This is the second in a series of five blogs where Ben is considering the issue of independence in general practice. This week he looks at the distinction between statutory bodies and independent contractors and asks whether the difference is of any consequence.

Can independent contractors be trusted?

During the 2017 Christmas holidays, when you would have thought attention may have been focussed elsewhere, there was something of a debate as to whether organisations that are not NHS statutory bodies, but rather ones that contract with the NHS, can be trusted.

The debate focussed on the pre-cursor of the new favourite (Integrated Care Systems) which was Accountable Care Organisations (remember them?). For example, Dr Phil Hammond, a doctor, radio presenter and NHS commentator, said,

“I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver.” (via Twitter, Jan 1^st)

Unfortunately, this debate brought the position of both GP practices and GP federations under the spotlight. If this is true for Accountable Care Organisations, is it not also true for GP organisations?

There is a fine line between being in the NHS and working with the NHS. Back in 1948, amidst the protracted negotiations required to start the NHS, a deal was brokered whereby GPs would not become salaried employees, but rather remain independent, providing services via a national contract with the NHS. This means GP practices provide NHS services, but are not NHS organisations, and “independent contractor” status was born.

Does the distinction between a statutory body and an independent contractor matter? At first it mattered little, but times have changed since 1948. In the 1980s the Conservative government privatised some of our national industries, including steel, railways, airports, gas, electricity, telecoms and water. Although the NHS survived the cut, the purchaser provider split was introduced in 1990. Ever since, fears have remained this was the first step in a plan to privatise the health service, and anything not a statutory NHS body is treated with suspicion.

Over 25 years later, we now approach the end game of the purchaser provider split, in a strange closing manoeuvre whereby the Health and Social Care Act of 2012 seemingly opened the NHS up to more competition, but in practice the NHS itself has closed competition down with a focus on integration through the Five Year Forward View. Fears that accountable care organisations were a Trojan horse to enable the privatisation of the NHS led to their re-badging as integrated care systems.

At some point these integrated care systems will take on a population budget. It seems that rather than allow them to do this as “independent contractors”, the government is prepared to legislate to enable new types of statutory bodies to be created.

Where does that leave general practice? Is the current review of the partnership model an attempt to shift general practice from independent contractor into some form of statutory body status? Are the new, semi-mandated GP networks the first step towards groups of GP practices as statutory bodies? Will the public tolerate at-scale GP organisations that are not statutory bodies, or will the anti-ACO sentiment shift its focus towards federations and the like?

The currency of the new world is trust. People trust their GP, more than they trust their local NHS organisation, and much more than they trust national (statutory) NHS organisations. Being a statutory part of the NHS won’t make the public trust GPs any more. Our experience of CCGs should at least teach us that. My sense is the benefits of being independent (to GPs and to the delivery of health care) outweigh the costs and challenges.

GP practices know it is not the technical difference between an NHS statutory body and an independent contractor that matters, but rather what they do, and the trust they build with the people they serve. The same will be true for at scale general practice organisations. And for integrated care systems. Ironically, it is the relationships integrated care systems develop with their local (independent contractor) GPs that may determine how much their local population eventually choose to trust them.