The current agenda for general practice is disjointed.  On the one hand we are led to believe that neighbourhood working is the priority, but on the other hand the system is focussing heavily on GP access.  The problem is that we are now at a point where one is working against the other.

The real problem, of course, is that there is no money in the system.  General practice is on track to reach a new low in the percentage share it receives of NHS funding, despite the rhetoric around reversing this trend.  This means existing resources have to be prioritised.

The system is exerting huge pressure on practices when it comes to access.  A new target was imposed via this year’s GP contract, that all urgent patients have to be seen on the same day. No additional resource was provided to support delivery of this target.

Meanwhile, NHS England is ramping up the pressure on delivery against this target.  In its latest performance report it claims to be “preparing to improve operational grip” and is “facilitating tailored letters to practices based on their current delivery including noting potential for contractual action”.

At the same time, pressure on GP finances is greater than ever.  The continued list cleansing drive is a further crude mechanism for taking money out of the service, without any care for the consequences on the practices that it is affecting.

And in the midst of this stand PCNs.  They are being tasked with taking forward the neighbourhood agenda and supporting local neighbourhood delivery.  But in most areas no funding has been provided to support this.  So they are having to rely on existing PCN resources.

But what is happening is that the main source of PCN resources, the ARRS staff, are being shifted from supporting PCN neighbourhood schemes to tackle health inequalities or prevention, to supporting core practice delivery of the access targets.

The rules have been relaxed so that ARRS funding can be used to employ GPs.  Indeed, recently it has been relaxed even further to include locum GPs.  As a result practices are, quite understandably, pressuring PCNs to shift the use of ARRS funding from the social prescribing link workers, health and well being workers, care coordinators, and all of the roles that support many of the neighbourhood-style schemes to more GPs who can support practices with access.

In a recent podcast I was talking to the Clinical Director of one of the PCNs often used as a case-study for neighbourhood working who said that this was exactly the pressure she was coming under from her practices. The result will inevitably be a cutting back of the innovative and partnership-based schemes that are making a huge difference to the local community.

The system rhetoric is that neighbourhoods and access are perfectly aligned.  Access is the “bedrock” of neighbourhood working and is a base requirement for neighbourhoods to be effective.  Access is even one of the neighbourhood priorities in the neighbourhood guidance.

But this is clearly not true.  Neighbourhood working and access are not aligned.  Both require resources and both are pulling from the same pot.  In the absence of any new resources, or any mechanism to enable the left shift of funding as a result of neighbourhood schemes, they are now, and will continue to be, actively working against each other.