A primary care network consists of groups of general practices working together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations. Networks would normally be based around natural local communities typically serving populations of at least 30,000 and not tending to exceed 50,000. They should be small enough to maintain the traditional strengths of general practice but at the same time large enough to provide resilience and support the development of integrated teams.

General practice is at the core of any PCN and £1,799 billion will be made available to GP practices in PCNs via the Network Contract DES by 2023/24 as well as an additional £14,000 each year that a typical practice will receive from April 2019, in return for their initial and then continued active participation in a Primary Care Network.  We are committed to 100% geographical coverage of the Network Contract DES by 1 July 2019.  PCNs will need to sign up to the Network Contract Directed Enhanced Service to be able to benefit from the investment to be allocated through it.

Primary care networks will be expected to have a wide-reaching membership, led by groups of general practices. This should include providers from the local system such as community pharmacy, optometrists, dental providers, social care providers, voluntary sector organisations, community services providers or local government.

Primary care networks will provide proactive, coordinated care to their local populations, in different ways to match different people’s needs, with a strong focus on prevention and personalised care. This means supporting patients to make informed decisions about their own health and care and connecting them to a wide range of statutory and voluntary services to ensure they can access the care they need first time. Networks will also have a greater focus on population health and addressing health inequalities in their local area, using data and technology to inform the delivery of population scale care models. As an example, this will be supported by the introduction of a new Tackling Neighbourhood Inequalities Service Specification to be delivered by PCNs signed up to the Network Contract DES from 2021/22.

Primary care networks will also help ensure that the NHS designs support and services to get the best possible value out of their funding for their local communities.

As of 30 November 2018, 93.4% of practices across England considered themselves to be part of a network. This is based on CCG responses to the monthly GP Forward View Monitoring Survey.  In light of the more detailed information included in the Long Term Plan and “Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan” about the role and requirements of PCNs, groups of practices will be reviewing their position.  PCNs will exist formally once they have met registration requirements for the GP contract Network Directed Enhanced Service (DES) and been approved by their commissioner. The Network DES will start from 1 July 2019.  Information is available in the recently published “Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan”.

Membership of a primary care network will be down to local agreement, dependent on the needs of the local population. However, each PCN should have a boundary that makes sense to: (a) its constituent practices; (b) to other community-based providers, who configure their teams accordingly; and (c) to its local community, and which typically covers a population of at least 30,000 and not tend to exceed 50,000. Each PCN will be required to appoint a named accountable Clinical Director who does not have to be a GP. Information is available in the recently published “Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan”.

The core characteristics of a PCN are:

• Practices working together and with other local health and care providers, around natural local communities that geographically make sense, to provide coordinated care through integrated teams
• Typically a defined patient population of at least 30,000 and tend not to exceed 50,000
• Providing care in different ways to match different people’s needs, including flexible access to advice and support for ‘healthier’ sections of the population, and joined up care for those with complex conditions
• Focus on prevention and personalised care, supporting patients to make informed decisions about their care and look after their own health, by connecting them with the full range of statutory and voluntary services
• Use of data and technology to assess population health needs and health inequalities; to inform, design and deliver practice and populations scale care models; support clinical decision making, and monitor performance and variation to inform continuous service improvement
• Making best use of collective resources across practices and other local health and care providers to allow greater resilience, more sustainable workload and access to a larger range of professional groups.

A GP federation is generally a group of practices that come together to deliver services whereas a PCN is a broader collaboration of practices and other health and care partners’. There is also published material from the BMA and RCGP about the different structures federations can take. These are not mutually exclusive and can co-exist to deliver a broader set of integrated out of hospital services for their local communities. Work is underway to better understand/set out the relationship between PCNs and federations using practical examples.

PCNs will typically serve populations of at least 30,000 and not tend to exceed 50,000. This is because they need to operate at a level which maximises economies of scale, but is small enough to ensure understanding of local population needs. PCNs can be bigger than 50,000 if they meet all the registration requirements under the Network Contract DES but in reality, may require organising themselves into smaller neighbourhood teams within the 30,000 to 50,000 population size. But it would create extra bureaucracy to require each of these internal teams to register as a separate network.

The guidance around PCN size is provided to help areas early in their journey of developing PCNs have some structure to work around. It is anticipated that those PCNs with very different sizes will be able to articulate a clear reason why; and how they are working in a network way with other partners.

PCNs will typically serve populations of at least 30,000 and not tend to exceed 50,000. This is because they need to operate at a level which maximises economies of scale, but is small enough to ensure understanding of local population needs.

In exceptional circumstances commissioners can agree to vary the 30,000-population floor most likely where there is a low population density across large rural and remote areas.

PCNs can be bigger than 50,000 if they meet all the registration requirements but in reality, may require organising themselves into smaller neighbourhood teams within the 30,000 to 50,000 population size.

The Network Contract will be implemented as a Directed Enhanced Service (DES) for GP practices. It will start from 1 July 2019, subject to primary care networks having met the registration requirements and been approved by their commissioner.  The DES Directions and DES Enhanced Contract Specification will be published by 31 March 2019. Supporting guidance and information will be published at the same time.

