Adam Fazakerley is a GP and health systems leader in Sussex, he believes in the urgency of creating a more sustainable health system.
Becky Jarvis has been a GP in Brighton for over 30 years and worked in mental health commissioning as a clinical lead for 10 years.
Primary Care Networks (PCNs) were created to enable neighbourhood level relational care. In East and Central Brighton, we succeeded in delivering such care but discovered a fundamental tension along the way. In the first of three articles we explore why the original vision for neighbourhood working proved difficult to deliver and what we learned along the way.
Context: Intention Meets Reality
GPs are increasingly managing social problems shaped by inequality, isolation, and wider socioeconomic pressures.
GPs are increasingly managing social problems shaped by inequality, isolation, and wider socioeconomic pressures.1 We felt that using medical appointments to address loneliness or poverty, required structure, capacity, and multidisciplinary support. PCNs were designed with this challenge in mind. They introduced new roles and the mandate to work with community partners. Their ambition was clear: to create networks of local practices to help tackle the social determinants of health, whilst sharing infrastructure and staff.2
In practice, however, that ambition collided with the day to day realities of workload, estates, funding constraints and the operational pressures of general practice.
The Structural Tension
From the outset, PCNs operated within an economic paradox. While network funding increased, core funding to GP practices remained flat.3,4,5 At the same time, workload continued to rise. PCNs were tasked with supporting practices and creating neighbourhood working).
The result was a system trying to do two things at once:
• Stabilise core general practice under pressure
• Deliver long-term neighbourhood transformation
Faced with short-term need, many PCNs used their staff and resources to fill gaps in an already stretched system. As clinical directors of East and Central Brighton PCN, we tried to do both: to stabilise and transform.
East and Central Brighton: A different approach
Serving nine practices across some of Brighton’s most under-resourced communities, we recognised early on that much of our demand was driven by social complexity.1,6
Our predecessor, with support of the practices, made the decision to situate our PCN within the community. What began as a small team of four grew to around 45 staff working across the network in a variety of roles. We had social prescribing, frailty, pharmacy, mental health, patient engagement, benefits advice, and a paramedic visiting service.
Alongside this, we commissioned voluntary and community sector (VCSE) partners to provide targeted support for local needs, including addiction services and community-based practical help.6
Managing the tension
Embedding all roles within practices was not feasible. Estates constraints were significant, and equitable distribution across nine practices was impractical. Instead, we developed community-based multidisciplinary teams, coordinated centrally within the PCN. This approach allowed us to:
• Reach patients who were not engaging with traditional services
• Work more relationally, outside the constraints of short appointments
• Address social drivers of demand directly
• Reduce administrative burden on practices through central coordination
It also helped relieve pressure on GPs, particularly for patients with complex, non-medical needs. This approach formed the foundation of our ability to lead on neighbourhood working.
What were the Successes?
1. Improved Engagement: We were able to engage populations who had previously been underserved. Relationships with community partners and our integrated care board (ICB) strengthened.
2. Better Teamwork: Multidisciplinary working became the norm, and patients were informally supported by a range of professionals, reducing the need for strict referral routes.
3. Positive Feedback: Feedback from both patients and partners was positive. We were providing services for complex frail patients, many of whom were housebound.
What were the challenges?
At the same time, significant challenges emerged.
1. Lack of infrastructure: The PCN contract funded staff, but not the infrastructure required to support them. There was limited provision for shared space, coordination, and management. As a result, teams spent considerable time organising care rather than delivering it.7
2. Visibility and attribution: Because teams operated largely outside practices, their impact was not always immediately visible to GPs. In a system driven by activity, work that prevented future demand or improved wellbeing was harder to demonstrate.
3. Limits of commissioning: While we could commission VCSE services, we lacked the capacity to manage contracts or evaluate outcomes robustly. This meant some benefits were likely under-recognised, and alignment with shared goals was variable.
Neighbourhood working remains a compelling vision, but without the protected infrastructure, flexible commissioning, and stable core services needed to anchor it, transformation will always be precarious.
Lessons learned
1. Neighbourhood working requires infrastructure: Workforce alone is not enough. Shared estates, interoperable IT, and funded coordination are essential to making integrated care function.7,8
2. Transformation cannot take place within a system that is struggling with daily capacity: When general practice is under pressure, resources intended for innovation will inevitably be drawn into sustaining core services.3,5 This is a system-wide issue, not a local failure.
3. Access is dependent on how care is delivered: Community-based models enabled us to reach different populations, which were often those with the greatest need but the lowest engagement with traditional services.6
4. What gets measured by stakeholder shapes activity: Activity remains easier to measure than outcomes. If neighbourhood working is to succeed, metrics must evolve to reflect prevention, equity, and collaboration.6,9
PCNs created the conditions for neighbourhood working but did not fully equip systems to deliver it
The ambition was right, but the infrastructure, flexibility, and protected capacity required were often missing.
In East and Central Brighton, we found ways to begin bridging that gap, through community-based teams, central coordination, and strong partnerships. This did not resolve the underlying tensions, but demonstrated what is possible within existing constraints.
Neighbourhood working remains a compelling vision, but without the protected infrastructure, flexible commissioning, and stable core services needed to anchor it, transformation will always be precarious. Future policy must recognise that neighbourhood teams cannot simply be layered on top of a system already under strain.2,7,9
In our next article, we will outline the further steps we took towards neighbourhood working.
References
- Marmot M, Allen J, Boyce T, et al. Fair Society, Healthy Lives. London: Institute of Health Equity; 2010. Available from: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review [Accessed 8/5/26]
- Baird B, Beech J.Shahsway Primary Care Networks Explained [Internet]. London: The King’s Fund; 2020. Available from: https://www.kingsfund.org.uk/insight-and-analysis/long-reads/primary-care-networks-explained [Accessed 8/5/26]
- NHS England. NHS performance report 2023–24 [Internet]. London: NHS England; 2024. Available from: https://www.england.nhs.uk/long-read/performance-report-23-24/ [Accessed 8/5/26]
- NHS Digital. General practice workforce statistics [Internet]. London: NHS Digital; 2024. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-december-2024 [Accessed 8/5/26]
- https://www.health.org.uk/features-and-opinion/blogs/a-new-government-must-prioritise-general-practice-here-s-how [Accessed 8/5/26]
- Drinkwater C, Wildman J, Moffatt S. Social prescribing. BMJ. 2019 Mar 28;364:l1285. DOI: 10.1136/bmj.l1285
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Parkinson S, Smith J, Sidhu M. Early development of primary care networks in the NHS in England: a qualitative mixed-methods evaluation. BMJ Open. 2021;11(12):e055199. doi:10.1136/bmjopen-2021-055199. PMID: 34972718; PMCID: PMC8719211.
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Checkland K, Bramwell D, Warwick-Giles L, Bailey S, Hammond J. Primary care networks as a means of supporting primary care: findings from qualitative case study-based evaluation in the English NHS. BMJ Open. 2023;13(11):e075111. doi:10.1136/bmjopen-2023-075111. PMID: 37989389; PMCID: PMC10668191.
- Fuller M. Next steps for integrating primary care: Fuller Stocktake Report. [Internet]. London: NHS England; 2022 . Available from: https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf [Accessed 8/5/26]
Featured Photo by Ben Guerin on Unsplash
