The recent consultation on the proposed SNP and MNP contracts is underpinned by the belief that it would be better if general practice worked at greater scale.  In fact, to some observers the main outcome of the proposed changes would be to achieve exactly that.  The question is whether this is something that general practice should go along with or actively resist?

While the consultation is at great pains to stress that the core GMS contract is out of the scope of the changes, it then goes onto include these goals in the overall aims (10):

• ensure that enhanced primary medical services can be commissioned alongside other neighbourhood services, where appropriate, within a single contractual framework (i.e. to shift the commissioning of enhanced services from individual GP practices to an at-scale organisation)
• enable an at-scale organisation, working closely with general practice within a neighbourhood, to coordinate the consistent delivery of neighbourhood health services across multiple neighbourhoods (i.e. to develop at-scale provider organisations managing delivery across individual GP practices)
• encourage sustainable primary medical services at scale, including GP-led provider organisations, which have the capability to hold and deliver population-based contracts (i.e. to create at-scale organisations that GP practices will be part of)

It is undeniable, then, that a consequence of the proposed changes will be to reduce individual GP practice autonomy.

The NHS, and in particular NHS England, works under the assumption that it would be better if general practice worked at a greater scale than it does now.  It does not make the case for this.  Instead, it operates on the basis that this assertion is self-evidently true, with no need to justify it.

It is interesting to note recent developments with acute trusts.  Only a few years ago, NHS England did the same thing with them.  They made it clear that it would be better for acute trusts to be operating at greater scale under group models.  It treated the benefits of operating at such scale as self-evident, and trusts were pressured into moving into these arrangements, without any formal policy to this end being put in place.

But now we are seeing these arrangements unravel.  As just one example of many, a review into the group arrangement between Hull and North Lincolnshire and Goole found that “the current partnership arrangements do not provide sufficient clarity of local accountability and organisational focus, while HUTH and NLAG predominantly serve distinct populations and work within different local health and care systems.”  As a result, the arrangements are now being undone.

Meanwhile NHS England distances itself from the failure.  Indeed, it was NHS England that commissioned the review of the arrangements in North Lincolnshire that found them to be lacking.

The lesson, then, is to ensure that any changes that are made stack up in their own right.  Making changes because that is what everyone else is doing or because it seems to be the overall policy direction is not a good enough reason in itself, and is one that is likely to come back to bite practices in future.

The experience of general practice operating at scale to date is that it works most successfully when it generates a real source of additional income for member practices.  Providing a tangible return for practices, whether it is directly via a dividend or additional revenue streams, is the key to success.

The main problem with the NHS England proposals is that while they detail how layers will be introduced above general practice, and so how the independence of individual practices will be taken away, they are extremely light on how (or even whether) any additional income will come to practices.

This is the critical flaw.  Why would practices give up their independence in the ways outlined with nothing coming in return?  While there are hints at how this might enable the much-vaunted shift from secondary to primary care, there are no promises.  A brief glance at history suggests this is not a funding flow that can be relied on.

Operating at scale through SNPs and MNPs is not self-evidently a good thing.  It is no good simply explaining how it will work.  A case needs to be made for it, one that would most likely state how it would result in increased income for practices.  But as it stands this is lacking, and without it the case for actively resisting these proposals is the one that feels most compelling.