Five years after their introduction, GPs do not feel particularly positive about what PCNs have been able to achieve across several measures. Their concerns centre around funding for practices, the influx of new practice staff and a general feeling that pressures are increasing in primary care rather than being alleviated. Few of our respondents felt that PCNs had had a positive impact on their work, with most believing it had in fact destabilised general practice. Yet PCNs do seem to have forged greater connections between practices from the perspective of GPs. It is clear that pharmacists and physiotherapists are the roles that are the most welcome addition to the practice team.
It is perhaps unsurprising that GPs have strong views around funding given how squeezed practices have reported feeling. In all, 47% of our respondents strongly agree that PCN funding should be moved back into the core contract after 2024/25. Another 22% agreed but less vehemently. This supports the BMA position to end the network DES and fund practices through a core pot.
GPs are also sceptical that the ICBs that took over from CCGs in 2022 will ensure more funding is directed into primary care. Of our respondents, 64% strongly disagreed or disagreed this would be the case. A similar proportion also felt that engagement with commissioners had got worse since ICBs were introduced. Just under a quarter said they did not know if this had changed and less than 5% agreed that this had improved.
A key issue for ICBs and PCNs this year has been the implementation of same-day access hubs. This model is based on PCNs, or groups of PCNs, coming together to ‘deliver a single point of triage for same-day, low complexity’ appointments leaving GP practices with the longer-term complex cases. It was a concept first mooted in the 2022 Fuller Stocktake, a landmark review of primary care, which recommended that urgent on-the-day appointments be dealt with by a single care team based across a larger population. But there has been a backlash to this idea from GPs, including in North West London where the ICB had to step back from a mandatory imposition of the model. The opposition of GPs can be seen in our survey results with 21% agreeing but 58% disagreeing or strongly disagreeing they were a good idea.
Dr Paul Evans, a GP in Gateshead, is among those who believe strongly that this model will be ‘utterly disastrous’ and could lead to even more money being removed from the core GP contract. ‘It would fundamentally change the job and break the relationship with patients. It will also make training new GPs nigh on impossible.’
Practices are certainly under a great deal of pressure trying to meet ever-rising demand and with the long waiting lists for elective care having a knock-on impact. This is reflected in the finding that 69% feel that PCNs have been unsuccessful or very unsuccessful at freeing up GP time. Neither is there much support for the idea that PCNs have improved care for patients or access. In all, just 16% of GP respondents believe PCNs have boosted access and 14% think they have improved care.
There is a more even divide among GPs on whether PCNs have had success in recruiting and retaining ARRS roles – a quarter have a negative view and 32% report some success in this area with another quarter somewhere in the middle.
Professor Azeem Majeed, a GP in South London and professor of primary care and public health at Imperial College London, says more flexibility for practices would make the ARRS scheme more attractive. ‘Some practices might want to place posts within a PCN or a GP federation. Others may want to invest more in posts within their own practices. There should also be flexibility in the roles that are funded – for example, allowing ARRS funding to be used on GP and nurse posts,’ he adds.
Dr Neil Banik, a GP in Kent, agrees. ‘Some ARRS roles have proved to be particularly valuable like physiotherapy, dieticians, mental health. Especially valuable have been the pharmacists and pharmacy technicians embedded in practices. Others have not been helpful but adding advanced nurse practitioners and GPs would be a big help if NHSE agrees’.
Overall, 62% of GP respondents disagree or strongly disagree that PCNs have had a positive impact on their work and 55% believe that the introduction of PCNs has destabilised general practice.
Dr Evans notes that after five years PCNs should have been able to demonstrate that the influx of additional staff has reduced GP workload as promised. ‘We were told that the job would become more manageable, and this has not been true.’ Partly this is because those staff were given additional tasks through increasing requirements placed on PCNs. ‘There has been more work coming with them as a condition of their employment which has meant a lot of administrative work and supervision requirements.’
GPs with a PCN role
For those GPs who have a role within the PCN, perhaps on the PCN board or as a clinical lead in a particular area, there are also widely held views that PCN funding should be moved back into the core contract after 2024/25. Of these respondents, 70% agreed or strongly agreed this should happen. A quarter thought ICB plans for same-day access hubs were a good idea but 54% did not.
This group also had concerns about the interaction with ICBs with 64% disagreeing with the statement ‘my ICB is highly engaged with primary care’ and a large majority saying engagement with primary care had got worse since ICBs replaced CCGs.
Dr Steven Rossi, a GP and practice lead at North East Derbyshire PCN, says ICBs are ‘distant’, leaving PCNs feeling they have little influence on policy decisions. ‘The creation of PCNs could have been positive but has resulted in increasing diversion of monies from the practice unit.’
GPs with a PCN role were slightly more positive about PCNs having freed up GP time but still 58% thought they had not been successful in this regard. More than a quarter thought PCNs had improved patient care and 35% were positive about PCNs having improved patient access. However, a larger majority cited that PCNs had been unsuccessful in this regard. Just over half believed PCNs to have been successful in recruiting and retaining ARRS roles, the survey found.
Dr Zoe Archer, a GP and PCN care home lead in St Leonards-on-Sea in East Sussex, says in her experience the first contact physiotherapists and pharmacists have been a great support and have reduced GP workload. Care coordinators have also been a great help, she adds. But she appreciates that ‘everyone has their own interpretation of the contract so each PCN is different and it is hard to compare’.
The future
Whatever concerns are apparent among all GPs about funding streams into primary care and relationships with ICBs, a majority of those who have a role within a network do want to see the continuation of PCNs. In all, 42% of respondents did not want to see them scrapped. Yet the profession is divided with 37% responding that they did not want to see PCNs continue.
Dr Evans says despite wanting funding to move back into the core, he can see a future for PCNs as long as it is light touch and genuinely voluntary for practices to take part. ‘The PCN format does need to be more relaxed and high trust. There should be a pot of money for networks of practices to spend on projects from a long list of options depending on their population.’
Dr Archer says the creation of PCNs has identified local leaders who want to and are able to make a difference. ‘Individual practices are overwhelmed and struggle to get projects off the ground due to time restraints, despite their diligence and dedication. With a central team, studies and pilots can be looked at and actually get beyond the idea stage.’
She gives the example of a proactive paramedic home visiting team that improves the care of their elderly and frail patients as well as working to improve asthma care in children in the most deprived areas.
‘Overall, I believe PCNs have been a positive for local areas. Like with most things, the longer they are established, the more successful they will be.’