The final PCN DES specification for 2026/27 includes an opportunity for ICBs to introduce what is termed a ‘local variation agreement ‘. This gives the opportunity for local areas to change the PCN DES to suit local needs, and to tailor it according to their own neighbourhood development programme. The big question is what the implications of these are for PCNs?
The timeline itself is interesting. When the changes to the contract were first announced at the end of February this was nowhere to be seen, which does give the impression that it was included either last minute or as something of an afterthought.
In fact, what happened was that the PCN DES specification was published at the end of March with no sign of local variation agreements, and then reissued on 30 April with a note explaining that local variation agreements were now to be included in a new version starting from 1 May.
On the 4 June Kent and Medway announced a local variation agreement for practices across Kent and Medway. Given all practices had until the end of May to opt out of the revised PCN DES, the timing implies that events in Kent and Medway were at least influencing national policy.
So what are we to make of it all? The first thing to say is that local variation agreements seem to be almost entirely positive for general practice. There are a number of safeguards in the revised PCN DES specification to ensure this. First is that each practice has to individually agree to the change. In Kent and Medway it looks like all the practices have a month to decide whether to change to the new local agreement or stick with the national PCN DES.
The PCN DES part B guidance also 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). So essentially more money has to be put on the table for general practice.
In Kent the full-year funding will apparently be £13.5m, broken down as £9.9m made up of both underspends in the primary care budget and new ‘left shift’ investment to support the shift of care from hospital to community, alongside £3.6m from existing ‘local enhanced services ‘ already commissioned by the ICB from GP practices.
On top of that, the ICB has to engage with the local LMC in making any changes, adding a further safeguard for local practices. The Kent LMC Chair has spoken very positively about the proposed changes, on the basis that it starts with a clearly defined cohort where neighbourhood care adds real value, it simplifies existing arrangements rather than adding new layers, and it backs general practice with meaningful investment and influence.
For general practice the huge benefit of a local variation agreement over a new SNP contract is that control remains with practices, who hold the PCN DES. It can’t go outside of general practice (which is the big fear with the proposed SNP contract). It is hard to see anyone within general practice choosing an SNP contract if given the choice between the two.
So the big question all this raises is if ICBs can put local variation agreements in place, do we even need Single Neighbourhood Provider contracts?
NHS England said in March, ‘We will also continue to work closely alongside providers and commissioners to provide further technical guidance for consultation on the implementation of novel SNP and MNP contracts… We will consult on how MNPs, SNPs, GMS and the Primary Care Network Directed Enhanced Service (PCN DES) will work together, including how PCNs might evolve into SNPs. ‘
But that was pre-local variation agreements. Are NHS England coming round to the idea that adapting the existing PCN DES might be a much easier implementation route than a whole new contract model (MCP contracts anyone?)?
Or are they worried about the current political uncertainty. We have a new Secretary of State, but for how long? If the leadership of the Labour Party changes, will there be a change in health policy direction? This seems even more likely if there is a complete change of government.
So, we may have to wait and see whether or not SNP contracts eventually transpire. In the meantime local variation agreements are concrete, are here now, and are built firmly on PCNs. As such, it seems they may well offer a very real lifeline to PCNs.
Ben Gowland is director and principal consultant at Ockham Healthcare, a think tank and consultancy. He was an NHS chief executive for eight years and has also been a director of Croydon Health Services NHS Trust. He established Nene Commissioning, first as a PBC organisation and then as one of the largest CCGs.