we hope will bring rewards in the future’.
Among CDs responding to the survey, 30% said their PCN had been unsuccessful or very unsuccessful at freeing up GP time with 36% feeling neutral about this part of their work. This perhaps reflects the well-documented pressures seen in general practice overall. As has also been widely reported, the addition of new practice staff also comes with supervisory responsibilities for the GP members of the team.
While the results around digital transformation and improving health inequalities were also broadly positive more than one in five CDs did report a lack of success in these areas.
Dr Manraj Barhey, CD at Medics PCN, Luton, Bedfordshire, says PCNs provide a ‘really good opportunity to tackle health inequalities’.
‘We focus a lot on outcomes and they have been pretty phenomenal. There is a lot of hidden need out there,’ he says. Medics PCN has identified thousands of patients with conditions such as hypertension that were going undiagnosed or unmanaged as well as success in tackling very frequent attenders through non-clinical interventions.
ARRS
A more in-depth look at survey results around the additional roles scheme specifically shows a great deal of consensus that it has improved joint working between practices, with 84% agreeing or strongly agreeing with this view.
There was also a very positive outlook for ARRS having improved patient care and access. Yet the responses from CDs also show a bit of a mixed bag when it comes to the impact of the new staff on the GP and the rest of the team. Half of respondents said the ARRS scheme had increased workload for practice staff and 46% said it had put more pressure on GPs and general practice nurses. The balance of opinion as to whether the hiring of ARRS staff had reduced GP workload was a relatively even split, with 50% believing it had but 42% saying it had not, and 8% unsure.
Dr Barhey said they had freed up tens of thousands of appointments that would have gone to GPs as well as case finding and prevention work. ‘We are a large PCN of 60,000 patients and we have 28 staff that we use to ensure we can offer capacity to practices.
‘For our practices and GPs, there has been a noticeable difference, and we are not as stretched’. He added that the impact that PCNs have made on access is considerable and ‘perhaps not recognised enough’ because of the pressures that primary care is under.
He is among those who would like to see far more freedom in how PCNs can use their ARRS money. ‘It should be: “Here is your budget, do what you like with it”. We need that flexibility.’
Dr Jackson adds that GPs still feel significantly overstretched because of the additional burden of supervision and there has also been an unintended effect of ARRS roles in ‘introducing duplication and inefficiency’ and multiple appointments that could have been all handled by a GP in one appointment.
In general though, the hiring of ARRS staff is viewed as having had a positive impact on GP practice staff and CDs were particularly upbeat about the impact of ARRS staff on their own GP practice, with 82% saying this had been positive or very positive, perhaps showing how well the newer members of staff had embedded within existing teams.
Eight in ten respondents also cited the ARRS scheme as having had a positive impact on their patients and 59% said these new members of staff had also had a positive impact on the GP profession.
Since the ARRS funding stream was introduced, PCNs have raised concerns that they can struggle to recruit the specific roles set out by the network DES. The list of eligible roles now includes clinical pharmacists, paramedics, first contact physiotherapists and social prescribers but also mental health practitioners, physician associates, general practice assistants and dieticians.
Pulse PCN has recently revealed that tens of millions of pounds available to PCNs through this scheme have been lost to primary care. PCNs have reported being unable to make full use of this money because they cannot recruit, or the funding is inadequate when they do find someone or the staff they need in their practice are not included in the scheme.
In the past year there does seem to have been some improvement on this front from previous reports where 65% of CDs have said they have struggled to fill ARRS roles. In the latest survey, 81% said they had been able to spend all the ARRS money available to them under the network DES, which may reflect the expansion of roles included in the scheme over time. In all, 16% of respondents said they had not been able to spend the ARRS money they were eligible for.
Yet some respondents said it had been a source of significant stress to spend the funding as the rules were complex and difficult to administer, while others noted they had got close to spending the money but had difficulty recruiting specific roles or had been unable to have their first choice of staff, for example, a paramedic.
Dr Sian Stanley, CD at Stort Valley and Villages PCN, Hertfordshire and Essex, said general practice is very efficient but has been hampered by ‘not being able to employ the people who could make a real difference to capacity and access because the ARRS scheme has been so restrictive’.
When it comes to the ARRS staff most valued by CDs in helping support the PCNs’ practices and patients, our survey shows pharmacists coming out top, with 81% saying they had been most successful in this role. Physiotherapists, care coordinators, social prescribing link workers and paramedics were also all seen as successful in supporting practices and patients by at least half of respondents.
Around 60% of CDs said they did want to see other roles including in the ARRS, with GPs and practice nurses being suggested most frequently.
One respondent who said doctors and nurses should be included added ‘this is what patients want’.
