As it stands, we know very little about the Single Neighbourhood Provider contract. The information provided about it within the 10-year plan is scarce. But what can we glean from the information that is there about its potential impact on PCNs and the PCN DES?
A single contract
First off, the plan is clear that it will be a single contract. There won’t be separate contracts for each of the different providers within the neighbourhood. It will be up to the different providers within the neighbourhood to work out and agree who who will be doing what, how they will be reimbursed and how they will be accountable for their performance.
This means there will not be a neighbourhood contract specifically for general practice, in the same way as the PCN DES functions. As such it will not be a like for like replacement.
In fact, the plan envisages (one assumes over time) that the neighbourhood will become an entity itself. Neighbourhood teams will be created that adjust their skill mix based on individual or population insights. They will operate out of Neighbourhood Health Centres. To facilitate multidisciplinary working the plan promises to, 'simplify and standardise staff policies and making training portable when staff move organisation' (pp106).
Collective delivery
The vision of the 10-year plan is not a lead contractor type arrangement, where one organisation takes the lead and then sub-contracts components out to other organisations, but rather a model whereby each organisation co-designs new collective service delivery models and then provides the relevant staff and resources to enable these.
There is also a sense of primacy for this (collective) single neighbourhood provider over the individual providers. In the neighbourhood health guidelines published in January the neighbourhood is envisaged as having responsibility for the delivery of modern general practice and for standardising community health services. The plan is not seeking the addition of a new provider into a neighbourhood to make delivery even more complex, but rather a collective function that oversees all the delivery (both new and existing) within the neighbourhood area.
Where does this leave the PCNs?
The NHS does not want to move backwards from practices working together as PCNs. It will be much more difficult for a neighbourhood to function if practices revert to operating individually rather than collectively via a PCN. At the same time, the delivery aspects of the PCN DES (that have been pretty limited in recent years) are reflective of the aspirations of neighbourhoods. Delivering enhanced access, implementing modern general practice, risk stratifying patients in accordance with need, and the requirement to collaborate with other local providers are all within the scope of what neighbourhoods are expected to do.
Over time we would expect the majority of PCN work to come via the neighbourhood rather than via any national contract. Most likely, then, is that the PCN DES will remain without changing or expanding much, but with its main requirement being to participate within the neighbourhood. How far this goes in terms of requiring a commitment of PCN resources (ARRS staff) to the neighbourhood remains to be seen.
The 10-year plan is also clear that the new contract will be a provider contract. It will be for the delivery of services. The requirement will be for the contract holder to bring together all those in the neighbourhood delivering relevant services and hold responsibility for delivery across all partners.
For PCNs as potential contract holders this is not going to be easy. Consider how difficult it is to ensure delivery across each of the member practices of a PCN. This difficulty is going to be multiplied once community services, social care, the voluntary sector and others are added in. GP practices understand how each other work (to an extent!), but the inside workings of these other organisations is often totally alien.
This delivery focus means that a much wider governance infrastructure than that of a PCN is going to be required. It will need to include the whole range of local providers to determine how services are to be designed, funded, staffed, implemented and monitored. This won’t replace PCNs, who instead will feed in as one component of this governance. But the challenge of putting this in place will be significant.
In fact, if PCNs want to become the contract holder then the task of establishing such an infrastructure is potentially the most difficult. This infrastructure will only work if relationships are strong and trust has been developed. The priority for now must be in building these relationships, because once the financial realities of a contract come into play this challenge will only get harder.
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.