Two sides of the system: primary care networks and integrated care systems

The NHS Long Term Plan is about thinking big on collaboration. PCNs are the “building blocks” of ICSs and will be the means by which improvements are made in primary care – the hope is that PCNs will improve the range and effectiveness of primary care services. According to the King’s Fund, the formation of PCNs is “an opportunity to bring greater balance to local systems by strengthening the voice of primary and community care”.

Ambitions for primary care networks and their role in the wider system

Primary care networks went live in July with some 1259 PCNs covering all patients in England but it is still unclear how they will fit within their integrated care systems.

There is no blueprint for how PCNs will integrate into the wider health care system. That said, there are certain uniform characteristics that will exist between integrated care systems in terms of encouraging the development and integration of PCNs and the involvement of PCNs at the three recognised levels that an ICS will operate, namely: the neighbourhood level, place level and system level.

In terms of encouraging integration, the uniform characteristic will include:

• The need for every PCN to have a clinical director who will feed into and support their ICS.
• The need for ICSs to establish a lead (at director level) to support the development of PCNs.
• Establishing a partnership board drawn from commissioners, providers, PCNs, local authorities and third sector organisations.

In terms of the involvement of PCNs at the three recognised levels that the ICSs will operate:

• At a neighbourhood level, GP practices will continue to provide core services and will, via their networks, work with partners in voluntary, community and social care sectors to deliver new services.
• At a place level, PCNs will integrate with hospitals, mental health trusts, local authorities and community providers to provide integrated care.
• At a system level, the clinical directors will participate in decision-making on strategy and funding.

Time will tell whether the aspirations for PCN integration into the wider system will be realised. If this is to occur as hoped, then there are already two emerging issues that need to be considered and addressed.

The first is that it is unrealistic for every clinical director to have a seat at the table when it comes to feeding into the ICS. For primary care to have an effective and uniform voice at ICS level, then PCNs and/or clinical directors in any distinct area should be looking to implement a process for choosing a manageable number of individuals to represent them at ICS level.

The second is to ensure that clinical directors, who are largely practising clinicians with other work pressures, are given the time and training to help them spearhead change for the practices they represent.

Finally, and most importantly, the “relationship between ICSs and primary care networks must reflect a commitment to a two-way conversation”. Both have equally important roles to play. 

How to approach future commissioning given the unknown primary care networks service specifications

This poses a real challenge for commissioners. As the PCN Directed Enhanced Service develops over the next five years we will see the introduction of seven national service specifications set out in the network GP contract in return for the new funding.

These include the provision of:

• Structured medicines review and optimisation (to apply in full from 2020/21).
• Enhanced health in care homes: to implement the vanguard models tested (to apply in full from 2020/21).
• Anticipatory care requirements for high need patients typically experiencing several long-term conditions joint with community services (to commence in 2020/21 and develop over subsequent years).
• Personalised care: to implement the NHS Comprehensive Model of Personalised Care (to commence in 2020/21 and develop over subsequent years).

The problem for commissioners is the lack of specific detail on what the specifications will cover. Given this uncertainty, there is a very real risk that the GP contract will start to incorporate services that commissioners have already commissioned or are looking to commission. In the absence of any subsequent national commissioning approach, commissioners will need to be alive to the possibility of double commissioning a service. To this end, thought should be given as to whether any contract award is subject to a contractual right to terminate elements of the service requirement within commissioned contracts if it is subsequently found that the PCN DES duplicates the same.