The Network Contract will be a Directed Enhanced Service held by GP practices, and underpinned by a Network Agreement between them. Practices with an in-hours (essential) primary medical care contract will be eligible to sign-up to the DES as part of their network. Federations cannot hold the Network Contract DES.

If a PCN doesn’t have a core set of GPs and practices, it isn’t a PCN – the Network Contract DES is a mechanism for flowing funding to PCNs, and general practice is expected to be the  core around which PCNs are built upon.

The Network Contract DES is contractually practice-based. It will be the collective responsibility of the PCN GP practices to deliver.

Every practice will have the right to join a Primary Care Network in its CCG, but the Network Contract DES remains voluntary. Close working is needed between Clinical Commissioning Groups and Local Medical Committees to help ensure 100% coverage is achieved.

In the highly unlikely event that a practice doesn’t want to sign-up to the Network Contract DES, its patient list will nonetheless need to be added into one of its local Primary Care Networks to ensure all patients have access to network services. That PCN then takes on the responsibility of the Network Contract DES for the patients of the non-participating practice through a locally commissioned agreement. The practice remains responsible for delivering core contract services to its registered list,

From 1 April 2019, a new SFE Network Participation Payment will be introduced, payable for practice activity to support the delivery of network services to its population, thereby achieving 100% coverage of the population within a PCN. A typical practice will receive over £14,000 each year (this is a practice size of approximately 8,000 patients). This payment will only apply to practices who sign-up to the Network Contract DES on an ongoing basis as an active participant. The payment will be payable from 1 July 2019 following commissioner approval and will be backdated to 1 April 2019.

We anticipate that practices will work together in geographically coterminous areas, rather than because of historic performance. The ongoing development of PCNs should be reinforced by strong system leadership, which should dispel some of this fear locally.

All Primary Care Networks will have a Network Agreement, even those with one large practice. This is because the Network Agreement is both the means by which the Primary Care Network describes how the practices will work together to discharge the Network contract but also how it will partner with non-GP practice stakeholders. It is needed for the PCN to claim its financial entitlements and deliver national and local services to its whole Network list and area. Delivery and achievement of the contract requirements will depend on collaborative working by network members.

As set out in Investment and evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan, there will be a registration process whereby PCNs will need to be recognised and meet minimum requirements to sign-up and participate in the Network Contract DES and be eligible to claim financial entitlements. The core characteristics of a primary care network are set out in the PCN reference guide (available in draft at https://future.nhs.uk/connect.ti/P_C_N). Practices should refer to the reference guide to help guide the development of their network and to help provide further details about some of the core components of a PCN. The guide is intended to give a sense of the starting point for a network and each step along the way as practices begin to work together.

It is a requirement of the Network Contract DES that every primary care network would have a named accountable Clinical Director who does not have to be a GP. However the governance structure within a PCN will be determined locally and recorded as part of completing a nationally mandated Network Agreement. We anticipate there will be a variety of staff engaged in the structure of each network.

Each PCN will be required to appoint a named accountable Clinical Director. A description of the role is available in the recently published “Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan”. Work is currently underway, as part of the national support offer, to review the core characteristics and skills needed for this role and further information will be made available shortly.

A Primary Care Network must appoint a Clinical Director as its named, accountable leader, responsible for delivery.

Together, the Clinical Directors will play a critical role in shaping and supporting their Integrated Care System. They will help ensure the full engagement of primary care in developing and implementing local system plans to implement the NHS Long-Term Plan. These local plans will go much further than the national parts of the Network Contract DES in addressing how each ICS will achieve the commitments set out in the Long Term Plan.

In recognition of the importance of this role and as a contribution to the costs, each Network will receive an additional ongoing entitlement to the equivalent of 0.25 FTE funding per 50,000 population size. The amount will vary in proportion to network list size. The legal entitlement under the Network Contract DES starts from 1 July 2019.

PCNs are a critical building block for the development of the NHS to a population focus for health and care improvement. They need to align with and support work at neighbourhood, Place, and System levels. For this reason, it is important that whilst they should develop in a way that meets their specific local needs, they must also provide a consistent level of support and integration with the wider health and care system. The maturity matrix is designed to enable local innovation within a national framework. All systems should use the provided maturity matrix in the first instance to assist with assessing relative maturity of their networks. We are aware that in some instances, building on this maturity matrix and adapting it for local use has led to positive engagement of all networks, which we would encourage.  All PCNs will need to consider the evolving requirements of the Network Contract DES as they mature and plan for this.

The maturity matrix is not an assurance vehicle for PCN performance. It is a key tool to be used to assess both current maturity and provide direction to developing PCNs. PCNs will need to consider the evolving requirements of the Network Contract DES as they mature and plan for this.

The Network Contract DES will support practice/partnership to achieve collaborative working and the Network Agreement will set out how they will do this.

Joint working between practices is nothing new.  The new Network Contract DES provides significant funding to support practices to formally work together, irrespective of their individual motivations for doing so.

There have been a number of reports conducted into the sustainability of primary care networks all over the world.

