In a tumultuous couple of weeks for the NHS the government announced that NHS England is to be abolished, and that Integrated Care Boards (ICBs) are to reduce costs by 50% by October.  What will these changes mean for general practice?

The BMA does not come out either in favour or against the abolition of NHS England, seeing the potential of the removal of a layer of bureaucracy but expressing concern about the disruption such a change will bring.

The staff affected have already not been well treated by the way the communication has been handled, and the political point scoring around reducing bureaucrats has exacerbated this.  It is inevitable that the changes are going to cause a huge amount of disruption, and I very much feel for those caught up in the middle of all this.

My sense, however, is that the biggest impact on general practice will not be just the turmoil of the coming months.  In the medium to longer term these changes could impact the freedom of local areas, fundamentally change local contracting arrangements and potentially have significant implications for the future of the independent contractor model.

1. The Freedom of Local Areas

The Department of Health insists the changes will lead to more devolution of powers and responsibilities to local areas.  However, concerns have been raised in certain quarters (in particular outgoing ICB Chair and former Secretary of State Patricia Hewitt) that overbearing performance management by ICBs and NHS England regional teams will simply be replaced by (worse) micromanagement direct from the centre.

What remains to be seen is whether as part of these changes the government is prepared to relinquish the notion of “grip” that came to the fore 20 years ago and support local innovation and autonomy, or whether it will simply seek to centralise the mechanism for exercising control.

The status of general practice as independent contractors has largely protected it from the control the NHS machinery inflicts on front line providers and local area teams.  Those GPs who have engaged with CCGs and ICBs will have experienced it, and it is something that has undoubtedly contributed negatively to both NHS performance and staff experience in recent times.

However, it is likely to become much more relevant to general practice because this freedom (or control) will apply to the new neighbourhoods that emerge from the forthcoming 10 year plan, to which the future of general practice seems inextricably linked.  Even in his letter to the GPC confirming the government’s commitment to securing a new substantive GP contract Secretary of State Wes Streeting said he was committed to, “deliver meaningful reform to establish a modern general practice at the heart of a neighbourhood health service”.

The desire for central control has stifled local innovation and freedom to act, and diverted huge amounts of time, resources and energy away from driving local change.  The changes could be positive and mean neighbourhoods have a freedom to shape services to meet local needs that has been absent in recent times, or it may have the opposite impact. We will have to wait and see to find out.

2. Local Contracting Arrangements

The biggest direct role of NHS England and ICBs concerning general practice has been contract management and support via the local primary care teams.   After their dismantling in 2013 when responsibility was shifted from PCTs to NHS England, and then shifted to first CGGs and subsequently ICBs, it is not a surprise these have not been in great shape in recent years (although some have done remarkably well despite all of this).

There has been more of a focus by the centre on the contract itself in recent years, e.g. when primary legislation was passed in May 2023 changing the contract to require practices to respond to patient requests on the day the request is received.  In this year’s planning guidance NHS England promised a new “Commissioning and Transformation Support Programme” to support ICBs to “create the right conditions for improving general practice, including contractual management and transformation”.  This was backed up by Secretary of State condemning “unwarranted variation” in GP performance and exhorting ICBs to target practices who are “coasting”.

So, the question is whether these latest cuts mean all of this will fall by the wayside, or will we see a more distant, impersonal and potentially harsher contract management approach being taken towards general practice?

Meanwhile it is neighbourhoods that have been tasked with improving access to general practice.  What we need to look out for is whether it will be neighbourhoods as they emerge who take on the role of local general practice contract support, or whether we will see a shift to a more formal style of GP contract management from larger more remote ICB teams.

The demise of NHS England and shrinkage of ICBs may even lead to local providers taking on the GP contracting role.  The HSJ has suggested that the changes will inevitably lead to the rise of “local care organisations”, with a lead provider responsible for neighbourhood services.  The predominance of acute trust CEOs on the NHS England transition executive, along with the model already operating in new NHS CEO Jim Mackey’s home patch of Northumbria, may signal a shift to these being led in many places by the local acute trust.

3. The Independent Contractor Model

The lack of anyone to manage the GP contract even raises the question of what the consequences could be for the independent contractor model.  In what is unlikely to be coincidental timing, the Nuffield Trust have just published a report questioning the longer term viability of the partnership model, and called for alternatives to be urgently explored.  The Secretary of State has seemed more positive in recent weeks about the model, but has in the past suggested a wider range of options also need to be considered.

Even if the core national contract remains into the longer term, it does seem there is the very real possibility that local enhanced service contracts will be picked up and managed by lead local providers overseeing the new neighbourhoods.  This in turn could well accelerate the development of other models for general practice, as local areas seek to replicate the type of model in existence in Northumbria.