The new NHS obsession is integration.  How can we join everything up so that it better meets the needs of patients?  But could this obsession spell the end of the independent contractor model for general practice?

The shift to integrated care systems is not helping general practice.  The internal market was the prevailing system in the NHS from 1991 when it was first introduced, right through until 2019 when the Long Term Plan was published.  Technically it continued until the new legislation was enacted last year, but to all intents and purposes we have been working under the new system for the last 4 years.

While the internal market was in place the system wanted to find a way to make general practice the “purchaser”.  Numerous different mechanisms to make this happen were attempted, starting with GP fundholding (remember that?) back in the 1990s, right through Primary Care Groups, practice based commissioning and then finally Clinical Commissioning Groups.

But the shift to Integrated Care Systems has stopped all of that. The strategic question the system is trying to answer is no longer how do we make general practice effective purchasers.  Instead the question now is how do we integrate general practice with the rest of the system.

The NHS Long Term Plan proudly states as its number one action in chapter one:

“We will boost ‘out of hospital’ care, and finally dissolve the historic divide between primary and community health care”

The problem with general practice (according to the system) is that it is too separate, too independent and not linked up enough with community and hospital services.

Plan number one to tackle this problem was the introduction of Primary Care Networks (PCNs).  The NHS Long Term Plan, the first place the idea of PCNs appeared, introduced them like this,

“GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff”

I sometimes wonder if the first part of that description (“to deal with the pressures in primary care”) has been forgotten, but that aside it is clear the intention of PCNs is as an enabler of integration.  The original PCN DES stated that after one year a requirement to include collaboration with non-GP providers would be added to PCNs, but then Covid came and this never happened.  Instead the Fuller report (which as you recall was entitled, “Next Steps for Integrating Primary Care”, another clear pointer to the goal the policy makers are now trying to achieve) introduced the idea of Integrated Neighbourhood Teams, as the new souped-up PCN model to enable integration in a way that PCNs so far have not.

But will networks and neighbourhoods succeed in the goal of integrating general practice with the rest of the NHS?  If they don’t then the default is most likely a structural solution.  The structural solution would be to nationalise general practice and make it part of the NHS.  Then the integration box could be considered ticked.

This is why politicians on both sides of the political divide in recent years have suddenly started talking about the end of the independent contractor model.  Sajid Javid when he was Secretary of State got the ball rolling when he claimed in a Times article that nationalising general practice was a way to reduce hospital admissions.  Then earlier this year Keir Starmer said the GP partnership model was “coming to the end of its natural life”.  They, along with certain NHS leaders, are attracted to structural integration solutions because they are clear and can be imposed, even if they do nothing to develop the relationships that are required to make integration effective.

The last we heard there was not going to be any forced nationalisation of general practice.  But the question of how to integrate general practice remains uppermost in the minds of policy makers, and unless PCNs and integrated neighbourhood teams start making more progress soon a heavier push for general practice to be made a full part of the NHS seems inevitable.