Angela Coulter

Angela Coulter, member of the Rethinking Medicine working group.

Publication of the draft service contract for Primary Care Networks (PCNs) has led to a flurry of negative headlines: “GPs in revolt”, “Flawed”, “Unreasonable and completely unachievable”, and so on. It looks as if the draft will be rejected out of hand, and NHS England and Improvement will have to go back to the drawing board.

The proposed contract specifications were intended to improve care for people with long-term conditions – a key priority for the NHS. The draft contract set out ways in which this could be achieved through offering more personalised anticipatory care. The specific means for achieving this are underpinned by evidence and prior experience, so why has the plan sparked such negative reactions?

There’s no need to rehearse the pressures on primary care caused by workforce shortages, inadequate funds and low morale. This is not an ideal time to ask people to change the way they work, especially when couched in contractual requirements implying additional time-consuming work and yet more bureaucratic box-ticking. 

But personalised anticipatory care does not have to be burdensome if it’s well-supported. It shouldn’t be seen as an extra service that’s nice to have but not essential. On the contrary, it implies a fundamental transformation in the way primary care is delivered. Achieving it will mean providing training and support for all involved, ensuring the desired changes are feasible and straightforward to implement, clearing away the bureaucratic undergrowth and allowing for experimentation and reflection – the antithesis of a contractual approach.

Take the example of shared decision making. It’s a core skill for personalised care, and an essential component of care and support planning, and medicines optimisation – two of the initiatives that PCNs are supposed to promote. Many clinicians believe that informing patients about options for treating or managing their condition(s), asking about their preferences and making decisions together, takes far too long and cannot be accommodated within a standard consultation. Yet the evidence refutes this, with no increase in time taken when shared decision making is supported by decision aids that make it easier to carry out.

Personalised anticipatory care does not have to be burdensome if it’s well-supported.

Personalised care is now seen as an essential attribute of a high quality health system. By pooling lessons from various international efforts to help clinicians have better conversations with patients, we can see that success depends on having the following attributes in place:

  • leadership from professionals, patients and policymakers.
  • infrastructure, such as training courses, adaptable IT systems, patient information and social marketing to explain the need for change.
  • practical support, including facilitation, coordination, demonstration and funding.


This underlines the need for a comprehensive approach, including adaptation to local circumstances, testing and refining as you go along. The Year of Care approach has shown how it can be done, and the rewards can be considerable, both for patients and for clinicians. 


Pushing fledgling PCNs too far too fast is playing with fire. And relying on contracts and metrics to initiate this type of fundamental change is missing the point. Presumably contracts are required to enable the funds to flow, but I wish they could have waited until the battle for hearts and minds had been won.

To be fair, the policymakers at NHS England do have plans to put in place many of the essential supports listed above. Once these have been rolled out, the burden on PCNs and on practice staff should look far less daunting. But the response to the draft contract specifications has set them back. It’s crucial that they get it right next time. Otherwise the clamour to throw the baby out with the bathwater will grow ever stronger.

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