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Primary care networks: NHS England under pressure to rein in its ambitions

BMJ 2020; 368 doi: (Published 21 January 2020) Cite this as: BMJ 2020;368:m230
  1. Gareth Iacobucci
  1. The BMJ

Waves of protest and resignations of doctors signed up to lead the new networks have sent the BMA and NHS England back to the negotiating table. Gareth Iacobucci finds out why

Mounting unrest over the proposed new terms and conditions for general practices to participate in primary care networks (PCNs) came to a head last week when GP leaders rejected an updated contract from NHS England.12

Practices that are part of a PCN are expected to agree new terms for the services they will deliver from April so as to receive extra funding agreed with NHS England designed to encourage closer collaboration in primary care. But draft terms and conditions published two days before Christmas caused alarm among many GPs, many of whom thought that too much was being asked of them.

The BMA’s General Practitioners Committee for England will now push for changes in response to the profession’s concerns, armed with what it called a “mandate” from GPs not to accept terms that would overload already overstretched practices.

The details of the government’s wider package of proposed changes to GPs’ contracts for 2020-21 remain confidential, but new conditions for participating in networks form a key part of the negotiations.

Unexpected demands

Doctors were concerned about specific requirements in the draft direct enhanced service (DES) that said that GPs would have to visit patients in care homes at least once a fortnight from September 2020, initiate structured medication reviews for patients most likely to benefit (including all those in care homes) from April 2020, and produce plans for providing anticipatory care and personalised care services by June 2020 at the latest. They must also have a clinical lead in place to support early cancer diagnosis from April 2020 and introduce a “safety netting approach for monitoring patients referred for suspected cancer” in 2020-21.

These diktats, many argue, are at odds with the locally driven collaborative working that GPs thought they had signed up for.

Across the country local medical committees, the bodies that represent GPs, raised objections to the plans, with many such as Birmingham, Nottinghamshire, and Cambridgeshire advising practices not to sign up to the DES without major changes.34

After a detailed analysis of the plans Berkshire, Buckinghamshire, and Oxfordshire LMCs estimated that each general practice would face a deficit of £105 000 a year on average as a result of the proposals, once clinical and administrative workload and other overheads were factored in.5


Significantly, clinical directors—the enthusiasts who had put themselves forward to run primary care networks—have also opposed the plans, with some stepping down in protest and others saying that only a major shift in both the tone and substance of the contract would stop the networks stalling from the start.

Suffolk GP Nick Rayner announced his resignation as a PCN clinical director on his Twitter page. “The level of work needed in these specs, with the speed of introduction suggested, makes me believe this is unachievable,” he wrote.6

Elsewhere, clinical directors representing 19 PCNs in Oxfordshire said that they would have no choice but to withdraw from the DES unless it was “substantially modified.” In their consultation response, shared with The BMJ, they wrote, “The centralised ‘one size fits all’ direction of these specifications are entirely contrary to the original locally led ethos of the PCN concept.”

And clinical directors of four networks in the Guildford and Waverley area also advised practices not to sign up unless the DES underwent “significant alteration,” because of the “overwhelming clinical and financial burdens” it would create.

The Oxfordshire clinical directors said that the service specifications should be “aspirations” rather than contractual requirements at this stage. They specifically called for extra demands on GPs’ time—such as stipulations on number of care home visits—to be removed, arguing that this was “not deliverable and contrary to the principle of multiprofessional team working,” unless more money was attached.

Way forward

NHS England and the General Practitioners Committee must now try to negotiate a deal that pleases both sides and salvages some of the enthusiasm and trust that has been lost since the service specification was published.

Matt Neligan, NHS England’s director of primary care and system transformation, has conceded on Twitter that NHS England “cannot afford to make [PCNs] over-ambitious.”7 Just before the consultation closed, he said that clinical directors and practice teams “should feel the final versions are deliverable and that they are aimed at the right areas.”7 But he added, “Equally we cannot afford to make them under-ambitious: the £4.5bn going into primary and community care in the NHS long term plan should create room to do more.”

Martin Marshall, chair of the Royal College of General Practitioners, said that the networks would succeed only if they had buy-in from GPs.

In a letter to NHS England’s chief executive, Simon Stevens, sent alongside the college’s response to the consultation, Marshall wrote: “The service specifications as they stand are overly prescriptive. Many PCNs are still in their infancy and should not be overloaded with work before they have had time to mature, or they will fail.”

Primary care networks: a timeline


  • January—The plan to create small networks of neighbouring general practices working together in multidisciplinary teams is unveiled as part of the five year GP contract deal.8

  • April—Primary care networks directed enhanced service (DES) is launched as part of the 2019-20 GP contract. The key requirement in the first year is for practices that sign up to join a network.

  • 1 July—Nearly all practices in England (99%) meet NHS England’s 30 June deadline to group together in around 1300 networks each serving 30 000 to 50 000 patients.9

  • 23 December—NHS England and NHS Improvement publish draft service specifications for the 2020-21 DES for consultation.1


  • 15 January—Consultation closes.

  • 16 January—BMA’s General Practitioners Committee for England votes not to accept the contract agreement with NHS England and condemns the draft DES specifications.2 The committee says it will return to negotiations with NHS England.

  • April—The 2020-21 DES is due to start.