In October last year the government announced that it was reviewing the Carr-Hill funding formula for general practice, which is used to calculate the payments GP practices receive.  But what should we be looking out for once this review from the National Institute for Health and Care Research (NIHR) lands?  How will we know whether what is proposed will make the situation any better?

I had a fascinating conversation on the podcast recently with Dr Matt Jones about the Carr-Hill formula and why it does not work.  What is clear is that very few people understand the formula and the impact it has, even on their own practices.  If we don’t understand the problem, it will be very hard to work out what changes will improve things.

I took away five key issues that we need to look out for when the new recommendations finally land:

1. Is there an up to date, meaningful marker of deprivation?

It turns out deprivation is one of the markers used within the Carr-Hill formula, termed the practice additional needs index.  However, astonishingly, this is based on survey data carried out before 2000. This has the double problem of one not being very accurate to start off with, and two being at least 26 years out of date.

The new formula will need to use a better marker for deprivation, and some mechanism for ensuring it is updated on a regular basis as the characteristics of local communities can change extremely rapidly.

2. Are fixed costs adequately taken into account?

Dr Jones very eloquently points out on the podcast that even though practices might only be receiving 80% of the global sum as a result of the Carr-Hill formula, they are not able to pay for only 80% of their electricity bill.

Whatever the practice, wherever it is, there are some costs that are fixed, regardless of deprivation, rurality or the age and sex profile of the local population.   The current formula does not take this into account, which means the impact of the formula is amplified as practices that lose out through it have first to cover their fixed costs and are then left with an even lower proportion of funding every year to cover their variable costs.  This in turn affects their ability to provide sufficient clinical capacity, a problem that is now being exacerbated with the new access requirements.

The new formula must provide some recognition of the fixed costs facing all practices.

3. Is there a commitment to regularly review the formula?

One of the key problems with the Carr-Hill formula is that is has not been reviewed or updated in over 20 years.  In 2004/05 the global sum was £54.72 per patient, but this year it is £130.07 per patient.  This means the impact on practices being underfunded as a result of the formula has more than doubled over the last 20 years.

It is highly unlikely that whatever new funding formula is generated will be perfect.  Many practices could tell immediately that there were problems with Carr-Hill when it first came out.  Regular checks and reviews should be put in place up front to allow issues to be addressed quickly, rather than allowing them to compound and result in the same situation we are in now.

4. Will there be transparency over funding at an individual practice level?

The result of any funding formula will mean some practices will receive more money than others.  The situation with Carr-Hill, however, is that many practices do not understand these differences, let alone the patients.

If one equal-sized practice is receiving over a million pounds more funding than another, albeit for justifiable reasons, then there needs to be transparency with patients, practices and commissioners, so that expectations can be adjusted accordingly.

5. Will a manageable transition plan be put in place from the existing to the new formula?

If the new formula is not accompanied by any form of cash injection then the big risk with the change is that money will simply end up being moved from some practices to others.  No practices are finding life easy at the moment, so there needs to be a realistic, thought-out plan (i.e. not an MPIG) put in place that will enable those practices requiring more funding to be able to receive it without destabilising others.

NHS England has published a number of documents recently that shed a bit more light on how the NHS architecture is changing.  What are the main changes, and what are the implications of these for general practice?

The documents in question are the Strategic Commissioning Framework and the Advanced Foundation Trust Programme.  They are significant because they set out a clear shift in the way the NHS is to function.  In recent years we have seen a move away from the purchaser provider split, with ICBs being given the role of system integrators aiming to bring the system together to collectively decide how to make the best use of the limited resources.  These documents, however, represent a shift away from this thinking.

Instead, we have a return to the purchaser provider split.  The role of ICBs is now to be very clearly demarcated as that of “strategic commissioners”.  Strategic commissioning, it turns out, is the updated term for what became “world class commissioning”.  The document lists out the seven features or characteristics of strategic commissioning, in very much the same way world class commissioning identified 11 competencies when it was launched in 2007.

ICBs are expected to make this change quickly, “A strategic commissioning development programme will be in place from April 2026 to support ICBs and others who commission NHS services to develop as strategic commissioners. As part of this we expect ICBs to carry out a baseline assessment against this framework in March 2026 to inform the development support they need. We plan to incorporate elements of the framework in the assessment of each ICB as a strategic commissioner that NHS England is required to undertake from 2026/27.”

The difference this time round to 2007 is that ICBs are expected to do this both with far less staff and resources, and it is not the purpose for which they were originally established.  How able ICBs will be to adapt and take on this new role remains to be seen, but given the inability of the NHS to produce effective commissioners in the past the odds don’t look good.  This change in role may or may not be what has been behind the recent exodus of a large number of ICB leaders.