The clinical director role
There is experience among those doing the job, with the majority of our respondents – 38% – having been in the CD role since PCNs were formed, with 30% having had the job for four to five years.
A quarter also said they would like to stay in the role for five years or more but just over a quarter responding say this is a role they can only see themselves doing for one to three years.
The job takes time, with 28% of respondents spending 16 to 20 hours a week in the role. Another 38% of respondents said they spend more than 20 hours doing CD work. Only 16% spend up to ten hours which seems quite a shift from our 2021 report when this was the most common response.
Dr Barhey says his role as a CD has grown hugely, having gone from no staff employed by the PCN to 28 who need managing and training. ‘It is our job to set the strategic direction and the biggest problem has been having CDs who are trained in those leadership roles.’
It also appears from our survey responses that more appointments a week are being lost through CD activity. Our 2021 report found that CDs who reported losing appointments mostly set it at 16 to 20 per week, but in this survey, 10% selected 26 to 30 hours and 8% selected 41 to 45 hours, another indication that the role is increasingly taking up more time.
Dr Paul Evans, a GP in Gateshead without a PCN role, says their local experience is that over time, it has been increasingly difficult to attract CDs to the job. ‘There was a lot of initial enthusiasm, but while the workload has grown, the funding for the job has not. It has been taking up more time and impacting on the ability to do their practice job. It is a lot of work.’
The wider system
The survey does show a real mix of views among CDs about how PCNs are interacting with the wider system, including neighbourhood teams and ICBs. The vast majority (78%) are aware of what neighbouring PCNs are doing and 53% say their PCN is part of an integrated neighbourhood team.
Dr Alison Challens, CD of Chippenham, Corsham and Box PCN, Wiltshire, thinks the idea of integrated neighbourhood teams is good but needs to be adequately funded and she also commented that the development of them is ill-defined as ‘No one knows what an integrated neighbourhood team should be’.
While a majority do say there is good engagement with primary care and the ICB and they know who their representative is, 41% strongly disagree that this is better than it was with CCGs and 38% also feel strongly that ICBs will not ensure more funding is directed into primary care. CDs appear to have very split views on whether PCN same-day access hubs are a good idea, the future role of general practice and whether PCN funding should be moved into the core contract.
Funding
For 2024/25, funding into general practice increased by 2.23% or £259 million, which breaks down as £215 million for the core contract and £44 million for the DES. In all, 72% of CDs responding to our survey said the resources in the network DES were inadequate for the workload requirements. This is a similar response to our report in 2021. One respondent noted that finances were so tight there was nothing left for developing at-scale provision, while another noted that to run a good functional PCN is a huge undertaking that requires people who care to make it work.
Dr Challens said core funding of general practice also needs to increase – ‘it should be both, not either/or’.
‘There is less flexibility in the system so this reduces innovation due to lack of resources. We are having to reduce services to patients as we can no longer afford to provide them, we are being told that there is likely to be a further reduction in funding in real terms. Most PCNs are trying to ensure max funding and staff go to practices from the PCN as there is such a lack of funding and staff through core funding,’ she says.
The initial five-year PCN contract was subject to considerable changes throughout, in part due to the pressures incurred by the pandemic. It ended in March this year and NHS England put out a one-year version. This detailed several changes that CDs are largely positive about.
The two changes CDs were most positive about were releasing the capacity and access improvement payment (CAIP) at the start of the year rather than at the end and reducing the service specifications.
Most CDs do see a future for PCNs, with only 18% seeing scrapping them as a priority for the next government and 48% listing this as a very low priority. Much progress and hard work has been put into PCNs over the past few years not least being mobilised to deliver a nationwide Covid vaccination scheme. Far higher up the agenda for those leading PCNs is recruitment of more GPs and practice nurses, and better pay for all NHS staff. This is followed by reducing the elective care backlog, improving access to primary care for patients and better movement of patients between primary and secondary care.
Dr Jackson says: ‘I think it would be a tragedy to lose all the good work and staff we have put in place through PCN’s, but I understand the argument that more funding should be directed towards recruiting GPs and nurses.
‘I always describe it as like living in a house which is falling down – we need builders and scaffolders to come and repair it (and build an extension ideally) but all we can find in the Yellow Pages are landscape gardeners and trainee plumbers – skilled people doing a good job, but not really equipped to fix the problem.
Dr Stanley adds that to run a good, functional PCN is hard work and needs a huge skill set. ‘The successful ones have been led well but the work needed to make sure the needs are met of the participating practices is huge. I do want some acknowledgement that this has been a tough road and only made successful due to people like myself who cared enough to make it work.’