At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future.   The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.