Just as ICBs are to become the new commissioners, NHS Trusts are to once again become foundation trusts, only this time they will be called “Advanced Foundation Trusts”.  As in the past, NHS Trusts will be able to secure more operational and financial freedoms once they achieve this status.  The main difference this time is that the role of system integrators is also effectively being shifted from ICBs to them.

Once an NHS Trust has achieved advanced foundation trust status it can take on an integrated health organisation contract, whereby it can hold the health budget for a defined local population.  It will not be expected to provide all services under the scope of the contract directly, but rather will need to work with other providers (including general practice) to deliver these services.

So the new delineation is quite distinct: ICBs are to become very clearly defined as commissioners, and NHS trusts as both autonomous providers and the integrators of providers across the system.  The question is where all of this leaves general practice?

The indications are that the impact could be significant.  We get a strong hint of this in the Strategic Commissioning Framework, which states that,

“The 10 Year Health Plan sets out a new provider system architecture for neighbourhood health. This – for the first time since the creation of the purchaser–provider split in 1991 – has the potential to shift the majority of NHS provision from a ‘receive and treat’ model to a population-based model. Individual GP practices, single neighbourhood providers (SNPs) and multi-neighbourhood providers (MNPs) are all population-based entities.” (5.2)

ICBs are exhorted to “shape the development of providers and use of novel contract models to create the right provider landscape to deliver population health improvement”.  It very much seems as though the main lever that will be used to influence general practice will be the new neighbourhood contracts.

This was reinforced by Wes Streeting who suggested that these new contracts would be the tool to enact a “fundamental modernisation” of general practice in his speech to NHS Providers on 12^th November,

“But the bright future that general practice deserves will only come through fundamental modernisation. That’s why we’re introducing two new neighbourhood contracts. A single neighbourhood provider contract for the delivery of enhanced services, for patients, through expert, multi-disciplinary teams and a multi-neighbourhood provider contract to lead the Neighbourhood Health Service at scale.”

This appears to suggest that enhanced services may be commissioned in future via the single neighbourhood contract, a concern that GPC Chair Katie Bramall-Stainer also raised at the recent LMC conference.  If this ends up being the case practices will get tied into neighbourhoods in very much the same way as they have with PCNs, as being without the enhanced service funding will be simply unaffordable.

According to the Strategic Commissioning Framework, “Primary care leaders are working with their ICBs to explore how best to organise their work, including through horizontal and vertical integration with other parts of the NHS, so that patients receive the appropriate care, whether episodic or ongoing co-ordinated care or part of a wider pathway of care. They are also playing a leading role in the development of neighbourhood health.” (5.1).  In reality I suspect very few primary care leaders on the ground are looking to horizontal and vertical integration, but it seems likely that this is the agenda at a national level.  All three of the new contracts (single neighbourhood, multi neighbourhood and integrated health organisation) may well end up pushing general practice in this direction.

This makes the guidance (promised in November in the medium term planning framework) on these new contracts extremely important indeed for general practice.  The NHS is changing rapidly, and general practice will need to work hard to establish its place and maintain its independence in this new architecture.

NHS England has released planning guidance for the next three years (2026/27 to 2028/29), in a move away from the traditional one-year planning guidance.  It also appears as if (although this is not explicit) this is the promised implementation plan for the 10 Year Plan.  What does it mean for general practice?

Unsurprisingly, the focus for general practice is (yet again) on access.  A new target is even introduced, “Improve access to primary care, including reducing unwarranted variation in access. Ensure 90% of clinically urgent patients are seen on the same day. We will consult with the profession on this new ambition and approach.”

Bear in mind the NHS’s recent history of consulting with the profession is not strong, with broken promises around the changes introduced on 1^st October and the lack of BMA involvement in the Carr Hill review obvious examples.

For 2026/27, ICBs are specifically instructed to “identify GP practices where demand is above capacity and create a plan to help decompress or support to improve access and reduce unwarranted variation”.   Who will actually do this (given the downsizing of ICBs) remains to be seen.

It could fall to neighbourhoods.  These feature heavily in the document, and the expectation that began in the 10-year plan that neighbourhoods will be the golden bullet to solve all the NHS’s ills continues, e.g. “The delivery of neighbourhood care has to be a priority for every leader in the NHS because it will create more space to do elective work, reduce waiting times, improve the quality of care and make headroom for leaders to focus on innovation”.

