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PCNs – the new phase of Managing Growth

PCNs have now successfully established themselves, and are beginning to find their place in the NHS. They have usually engaged a number of ARRS resources, are normally delivering the COVID vaccines, and have, in general, achieved more in the last 2 years than many people believed possible. With 99% of practices now members of a PCN, many of the key organisations in healthcare are talking about how PCNs can deliver for them and their patients. In many ways it is hard to describe PCNs as anything other than a great success.

Take a step back for a moment to June 2019, when PCNs were set up.  The focus was on getting the whole of England moved simultaneously into PCNs so it was done quickly, informally and with little consideration to structure and future-proofing.  During this ‘Establishment’ phase, this informality was a strength and not a problem: risks were generally manageable and the money involved was not huge. However as PCNs have matured, the problems with this informality are becoming clear as PCNs are finding it challenging to scale-up. To continue to grow successfully PCNs are having to find new, more formal ways of working.

In our opinion PCNs now need to move on from the ‘Establishment’ phase, and into a new phase of ‘Managing Growth’

What are the key issues to be resolved in the phase of Managing Growth? 

1. The models of engaging the ARRS resources need to be formalised properly. Some of the scenarios that we are seeing frequently, include: 

  • who will cover my Clinical Pharmacist when she’s on maternity leave? 
  • my Occupational Therapist is under-performing and I want to move to an alternative provider – can I do so?
  • our Health & Wellbeing Coach has been shielding. We need him back in the Practice but the Federation (who provide him) says they will continue to support him to work from home. What are my options? 
  • we have a PCN Social Prescriber from a third party provider. She doesn’t fit in and is rude to patients, who have complained, so we’ve told the third party provider that we don’t want her any more. She has now alleged that we are discriminating against her – something we strongly refute. The third party provider also says we’ve got to pay for her until they find her somewhere else to work. 
  • who picks up liability in a redundancy situation?

Whilst you’re never going to stop these tricky employment scenarios occurring, the questions they are raising do not always have clear answers due to contractual uncertainty. The ideal position would have been that the questions were thought through beforehand and the answers built into contracts, but unfortunately most PCNs simply didn’t have the time to give this enough thought, and they now need to do so if they want to move into the Managing Growth phase with confidence.  We will explore this further in a separate blog. 

2. PCNs are going to have to develop management structures characteristic of a well-run business. For many PCNs, this is likely to lead to a decision to form some form of incorporated entity which will be run as a captive shared service centre. Such a company will act under instruction from the PCN, but will have separate legal form and therefore be able to better manage and contain risks. This could be a modified Federation or a separately incorporated PCN Company. If you missed it, you might be interested to view our V-blog on the subject of incorporating your PCN. 

3. PCNs and Federations need to figure out how to work together. Federations have typically been around longer and already have contracts and resources in their name. Some have been more successful than others but they are all GP-led, local businesses.  PCNs have all of the ARRS money to spend and are seen as the point of integration for future services. There is a risk that the two entities compete with each other, when usually the best answer will be reached through collaboration rather than competition. 

How Federations and PCNs work together will undoubtedly differ on a case by case basis and we have seen a variety of different models emerge, but what is clear is that if PCNs and Federations are allowed to compete, neither is likely to be as successful as they would be if they collaborated. 

We will discuss the different models for Federations and PCNs to work together in a separate blog. 

Next Steps

In conclusion, PCNs have become victims of their own success. Unless they quickly move into the Managing Growth phase and update their management structures and contracts to reflect working at scale, they are likely to find that problems begin to emerge. The list of potential issues is long: is there sufficient financial control around the PCN funds?; are there hidden tax liabilities such as VAT?; is the staffing model clear and documented?; the list goes on. 

In our view, the Managing Growth phase means looking at PCNs with a commercial mindset, and ensuring that they are managed and operated as efficiently as a well-run practice. Care must be taken to ensure that PCNs do not develop a ‘mind of their own’, but there is no reason why this should happen if proper governance structures are put in place. 

We will be covering more on this subject in future blogs, but in the meantime, if you have any queries relating to your PCN, please get in touch with Nils Christiansen on 01483 511555, email n.christiansen@drsolicitors.com