COVID-19 has had a major impact on primary care in England. General practices have had to reorganise services, shift to remote consultations where possible, and learn to work alongside the virus to keep services running. The effects of COVID-19 and social restrictions to control the pandemic are likely to exacerbate chronic conditions and create additional health needs to be managed over the long term. Primary care also faces the significant task of vaccinating the population against COVID-19. The challenges ahead are enormous.

To further compound the situation, primary care in England may soon also have to contend with the effects of an NHS reorganisation. In November 2020, national NHS leaders in England published proposals for new NHS structures and legislation. The main aim of the changes – which could be implemented by 2022 – is to support NHS organisations to collaborate to improve care and manage resources. The proposals include removing requirements to competitively tender some NHS services, creating new NHS provider collaborations (networks of hospitals, mental health, primary care and community health care organisations), and establishing integrated care systems – area-based partnerships of NHS organisations and local government – as new statutory agencies (see Box 1).

The options set out by NHS England in its consultation paper spell significant change for clinical commissioning groups (CCGs). Even if there is no legislative change, NHS England wants all CCGs to merge to match an integrated care system footprint – a significant shift since there are currently 135 CCGs and will likely be 42 integrated care systems. But this is NHS England’s second choice. Its preferred option ushers in more sweeping reform – the end of CCGs, with commissioning functions folded into the new integrated care systems.

This causes uncertainty for PCNs. For better or worse (and we know from our research that there are examples across the spectrum), CCGs have played a central role in PCN set up and development. Under delegated arrangements with NHS England, CCGs carry out contract management of primary medical services, including distributing and monitoring most PCN funding. PCNs report to commissioners on network services – including progress on recruitment, achievement against service specifications, and on advances necessary to unlock additional funding from the investment and impact fund (incentive payments for networks based on delivery of defined services). CCGs are involved in the development, functioning and monitoring of PCNs. Uncertainty about the future of CCGs will inevitably have knock-on effects for PCNs, with potentially destabilising consequences.

There will be an impact on relationships too. PCN clinical directors have invested significant time and energy in developing working relationships with CCG officials, whose future roles are now in doubt or may change. Clinical directors risk losing these links, and will likely need to invest extra time in developing equivalent relationships and ways of working in whatever primary care commissioning and support system emerges from the remains of CCGs.

NHS England is clear that integrated care systems should ‘embed system-wide clinical and professional leadership’ through their local integrated care system partnership board, including ‘primary care network representation’. This makes sense: PCNs are important primary care ‘provider collaboratives’ (to use the terminology of the new proposals) in the current NHS landscape, funding and delivering an expanding range of local services. PCN representation on new integrated care system boards – along with primary care buy-in to the process of their development – will be essential if the proposed changes are to achieve their goal of enabling better integration between primary care, acute hospitals, and other services.

But this will not be easy. PCN clinical directors are not perceived as having equal standing with the clinical or managerial leaders of larger NHS providers, such as hospitals and mental health or community trusts – nor do they have as much time allocated to the managerial part of their role. Clinical directors are usually practising clinicians, working in an overstretched primary care system, and are typically funded as 0.25 whole-time equivalent for their PCN leadership role. In comparison with prior forms of primary care involvement in local planning and commissioning, there is no designated national funding for management support for PCNs (although some CCGs have sought to remedy this through PCN development funding), and the job description for clinical directors is wide-ranging and expanding. Many PCN clinical directors are also in their first leadership role and hence still getting to grips with management and leadership responsibilities. As emergent organisations in need of nurturing, PCNs will need additional management support (including funded managerial roles) so that their clinical leaders can carry out these various leadership roles effectively.

The new proposals from NHS England and Improvement do not specify what PCN representation on an integrated care system board will look like in practice, but it is likely that PCN clinical directors will not each have a say at this level, instead nominating one of their number to represent them. This is logical, as integrated care systems will cover populations of around 1–3 million people, and may include as many as 60 PCNs. The recently published BRACE Centre research highlights that PCNs are at varying stages of maturity, based on a number of factors. These include previous collaborative relationships in local general practice, the degree to which practices in a PCN share similar patient populations and working cultures, and variation in the level of management, leadership and support available from their CCG. There may be a challenge in ensuring genuine primary care representation, avoiding the likely tendency for system-leadership seats to go to clinical directors of the more influential and evolved PCNs in an integrated care system.

