What did we learn from our development work with primary care networks in 2022?

During 2022, we worked with primary care networks (PCNs) all over England. Similar themes came up in different places, and we’d like to share some insights so PCN leaders can think about these issues in their own contexts. Integrated care system leaders and those commissioning PCN development may also find it useful to see the kinds of issues they may be able to support PCNs to address.

For general practice, PCNs and the rest of the health and care sector, 2022 was one of the most challenging years they have ever experienced. Everywhere we went, we heard about the impact on primary care staff of challenges including unprecedented demand, workforce shortages, and concerns, sometimes alongside cynicism and frustration, from being part of a political process and its impact on policy consistency over time. There was also shock and dismay about the deteriorating public perception of general practice. We heard how PCN leaders and their teams were navigating these challenges and have drawn out some common themes, followed by some reflective questions to help you reflect on your local situation.

What’s driving the strategic direction for PCNs?

PCNs seemed to be taking their strategic focus from a combination of three main factors; the balance of these factors varied from place to place.

• Responding to national mandates – some PCNs were very focused on meeting the latest requirement or milestone from NHS England. Sometimes this was because achieving these milestones confirmed where PCNs had already decided they were going. For others, a minimal compliance was as much as they could do given other pressures, while still ensuring they received the funding available thus providing greater stability. Others still were sceptical about the longevity of PCNs as a policy and weren’t yet prepared to invest in the wider agenda of embedding new ways of working.

• Using PCN resource to stabilise general practice – some saw PCN resources as a key means of shoring up capacity by supplementing and sharing resources, through, for example, implementing the Additional Roles Reimbursement Scheme (ARRS) roles comes with its own challenges. Some were setting up their PCN as a limited company to address the technical issues of working at scale such as, enabling ARRS staff to be employed and deployed more easily, working with employment agencies, managing tax, establishing effective governance and accountability for resources, managing estates, and increasing the diversity of primary care leadership. These issues add to the complexity of working in PCNs, and ICS leaders in particular could help PCNs by supporting the resolution of the more technical issues and problems rather than leaving each PCN to work it out on their own.

• Working with system partners and communities – some PCNs were deeply engaged in work with local authority and voluntary sector partners to embed primary care in the needs of local communities. For some, this was a way of trying to change the relationship between the public and the NHS locally, and tackle some of the causes of increasing demand and this meant they could see delivering national mandates as enabling what they wanted to do, rather than an end in itself. As such, this seemed to offer a more secure grounding for service development, especially for population health initiatives, though required more effort and creativity around roles and engagement.

The balance of priorities was often reflected in governance arrangements – for example, in how practice representatives on the PCN were authorised to act on behalf of their practices. Some representatives were fully authorised, some authorised on specified matters, and some were only able to observe with all decisions taken in practices, which seemed to relate to how unified PCN leaders were around purpose and ambition.

Reflective questions for PCN leaders:

• Where is the balance of your strategic focus against these three factors, and how is it changing over time?

• What do you gain from this balance, what do you lose?

• What changes would you like to make to the balance?

• How do your structures and governance processes fit with your strategic direction?

• What changes would you like to make, if at all, to your level of authorisation? How would this help or hinder your progress?

Maintaining relationships and managing disagreement

Making PCNs work requires ongoing negotiation of priorities and ways of working, which inevitably gives rise to conflict. Some groups we met were dealing with this conflict productively, discussing differences in their needs, perspectives, aims and authorisations. Generally, it seemed easier to work together when the stakes were lower, for example, when individual practices were less affected by PCN work, or when the support of the PCN was much needed and welcomed; the stakes seemed to greatly increase when practices felt their independence was being renegotiated, and especially when this threatened practice income.

Other groups seemed stuck in patterns of mis-trust or avoidant politeness, which often seemed to relate to actual or perceived differences in values that made it hard to reach consensus or follow through on agreements. This can happen because people come to work for a variety of reasons and therefore prioritise different things, for example, social justice, income generation, clinical quality, efficiency and sustainability, and these all featured in our conversations with PCN teams as sources of tensions.

Other kinds of difference emerged from team members’ personal circumstances. How people engaged with PCN working seemed to also depend on their previous experience of leading, or if they had young families, or were towards the end of their careers, or experienced themselves as similar to or different from their colleagues, for example, in terms of race or gender. Some relished the challenges of making a difference even in difficult circumstances, and some felt overwhelmed and worried about burning out. We found that these kinds of differences could be hard to talk about for fear of upsetting others, adding to colleagues’ pressures, appearing weak or feeling like an imposter. These feelings were more common than many people expected and getting them out in the open offered opportunities to think about new ways of working together and supporting each other.

Supporting PCNs in 2023

These are just some of the issues that we noticed, and with which we were able to offer development support. We will share our emerging learning about PCN working in 2023 as we continue to work with PCNs and primary care more generally through what will, no doubt, be another challenging year.