Seek independent advice

The purpose of this document is to provide guidance for independent contractor doctors who may be considering opting out of the PCN DES. It does not constitute legal or financial advice.

As ever, practices should seek independent expert opinion before deciding whether to opt out of the DES which may include legal and accounting advice, as well as contractual guidance from your LMC.

Know your rights

Practices have a right, written into the PCN DES Contract Specification, to opt out should they so choose. This can be under certain specific circumstances in year (4.9.7 of DES spec), in April at the renewal of the DES (4.9.4 of DES spec), or in the instance of an in year DES contractual variation (4.9.5 of DES spec).  

Opting out is not a breach of the core contract or the PCN DES, but if practices do not opt out their DES contract will automatically "roll over" and continue with NHSE's most recent changes to the DES in place.

The DES renewal opt out window is available during April 2023. We also anticipate an in-year variation of the DES later in 2023, which would trigger another opt out window.

Practices who opt out:

• cease providing the services and any other responsibilities or activities required through the PCN DES service specification including IIF performance indicators and extended access requirements.
• lose the funding currently provided through the PCN DES (a summary of PCN DES financial entitlements)
• might lose ARRS staff, depending on the employment relationship the PCN has with the ARRS staff, and any non-DES services ARRS staff are currently being used to provide, potentially increasing workload for practice staff or increasing staffing costs that would then need to be found from the practice's core contract funding baseline
• might still hold liability for ARRS staff, depending on the employment relationship the PCN has with the ARRS staff but would not receive the associated ARRS funding that currently supports their employment.

Whether to opt-out or remain in the PCN DES is an individual practice decision.

We encourage all practices who may be considering this question to reflect on the recent changes to the DES, as well as the current impact of the PCN DES on the practice and its patients.

Financial considerations

Outside of the core contract(s), the PCN DES is a major vector through which NHSE funds additional general practice and primary care services.

This means that there may be significant financial consequences associated with opting out, though practices could see this as a fair trade for the reduction in workload this choice may entail.

See a full list of PCN DES funding streams

Several of them are passed directly through PCN/practice accounts for specific purposes with little impact on practice finance. They have, therefore, been discounted for the purposes of this guidance.

The table below can be used to give practices a rough and ready sense of how opting out of the DES might impact practice finance:

Relevant PCN DES funding streams from April 2023

NHSE has published a ready reckoner, which can provide practices with a sense of funding across the entirety of the a GMS practice that is also a part of the PCN DES.

We recommend caution to practices using the NHSE ready reckoner to inform opt-out decisions; the tool takes a fairly narrow view of available funding streams and relies on a series of assumptions, including meeting 100% of IIF targets.

Workload considerations

We have heard from some practices across England that the PCN DES adds a considerable workload burden to GPs and other practice staff.

This may be as a result of direct involvement in delivering elements of the DES, such as, enhanced access, training and supervising ARRS staff, or as an incidental effect of delivering the DES e.g. administration, oversight or the general 'bureaucracy' it may entail.

Opting out means that the practice will not be responsible for the delivery of services under the DES, nor will they be required to participate in the administrative responsibilities associated with the specification.

Depending on how any given PCN DES is structured, opting out could free up significant portions of colleagues' time.

GPs and managers will have a sense of how much time is spent conducting DES activities, but for ease of reference we have captured key elements below:

• Enhanced access
• Medication Review and Medicines Optimisation
• Enhanced Health in Care Homes
• Early Cancer Diagnosis
• Social Prescribing Service
• ARRS (onboarding, HR processes etc)
• Cardiovascular Disease Prevention and Diagnosis
• Tackling Neighbourhood Health Inequalities
• Anticipatory Care
• Personalised Care
• PCN admin, paperwork, other

Practices could use the above list to estimate how much time is spend on these activities to arrive at an estimate of how much could be saved for simply delivering core general practice services, i.e. continuity of care, and limited additional services, which the contractors deem reasonable or viable to take on within their finite resources, if a decision is taken to opt out of the DES.

Workforce considerations

Practices considering opting out of the PCN DES should be cognisant of any liabilities they may incur with respect to ARRS staffing arrangements.

For ease of reference, affected staff may include:

• clinical pharmacists
• mental health practitioners
• podiatrists
• advanced practitioners
• paramedics
• first contact physiotherapists
• social prescribers
• care coordinators
• dieticians
• health and wellbeing coaches
• occupational therapists
• nursing associates
• pharmacy technicians
• physician associates

From October 2022, the PCN DES also includes GP Assistants and Digital Transformation Leads in the ARRS scheme. They are omitted here as practices considering opting-out will be yet to fill these roles.

Practices should review staffing arrangements to determine ongoing employment liabilities and determine redundancy costs if applicable.