To ensure representation from all PCNs within an integrated care system, networks will likely need to work out an approach to fairly and collaboratively represent themselves. This might include establishing a group for PCN clinical directors within an integrated care system, from which one or more representatives are nominated to the integrated care system board, contribute views from PCNs to influence integrated care system policy, and report back to local PCNs and constituent practices. The price of increased collaboration and fairer representation across PCNs may be increasing bureaucracy, and taking time away from the core functions of PCNs at neighbourhood and community level.

Evaluation of the implementation and early development of PCNs reveals that they have established themselves swiftly and made good progress in getting new services under way in a challenging context. But PCNs are at risk of having too much expected of them too soon. Their fragile management and organisational arrangements may come under undue pressure if required to fulfil too many nationally specified service requirements, particularly when still establishing local arrangements to strengthen and extend primary care.

The impact of COVID-19 on PCN development has been significant. COVID-19 drew some PCNs together – for example in the creation of ‘hot hubs’ to offer rapid assessment of patients with suspected COVID-19 symptoms. Other areas fell back on previous forms of local collaboration instead – for example where an existing GP federation or out-of-hours cooperative was better able to provide a now-necessary service. The pandemic derailed the timeline for the introduction of some aspects of the PCN service specifications (some such as anticipatory care were delayed, while others such as enhanced care home support were brought forward). Furthermore, although money remains available to PCNs, the pandemic has made recruiting additional roles more challenging. In winter 2020–21, as consultation on the new legislative proposals continues, PCNs are playing a central role in delivery of the COVID-19 vaccine programme, with no clarity as to how long this may last, nor what impact it will have on core PCN activity.

Establishing PCNs as well-functioning networks – engaged with and responsive to the needs of their local communities, and working with other NHS, social care and voluntary sector providers – was always a challenge when working to tight timelines. The first year of the 5-year PCN contract was intended for network setup, but was interrupted by COVID-19. The pandemic has monopolised the second year of PCN working and seems likely to continue to impact the third. The legislative changes proposed by NHS England are intended to come into effect in 2022, but will likely cause disruption before and after implementation, as NHS managers and leaders become busy doing what they have done so many times before: planning and enacting a reorganisation of local governance, management and other structures. If the new proposals are implemented, the entire lifespan of PCNs, as set-out in the NHS long term plan, will be played out against a backdrop of disruption.The BRACE evaluation shows that while PCNs have mobilised quickly, they vary significantly in their organisational capacity and maturity. This has been described in previous studies of primary care organisational development. At best, disruption from the likely organisational changes in the NHS will be an opportunity cost for PCNs – time invested in dealing with the effects of system change that might otherwise have been spent elsewhere. At worst, system reform may destabilise fledgling PCNs, stretching the limits of their resilience.

PCNs are expected to deliver a set of nationally-defined ‘service specifications’ covering areas such as improving early cancer diagnosis, supporting better health in care homes, and reducing health inequalities. In addition to fulfilling their contractual requirements, PCNs are expected to contribute towards a loftier goal: a more integrated local health and care system, where the NHS works with local government and other community partners to improve population health and reduce inequalities. This vision is what attracted many early supporters of PCNs to become involved.

But with that vision comes a potential tension: how can PCNs be ‘of the neighbourhood’ and ‘of the system’, and play both these roles effectively? The new proposals suggest that in addition to delivering services at the neighbourhood level (30,000– 50,000 people), PCNs will be expected to play a central role in the new ‘place’ level in the NHS – a more formally established tier of health and social care partnerships based around existing local authority boundaries. The proposals do not contain detail on the role PCNs are to play at place level, but there is a clear expectation of expanded responsibilities.

NHS England’s proposals also create ambiguity about future relationships between PCNs and other health and social care providers. As collaborations between general practices, PCNs are already provider collaboratives. But the proposals also call for new ‘vertical’ collaboratives – for example between primary, community, mental health and acute hospital services in a given area. How PCNs will function within these additional collaborative arrangements – and whether doing so will create a further governance and management ask – is unclear. Experience suggests that local partnerships between health and social services agencies are complex to manage and deliver – with expectations often exceeding what is achievable (Glasby et al 2011, Hayes et al 2012).

