Primary care networks (PCNs) have been the biggest change in the primary care landscape in a decade. As set out in the 2019 NHS Long Term Plan, the goal was for PCNs to be a vehicle for investing in primary care and community services. As then detailed in the 2019/20 GP contract, practices were offered the opportunity to sign up to a Network Directed Enhanced Service (DES) requiring them to form networks of 30,000 to 50,000 patients.
Various funding streams were channelled through these new networks with the goal of bringing practices together to provide care for their local populations. While signing up to the scheme was voluntary, 98% of practices did so to make the most of the billions of pounds of additional funding delivered through several mechanisms, including a core payment per patient, additional funding for specific professional roles to support the general practice team and fees for providing enhanced care, the focus of which changed over time.
The first major task of PCNs came in the pandemic with the organisation of a highly successful mass Covid vaccination campaign. This galvanised PCNs around a single aim, speeding up the collective joint working. The pandemic also gave practices a push to move to online working. Since that time, general practice, just like the rest of the health service, has been struggling to recover, facing ever-increasing demand despite providing record numbers of appointments – four million more each month. In 2022, integrated care boards (ICBs) replaced the clinical commissioning groups (CCGs) with which primary care had developed a close working relationship and this too has caused a certain amount of flux.
Across PCNs, the biggest slice of funding has come through the Additional Roles Reimbursement Scheme (ARRS), which provides a resource for PCNs to hire pharmacists, physiotherapists, social prescribers and a long list of other roles, which has been added to over time, including most recently an enhanced practice nurse. More than 31,000 staff have been recruited into primary care with the vast majority coming through the ARRS, and this has sent shockwaves across the sector. The large shift in roles over a short period has created issues with staff shortages within community pharmacy and concerns over the role of the practice nurse. It has also prompted serious concerns among GPs about how the ARRS scheme may have undermined the GP role, leading to fears that salaried GPs cannot find jobs.
As an investigation by Pulse revealed recently, there has been much debate in particular about the role of the physician associate, how that is regulated and supervised, and what it has meant for patient care. The inflexibility of the ARRS scheme has also led to GPs reporting a lack of salaried and locum jobs with practices warning they cannot fund these roles as much as they would want to hire them. And despite the success that PCNs have had with the scheme, an investigation by Pulse PCN revealed that more than £45 million went unspent last year, with only a fraction reallocated. This relates to ongoing issues with finding suitably trained staff, lack of funding for the support and training of staff who are new to primary care and restrictions placed by NHS England on who can be recruited.
Enhanced access has been a clear focus for PCNs in the past couple of years. They are tasked with improving digital transformation to increase the options that patients have for contacting the practice and booking appointments with different members of the team. PCNs have also been responsible for providing extended hours in the evening and on Saturdays, coming up with individual plans about the sort of appointments that would best suit their population needs. Tackling health inequalities has been on the agenda since the start but has perhaps become less of a priority for those overwhelmed with demand. PCNs are also working within a wider context of a cost-of-living crisis and lengthy waiting lists for patients to access specialist care.
Since PCNs were set up, there have been dramatic changes to the wider system in which they operate. When the CCGs – created in 2013 to put the GP at the centre of planning for their local populations – were replaced by ICBS in 2022, PCNs raised concerns about getting lost in these larger structures where acute care may attract a bigger focus. There does seem to be some evidence that relationships between primary care and the wider commissioning structure may have become more disconnected, as well as concern that ICBs have not prioritised funding for primary care services, having been heavily focused on cutting secondary care waiting lists.
The State of Primary Care survey was answered by more than 1,700 healthcare professionals. This PCN evaluation focuses on how different professions rate and interact with PCNs and what impact they have on their profession.
About the survey
The State of Primary Care survey took place between April 29 and May 20 2024 across Pulse PCN and our parent and sister titles, Pulse, Healthcare Leader, Nursing in Practice, The Pharmacist, Management in Practice, Hospital Healthcare Europe and Hospital Pharmacy Europe.
There were 1,795 responses from health professionals. The majority – 72% or 1,294 – of respondents work in primary care in England. There were answers from across England with all 42 ICBs represented.
Of those who stated their profession (1,104) the majority were GPs at 37% (411). Nearly a quarter of these GPs (83) have a PCN role and a further 6% (65) of the total respondents are clinical directors (CDs) who are also predominately GPs.
PCN and practice managers were the next largest cohort of respondents at 21% (231) with 2% (21) of participants working as network managers.
Nurses were the third largest group to respond, representing 16% (179) of participants. The largest majority were general practice nurses at 11% (122) followed by community nurses at 3% (29) and nurses with an ARRS role at 2% (28).
Pharmacists made up 10% (114) of respondents, with the majority being pharmacists employed via ARRS 4% (44) followed by community pharmacists at 3% (31) and practice pharmacists at 2% (25).