Ten Top Tips: Primary Care Networks

With an ultimate aim of supporting resilient and effective primary care, we look at some top tips when it comes to entering into a Primary Care Network (PCN) and the agreement that all members of a PCN will be required to enter into, namely the Network Agreement.  

1. Choose your constituent practices carefully

While there may be geographical constraints that make it difficult you should try to make sure the constituent practices and other members are capable of working with each other to meet the aims of integration as required by the Network Contract Directed Enhanced Service (DES). Bear in mind that a PCN’s area should make sense not only to its constituent practices but other community based providers and its local community.

2. Clearly map the network area covered by the PCN

The NHS commissioner must approve all network areas, but they cannot unreasonably withhold or delay their consent. The expectation is that they will only withhold approval where the network area and/or constituent practices create an extreme geographical spread (for instance, where constituent practices are located some distance apart).

3. It’s function before form

Crucially, there is no set way in which a PCN establishes itself to operate the PCNs’ functions. Despite this, the first tip is for PCNs to consider “function before form” as the legal structure you adopt must support your proposed operational model. While this may vary as the PCN DES and PCN itself develops, ask yourself a few questions. What are you looking to do with or via the PCN? How can you better support your patients through the network? And how, ideally, will the resulting aims/functions be delivered? These have to be the first and most fundamental questions.

Getting the right structure in place. Once you have discussed the suggested function of the PCN, it is then important for the PCN to discuss and agree its operating structure and model.
Who will employ staff? Who will deliver what services? Who will enter into any ancillary contracts on behalf of the PCN?

These are all questions to ask, and in answering them, we recommend you consider the possible implications when it comes to three main issues:

• Liabilities – where will that sit and does the party shouldering the liabilities have limited liability or unlimited liability status?
• VAT – will the proposal trigger any unforeseen issues with VAT (considered further below)?
• NHS Pensions – will the proposal cause any issues in terms of access to NHS pensions for any additional staff employed to work across the network?

​When thinking about possible structures it is worth remembering that the members of the network (whether constituent members or otherwise) are likely to operate via varying legal and operational models. Rather than reinventing the wheel, consider whether any of the existing structures and/or operating models are sufficient to operate the PCN functions.

5.  Take advice on the VAT implications

Take appropriate advice from your accountants/ tax advisors on the VAT implications of your proposed structure and operating model. NHS England has issued useful guidance entitled: “Contract DES and VAT”, which looks at VAT on the supply of services by a PCN and on the receipt and movement of PCN funding.

In doing so it:

• Anticipates that most supplies supporting the delivery of the PCN DES will be health care services and will be VAT exempt.
• Identifies that the movement of funds should not trigger a VAT charge, providing it is recorded in the Network Agreement that funds received by the nominee payee (on behalf of the PCN) are being received as a disclosed agent and that they are holding money on trust for the ultimate employer.

6. Adopt a clear and transparent process for the Clinical Director appointment

Given that a PCN must at all times have a Clinical Director (having oversight of, among other things, the leadership and strategic direction of the PCN), the PCN must have a clear process for their appointment. While there are various ways to do this, which include a nomination and election process, a simple vote at agreed intervals, rotation, or selection, it is strongly recommended that there is a default position in place to avoid a situation where the position is left unfilled.

7. Be clear on how the network will make decisions

Given that the network will develop to include various members (with core constituent and other members), it is highly likely that the decision-making process will change over time. As part of this, you may well find that while certain decisions may be reserved for the approval of the constituent practices and/or members (whether all of them, a set majority or a simple majority), various decisions are likely to be delegated to an executive board (and their sub-committees).

What works for you will depend on your circumstances, but we urge you to take on a decision-making model, which achieves a sensible balance between the three competing elements above. 

8. Dispute resolution and exit routes: don’t forget about the supplemental provisions

While the Network Agreement will cover certain items when it comes to disputes and exit routes, be clear on what supplemental provisions will apply for your particular PCN. With exit routes, is there to be an ability for practices to decide voluntarily to remove a member, if there is a breakdown in relationships? When a member decides they want to leave, will the remaining members be obligated to carry on the network? These are just two questions that will need to be discussed and agreed.

9. Don’t forget about your data protection and security arrangements

Members of the PCN will be required to open up their records (whether in whole or part) to achieve the ambition of integrated working (in particular to allow extended access across the network patch). This process will involve risks. While NHSE/the British Medical Association are preparing pro-forma data sharing and data processing agreements, it is recommended that PCNs consider other important elements, including the proposed flow of data, security arrangements, privacy policies and the processes for handling data breaches.

10. Do complete the Network Agreement

Make sure the Network Agreement is completed and updated when there are changes in membership, the operating model, the services to be delivered or otherwise. This includes the financial arrangements, workforce arrangements, service provision arrangements and arrangements with other non-constituent members. You should bear in mind that the document is split between national terms, which can’t be changed in many cases but can be supplemented, and locally determined terms, which are up to each PCN to decide.

We can help

This briefing note provides a brief overview of some of the top tips when it comes to starting a PCN.

If you need advice or support in relation to your PCN please do not hesitate to contact our team.