In some respects, PCNs are caught in a bind. Fail to represent themselves effectively at system level, and PCNs may risk losing out when key decisions and resource allocations are made. But the need to have system-level representation will present an opportunity cost for PCNs. PCNs are small general practice collaboratives with big and expanding to-do lists, including the pressing need to recruit new roles to fulfil their contractual requirements, and needing to secure and sustain the engagement of local primary care teams. As such PCNs may find themselves drawn away from their original purpose – delivering local care at neighbourhood level, and shoring up general practice in the process. This is a dilemma witnessed on countless occasions with prior primary care-based collaborations, whether focused on commissioning (eg GP fundholding, practice-based commissioning, GP commissioning) or provision (eg personal medical services, primary care trusts).

The long history of attempts to reform NHS architecture features familiar refrains. Time and resource are expended on the process of organisational change, managers and clinical leaders are often diverted from the vital (and more difficult) work of changing and improving local services, and promised financial and service benefits are rarely delivered at the anticipated scale (for examples see Mays et al 2011, Edwards 2010, Exworthy et al 2016).

The NHS is good at coming up with new initiatives, setting up structures and governance arrangements, and responding quickly to central policy direction. It is much less good at letting new primary care organisations focus on local priorities and giving them the time (years not months) to get going and prove themselves, developing a true sense of local ownership of primary care development. And the NHS has struggled to identify and apply meaningful measures of success for newly forming primary care organisations. Much learning could be gained from New Zealand, where the independent GP-owned and led practitioner associations of the 1980s and 1990s continue to thrive, having morphed into primary care provider and support organisations with a strong focus on population health. These organisations have been able to pursue a mix of local and national objectives, received additional funding for expanding responsibilities, and continued as locally-led, GP-governed entities.

If the new integrated care proposals draw PCNs from communities towards the wider health and care system, and away from their core focus of developing and extending local primary care, there is a risk that primary care teams may come to feel that their PCN is no longer theirs, but is ‘of the state’. This risk will be magnified if the need to straddle both neighbourhood and place results in PCNs merging to become larger primary care provider organisations. The experience of primary care groups and trusts from 1999 to 2002 is salutary here, as is that of practice-based commissioning.

Change in the NHS landscape seems inevitable – and the emphasis on collaboration at the heart of the new proposals fits with the existing direction of NHS policy set out in the NHS long term plan. But the proposals also carry risks for PCNs. PCNs will need to find their place within newly established integrated care systems, while also continuing to develop and strengthen local primary care – all in the context of additional pressures created by COVID-19. To help address the risks described here, NHS leaders should consider the following as they further develop their plans for new NHS legislation over the coming months:

• PCNs will need to work together to identify the needs of primary care within integrated care systems and how they vary depending on local context. System-wide priorities must be balanced with the need to support locally-led changes by PCNs and their partners.
• Governance and decision making within integrated care systems should be inclusive and flexible enough to allow fair representation of all PCNs. This means developing mechanisms to avoid the risk of more mature PCNs dominating decision making, or variations in local context for PCNs not being recognised in system-level planning.
• Clarity is needed on how much control integrated care systems will have over PCN budgets and decisions (or how the level of control will be determined by local systems).
• Clarity is also needed on the involvement and role of PCNs in the new ‘place’ tier of the NHS. This includes defining which organisations are accountable for which population health needs, as well as the support given for any expansion of PCN responsibilities.
• Time and resources will be needed to support relationship building between PCNs and integrated care systems, particularly where there are currently strong working relationships between PCNs and CCGs (which may be lost in the new arrangements).
• The intended benefits of the new arrangements should be clearly articulated to PCN leaders and local primary care teams. A nuanced approach to measuring and monitoring the progress of PCNs within integrated care systems should be developed, allowing flexibility for PCNs to address local needs alongside broader system goals.

Acknowledgements

Rebecca Fisher is GP and Senior Policy Fellow at the Health Foundation, Judith Smith is Director of Health Services Management Centre at the University of Birmingham, Manbinder Sidhu is Research Fellow, Health Services Management Centre, University of Birmingham, and Sarah Parkinson is Analyst, RAND Europe. Hugh Alderwick is Head of Policy at the Health Foundation. The authors are grateful to Health Foundation staff, in particular Sean Agass, for their assistance with this publication.

Some of the research on which this article draws was carried out by the Birmingham, RAND and Cambridge Evaluation Centre (BRACE), which is funded by the National Institute for Health Research (NIHR), Health Services and Delivery Research programme (Ref: HSDR 16/138/31). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.