Primary Care Networks (PCNs) are networks of GP practices collaboratively working together and with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas to achieve benefits for patients and the wider health system.
The King’s Fund’s ‘Primary care network’s explained’ describes how most PCNs are geographically based and, between them, cover all practices within a clinical commissioning group (CCG) boundary. There are some exceptions where there were already well-functioning networks that are not entirely geographically based. Some networks cross CCG boundaries. Practices within PCNs continue to be commissioned to provide services by their CCG/NHSE&I.
Questions have been asked as to how Patient Groups Directions (PGDs) can be used across PCNs.
For the provision of NHS services PCNs are not recognised within current legislation as a body that can authorise PGDs. This remains the responsibility of their NHS commissioner (e.g. NHS England, the CCG or Acute Trust or other appropriate authorising body commissioning the service being provided by the PCN).
When a service is being offered across a PCN (i.e. all the member practices working together to provide a combined service to patients across the PCN) it may be that staff from one GP practice are managing patients registered with another practice/s within the PCN. If a registered healthcare professional (HCP) is approved to operate under a PGD within the legislation and their own practice then it can be considered that that HCP is also authorised to operate under the same PGD for the treatment of patients across the PCN provided this has been agreed by the PCN. In this model consideration should be given to ensuring appropriate CQC registration is in place (https://www.england.nhs.uk/wp-content/uploads/2019/03/pcn-faqs-july-2019.pdf) and ensuring appropriate indemnity cover is in place with their provider/s.
Where such use of a PGD across a PCN occurs the PCN should ensure that any agreement is written within a Memorandum of Understanding (MOU), Service Level Agreement (SLA) or similar, agreed to by all PCN member practices and approved by the clinical governance group of the PCN. Such agreements may be made on a service by service basis or as a single overarching agreement to cover all combined services where PGD medicines are involved. Where PCN wide services are being offered consideration should be given to responsibility for stock ordering, storage and any required transportation of stock and disposal including ensuring compliance with Wholesaler Dealer legislation.
In addition to the factors outlined above the MOU/SLA or similar should include aspects such as agreed training requirements, record keeping and incident reporting. Any financial aspects and how any practice leaving a PCN is managed should also be considered and included in a MOU/SLA or similar document.
Many of the principles outlined above are included in the PGDs in Complex Commissioning Scenarios Q&A. This Q&A should be referred to if PGDs are being used by a service the PCN has commissioned from an external provider (e.g. a physiotherapy service being commissioned by a PCN from an acute Trust).
Example in practice
All the practices within a PCN wish to develop a single Musculoskeletal Service (MSK) clinic within one of the PCN member practices. One of the service’s provisions will be the administration of intra articular injections to patients registered with practices within the PCN. The clinic is run by a registered physiotherapist employed by one of the member practices on behalf of the whole PCN.
- Which PGD is to be used?
The MSK service will need to produce or adopt a PGD for the administration of an intra articular injection, with the agreement of the CCG, who will be commissioning the service and who will be responsible for authorising the PGD. The PGD will need to meet all the legal and good practice requirements outlined in the NICE guidance.
- Who can operate under the PGDs and how are staff authorised to operate under the PGDs?
The physiotherapist who will administer the intra articular injections within the clinic must be authorised as competent to operate under the locally approved PGD. This authorisation must be undertaken by the employing practice. The employing practice will be responsible for any educational and training requirements and to ensure that appropriate indemnity insurance is in place.
- Does there need to be a formal agreement between the PCN practices for this to take place?
A MOU, SLA or similar should be in place between the practices detailing the arrangements that have been agreed This should include those points outlined above and state that a registered Health Care Practitioner authorised and legally able to operate under a PGD within one practice within the PCN can also operate under that same PGD when managing patients registered with other practices within the PCN for the purpose set out in the MOU/SLA or similar.
Additionally, this should include details of how records will be maintained, any incidents recorded and how stock will be requisitioned/funded, stored, and if required monitored and disposed of, as should any additional financial aspects and staff indemnity cover.