A selection of these can be found below:

• National Association of Primary Care (2015). Primary Care Home: An Overview
• Dunbar R (2010). How many friends does one person need? London: Faber and Faber
• Ham C (2010). GP budget holding: Lessons from across the pond and from the NHS University of Birmingham HSM
• Martin S, Rice N, Smith P (1997) Risk and the GP Budget Holder York: Centre for Health Economics
• Bachmann M, Bevan G (1996) Determining the size of a total purchasing site to manage financial risks of rare costly referrals: computer simulation model British Medical Journal

The development of PCNs does not take away the need for a local neighbourhood ‘presence’ in terms of a GP practice, it enables a local focus set in the context of collaborations that bring together those services that need to be provided at scale. A PCN approach will drive continuity of care for those patients with complex long term conditions as ultimately it will ‘free up’ GP time to focus in more complex areas whilst using alternative practitioners to see those with routine needs. A PCN’s role is about looking at the population health needs and this is will involve working with patients and the public to understand their needs and requirements to deliver the best solutions to meet these.  This will involve balancing for example choice and convenience of services and the scale the services are delivered at.

To read about the research completed on continuity of care and primary care networks

• How can we get better at providing patient centred care: does continuity matter?
• Divided we fall: getting the best out of general practice.
• Personalising care for patient sub-groups in general practice.

We are working with local teams to develop an appropriate approach that helps provide the right level of assurance. This will initially focus on confirming practices are all part of a PCN by the end of June 2019.

CCGs (or NHSE local teams for the small number of CCGs without delegated primary care commissioning), will be responsible for overseeing the Network Contract DES registration process and ongoing assurance of PCNs’ delivery against the requirements of the DES. A new Primary Care Network Dashboard will be introduced from April 2020 to support the assurance process. CCGs, working with LMCs, must ensure all practice lists are covered by a Primary Care Network in their area for the provision of network services.

The PCN development offer will provide support to the system to meet policy commitments and enable the creation of effective and sustainable PCNs. It will have a focus on providing capacity to local teams and building capability in two key areas:

• Leadership development (including relationship management)
• Organisational development (including team development and change management)

Delivery options for the development support offer are still being agreed.

We have carried out significant engagement with the system and continue to do so as we develop the PCN offer.  Our aim is to ensure that we secure ‘the right’ support and that it gets to ‘the right’ place based on need. The support must add value and not duplicate offers that are already available.  Understanding the local context is essential to this, hence the focus on engaging with the system and regions.

The process to access the PCN development support offer is still in discussion. However, it is likely that funding will flow to ICS/STPs for them to draw down specific development support from a nationally agreed framework based on their local needs.

The national team have engaged with a range of stakeholders which has included local LMC representatives, regional teams, CCGs and primary care staff, including GP federations and practice managers in designing the primary care networks development programme.

Any funding specific to PCN development will need to be used based on the needs of the local system. Nationally we would support using the development funding to support integrated working, however the decision about this will be for local determination.

All practices and partners within a PCN, in line with local context and need.

Work is underway to determine the best way to deliver the development support needed by the system. It is likely that there will be a ‘menu of support’ covering a number of elements which will be provided by a variety of providers.

This is about giving teams the space to discuss the sort of environment that they would like to work in, what values are important to them so that local teams can develop a culture whereby staff feel valued and supported and are aligned with the values of the NHS. By behaviours we mean leading by example, whatever role you may be in, it is about treating others with dignity and respect.

Support is already being provided to ICSs to help them build population health management capabilities to turn data into actionable insight for primary care networks and integrated teams. The learning from this early work is being bought together to provide a range of practical resources and further advice and support. To access the practical guidance and learning to date, please email england.STGPHM@nhs.net to join the PHM Network.

Yes, this is integral to the development offer that is being developed based on feedback from the recent workshops and is exactly where we want to focus resources.

The Time For Care Programme is continuing in 2019/20 and beyond. The programme will continue to focus on quality improvement and change management working with practices, groups of practices and PCNs depending on local need.

NHS England has worked with NAPC to provide support to local areas to develop Primary Care Homes (PCH).  The NAPC Primary Care Homes approach has created a number of strong demonstrators of how excellent PCNs will work in the future and has informed our approach to designing PCNs, but it is not the only model. The NHS England PCN development programme will be designed to offer a range of support whereby ICS/STPs can draw down support relevant to them and their local PCN needs. Local systems should work with the partners who can best support the approach to PCN development that fits with local ambitions.

The national PCN programme team are linking with a number of stakeholders to ensure all future planning is aligned.

Further examples and case studies are available on the NHS England website at www.england.nhs.uk/pcn. Information is also being shared via weekly webinars involving presentations from local areas who are already working as part of primary care networks. Full details are listed on the above web page.

Additional resources and guidance related to the development of primary care networks are also available on the primary care networks FutureNHS site at https://future.nhs.uk/connect.ti/P_C_N/grouphome and further documents are being produced. Please email england.pcn@nhs.net to request an invitation to join to platform.

Please email england.pcn@nhs.net and a member of the team will be in touch.