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High variation in PCN size poses risk to future performance, warns study

CCG merger

By Rachel Carter
12 November 2020

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More than 40% of primary care networks (PCNs) are not configured to the size recommended by policy guidance, a National Institute for Health Research (NIHR) study has found.

The study found that 30% of PCNs have a list size of more than 50,000 patients, 5% cover more than 80,000, and 7% are undersized – covering less than 30,000 patients.

Meanwhile 58% cover a patient population of between 30,000 and 50,000 – the PCN size recommended by NHS England.

The study, which looked at the 1250 PCNs in operation as of January 2020, also found a range of different organisational structures and some ‘peculiar’ network configurations.

This included PCNs that contain two ‘super’ practices but cover nearly 100,000 people, networks composed of a single practice, and those that are made up of 10 different practices.

On average, a PCN is composed of five practices, the report said, but at the extremes 34 networks comprise a single practice, while 77 contain more than 10 practices.

There were also marked differences in the sociodemographic and epidemiological pressures that PCNs face, the study found, with undersized PCNs serving higher proportions of people living in rural areas, predominantly older people, and people with associated healthcare needs.

The researchers concluded that this ‘substantial variation’ in the size, composition and characteristic of PCNs was likely to pose a risk to their future performance.

Relationship with commissioners

The study was carried out by the NIHR Policy Research Unit for health and social care systems and is the first independent national evaluation of the size and characteristics of PCNs.

It also found significant variation in how many networks sit under a single CCG, with examples of one PCN to three CCGs, and more than 42 PCNs to one CCG uncovered.

Only six of the 135 CCGs managed to get all PCNs in the targeted 30,000 to 50,000 list size, the study found, and in seven CCGs all PCNS are outside that expected range.

The researchers suggested that the variation in network size and characteristics may also have an impact on the relationships between PCNs and their commissioners – namely CCGs, who will be responsible for operationalising the PCN contract and monitoring performance.

‘The ability of CCGs to perform their core functions of purchasing, regulation, and financing may depend on the relative sizes of the PCNs that have emerged in their area,’ they said.

Practice-level satisfaction

The report also pointed to the recent merging of some CCGs into larger groups and the ‘uncertainty’ around their role in the newly developing integrated care systems.

It said that research has shown effective commissioning of primary care services requires detailed local knowledge of practices and populations – and relationships between PCNs and CCGs will therefore be ‘crucial’ in determining outcomes from this new policy.

The researchers concluded that the variation in PCNs is a consequence of the decision to allow practices to choose their local configuration, albeit with CCG oversight, which they said may have helped to ensure ‘good collaborative relationships’ between constituent members.

But little is currently known about practice-level satisfaction with local PCN arrangements or the strength of inter-practice relationships, they added, which is crucial to their future delivery.

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