According to The Health Services Journal, the long-awaited NHS 10-Year Health Plan will include proposals for the introduction of two new Neighbourhood Health contracts which will be an ‘add on’ to the current GP contract: one covering a population of around 50,000 people, approximating to current Primary Care Network (PCN) coverage and presumably covering similar types of services to the current PCN contract; and one covering areas equivalent to multiple PCNs, held by a larger entity such as a GP federation, Community or Acute Trust, covering a population of around 250,000 and responsible for a wider range of services such as end of life care, community-based diagnostics or hospital at home services.
As we await the details of these proposals, it is instructive to look at what we already know about the provision of services across Neighbourhoods according to such ‘add-on’ contracts.
In 2019, the NIHR Policy Research Unit in Health and Care Systems and Commissioning started a project to explore the development and roll-out of PCNs. Interrupted by the pandemic, the project continued until 2022, with a variety of published reports and papers (Bramwell 2024; Checkland 2023).
Our study explored in detail the development of PCNs in seven PCNs in 6 Clinical Commissioning Group areas across England. We found significant variation in their geography, size, maturity and approach to their task, but we also found a number of common factors which may be relevant to the new contracts. Drawing on this and our wider research, we suggest the following issues for consideration:
1. PCNs were established with multiple, potentially conflicting, policy objectives. Different objectives suggest different policy and contract design choices, and confusion as to what is to be prioritised may impede progress. It is therefore important that any new Neighbourhood contracts are underpinned by clear and unambiguous policy objectives, which align with specific policy mechanisms.
2. Establishing collaborative working arrangements between practices and between GPs and other community-based providers requires significant managerial support. Whilst a large-scale entity such as a GP Federation or an Acute Trust will be well-placed to provide the relevant back-office, HR and data analysis needed, ours’ and others’ research suggests that, in addition, to this operational support, there will need to be robust commissioning arrangements to oversee the contract, hold the provider to account and set appropriate local objectives. This will require an entity with a sufficiently local presence and strong relationships to ensure the necessary trust and appropriate understanding of population needs; this is likely to need to be at Place level.
3. The ability of PCNs to work together internally and across Places (in multi-PCN contracts) varies significantly across the country, and is highly dependent upon trusting relationships, appropriate managerial support, available estates to house services and good local leaders. There is a danger that those areas with good local relationships and mature collaborations will be relatively privileged, exacerbating existing inequalities. Strong Place-based structures will be necessary to support those areas with less of a history of working together, and ICBs may need to differentially invest in areas that historically have struggled.
4. Investment needs to be carefully targeted, with additional focus upon supporting core primary and community services. Much of the funding associated with PCNs has been channelled via the Additional Roles Reimbursement Scheme, providing ring-fenced funding to support a wide range of additional staff working in general practice. At the same time, investment in community services has tended to be via ring-fenced initiatives such as Virtual Wards rather than by investment in the core contract. In primary care, some types of additional clinical staff (especially clinical pharmacists and advanced practitioners) have provided valuable services, but there is no evidence that such additional roles have alleviated the pressure on GPs or practice nurses. Our recent survey of GPs suggests that, when asked which types of clinical staff they would prefer to employ in the future, GPs overwhelmingly prioritise GPs and nurses above other clinical staff. In community services, the relative merits of initiating new ring-fenced initiatives such as Virtual Wards versus investing in core community services are unclear. In designing these new contracts, consideration needs to be given to the balance of funding between different types of services and staff to ensure that core services are strengthened alongside relevant innovations.
5. GPs are keen to work with their wider community-based colleagues in delivering services to support people to remain in their own homes. However, such activity sits alongside an increasing workload in both primary and community services. Continuity of care by GPs in the community has important positive effects on outcomes such as hospitalisation and mortality. It is important that new contracts are designed with this in mind, supporting rather than undermining GP-based continuity, with a focus on supporting practice-based patient care rather than focusing upon providing additional community-based services.
Thus, our research suggests that supporting and developing services in the community via neighbourhood-based contracts is achievable. However, both the design of any new or additional contracts and the infrastructure put in place to oversee and manage those contracts need careful consideration. Primary and community services are essentially local services, which need to be closely linked to local communities and delivered by professionals who know and trust one another. Research evidence suggests that successfully implementing these new contractual arrangements will require clarity of purpose, support for fundamental infrastructure and core service delivery, and mechanisms to protect and/or grow trusting collaborative arrangements and relationships at local levels. Their oversight requires skilled managers, who understand population needs and the landscape of local providers, and who have the authority and decision-making powers necessary to support service delivery and hold contract-holders to account. As ICBs merge to cover much larger populations, it is vital that meaningful structures are established within Places to do this important work.