These are most likely to arise where staff were employed under the ARRS scheme but not directly linked to the PCN DES, which will continue to operate once a practice has opted out.

Complexities may arise where ARRS staff are complementing a practice's core offer; this will require a degree of disentangling to distinguish between practice and PCN staff.

Commissioners may need to re-commission services to replace those which the practice will no longer be undertaking. It is likely that NHS England will seek to transfer staff via a TUPE (Transfer of Undertakings) to trusts or alternative providers to maintain as much of the PCN DES services as possible.  

Premises considerations

A lack of funding for premises has been an enduring criticism of the PCN DES. Many practices have made it clear that a lack of physical space has been one of the biggest obstacles to hiring ARRS staff. Consequently, some PCNs have secured extra space in the absence of additional funding through the DES.

For practices that have leased or purchased additional premises to implement the DES, thought should be given to the impact of an opt out. Practices will need to consider disposing of this property or putting it to use in a different manner – for example, reassigning the lease to another body in the PCN.

Practices may have reached local agreements with their PCN regarding the purchase or leasing of IT equipment, and should refer to these agreements to determine what to do with these assets.

Patient considerations

Opted-out practices will not be able to deliver PCN DES services to their patients and will have to rely on neighbouring practices within the PCN or other providers to do this on their behalf. This could jeopardise continuity of care for patients and possibly affect patient outcomes.

It might also entice patients to register with other practices who are delivering PCN DES services to their registered population, which would result in a loss of capitation.

Incorporated PCNs

Some PCNs have chosen to become incorporated; a practice seeking to opt out of an incorporated PCN may need to give thought to how to extricate itself from the corporate body.

In many cases, the partners, or other staff, of core PCN practices have become directors. These individuals should have regard to any relevant contracts or agreements relating to their role as director (e.g., a Directors Service Agreement), as well as the company's Articles of Association, which may have some bearing on resignation. Finally, if the practice is also a shareholder, shares should be disposed of in line with the shareholders agreement.

There is a generic process to follow to remove a director from an incorporated entity. Resigning directors must inform their fellow directors and relevant stakeholders, preferably in writing with effective date of termination, as well as submitting a TM01 form to the Companies House.

Opt-out process

If a practice chooses to opt-out, the Network Contract Directed Enhanced Service Contact Specification (2022/23) sets out the process for doing so:

4.9.5. Opting out of an in-year Network Contract DES Variation (1)

1. Where NHS England and NHS Improvement issues a Network Contract DES Variation, a Core Network Practice will automatically participate in that variation unless the Core Network Practice first notifies the commissioner of its intention to opt out of the Network Contract DES within 30 calendar days of the date of publication by NHS England and NHS Improvement of the Network Contract DES Variation.
2. If a Core Network Practice does not notify the commissioner in accordance with section 4.9.5.a, the Core Network Practice will automatically participate in the Network Contract DES Variation and the second sentence of section 4.2.5 will apply.
3. Where a Core Network Practice notifies the commissioner of its intention to opt out in accordance with section 4.9.5.a, section 4.9.2 will apply. Once the matters set out in section 4.9.2 are determined, section 4.9.3 will apply.

It also sets out the impact of opting-out:

4.9.3. With effect from the date agreed or, if not agreed, determined by the commissioner:

1. the opting out practice will no longer participate in the Network Contract DES;
2. in accordance with section 4.2.4.b the opting out practice’s primary medical services contract will be deemed to have been varied to remove the incorporation of this Network Contract DES Specification;
3. the opting out practice will no longer be a Core Network Practice of the PCN; and
4. where the PCN remains approved, it must remove the opting out practice from the Network Agreement before any changes to the PCN, such as the Network Area, financial entitlements, etc will take effect.

(1) The October 2022 opt-out window is considered an in-year DES variation opt-out window. Slightly different rules apply in April 2023, which is considered to be window for 'opting out of subsequent DES' - see 4.9.4.

Summary

The experience of practices across England of the PCN DES has been very variable. Some practices feel that it has provided great benefits, whilst for others the disadvantages outweigh those advantages.

This guide should not be used to replace formal accounting, legal or LMC guidance, but is designed to put practices in the best position to make the decision that works best for them and their patients.

The decision to stay or opt-out will be complex and individual, and will have ongoing effects on the practice, patients, and those practices remaining within the PCN. It is likely that a practice that has left the DES, or that was never signed up, would be able to join or re-join in the future should they choose to do so, and the DES specification outlines the process by which this is possible.

GPC England will continue to lobby and work with NHS England to ensure that all contracts and services are of benefit to our patients, and in support of a sustainable general practice in which  our practices and staff can flourish.