Unfortunately, as has been the case with all references to neighbourhoods so far, details about them remain scarce.  The most concrete guidance the document contains about neighbourhoods is this:

“Starting now and accelerating over the next 3 years, we want to deliver even more care in our neighbourhoods, providing more joined up care for high-priority cohorts through integrated neighbourhood teams (INTs), and make a material difference to patient experience and hospital demand. In implementing neighbourhood health, the immediate focus must be on:

• improving and tackling unwarranted variation in GP access for the whole population
• reducing unnecessary non-elective admissions and bed days from high priority cohorts – people who have moderate to severe frailty, people living in a care home, people who are housebound or at the end of life
• enabling patients requiring planned care to receive specialised support closer to home”

It remains unclear to me how the concept of neighbourhood working is expected to impact on GP access.  However, there is to be a “Model Neighbourhood Framework” which is “expected in November”.  This will “set out the definitions, goals and scope of neighbourhood health, along with priority actions for 2026/27”.  Maybe this will provide more clarity?

There will also be a “model neighbourhood health centres archetypes, which will describe different archetypes of provision of neighbourhood health services that can be used to inform the better utilisation and enhancement of existing estates, together with new-build solutions, where appropriate”.  I think this means guidance as to how the 10-year plan promise of a physical hub for every neighbourhood is to be realised, although the language used to describe it already suggests it may be less than useful.

“Archetypes” is clearly the vogue word of the moment, as also to come in November is “a system archetypes blueprint explaining the interplay of the new contract models set out in the 10 Year Health Plan (integrated health organisations, multi neighbourhood provider contracts and single neighbourhood provider contracts) and a draft integrated health organisation blueprint.”

This document characterises integrated health organisations as a contract model.  Rather than it being a goal for acute/foundation trusts to aspire to (the implication within the 10-year plan) it is now a contract.  The big question is whether this will include the funding for general practice.  What the document says is, “IHOs will work with the wider provider landscape to deliver high-quality care efficiently, including through sub-contracting arrangements and, where appropriate, delegation of commissioning”.

Does this mean sub-contracting arrangements from the acutes to general practice to fund the right to left shift of services, or acutes having a greater say as to what general practice does through its main contracts?  We don’t know yet, but it is clearly a concern.

Indeed, the big question for general practice is whether the new contract types will sit alongside the existing core contract or replace it.  A sceptic may look at the Carr-Hill review as an opportunity for the NHS to force many practices (i.e. the 50% of practices who will lose out as a result of it) to move onto whatever alternative option these contracts may present.

For general practice, then, it feels like significant changes are coming but we still don’t know what they are.  The key questions around the relationship between PCNs and neighbourhoods, and between the new contracts and the core GP contract, remain unanswered.  All eyes are on the promised November documents, although history has taught us that we rarely get straight answers, and we should not be surprised if yet more ambiguity is what we end up with.

The government has announced that there will be a review of the Carr-Hill funding formula.  What are the implications of this review for the profession, and could it mean that the future of the GMS contract is potentially under threat?

In the government’s announcement it states,

“The 6-month review will launch today (9 October) and will be conducted by the National Institute for Health and Care Research (NIHR).  The review will:

• identify a new allocation formula
• assess the impact and feasibility of implementing it while ensuring it aligns to the government’s 10 Year Health Plan
• make an overall recommendation to replace the outdated Carr-Hill formula”

Noone disagrees that the funding formula needs to be reviewed.  However, doing this in isolation poses a number of risks for the profession.

The first and most obvious risk is that if the funding formula is changed without an injection of additional money then some practices will receive more funding at the expense of other practices receiving less.  Practices that are already struggling to make ends meet are not going to be able to take another financial hit if their practice is one that will lose out.

The review does say it will look at the impact and feasibility of implementing it but that does not necessarily mean removing funding from practices won’t happen.  The minimum practice income guarantee (MPIG) was used to protect practices when the move to the global sum was first introduced, but that wasn’t pain free for practices (particularly as it was removed).  If there is no additional money announced (and the BMA have reportedly been told that the review may need to be cost-neutral) it is hard to see how such a guarantee could be introduced this time round.

It is noteworthy that the review of the Carr-Hill formula has been announced as a standalone exercise.  It has not been included as part of a total review of the GMS contract.  The GPC has been insisting on this review and only signed up to this year’s contract on the basis that this would happen, and yet no plans for this review have been put in place other than this review of the funding formula.

It also appears that the GPC and BMA were not consulted on the launch of the review and are not part of the review group.  Maybe the timing of the announcement coming only 9 days after the GPC announced it was entering dispute over the contract changes was not coincidental.  As I wrote about last time, one of the risks of entering dispute is the potential loss of voice and ability to influence policy and in particular the role of general practice within neighbourhoods.

But the biggest potential risk of this review is how it may link in with the new Neighbourhood Provider contracts.  Of course there may be no link at all, and the timing of this review to finish just as the contracts for next year are to be introduced could be entirely coincidental.  But there is the possibility that this review may be part of a wider change, and a move away from the existing GP standalone contract.  A scenario whereby this review recommends that potential “losers” on whatever comes out of the funding formula review shift to the neighbourhood contract instead to mitigate any loss does not feel totally outside of the realms of possibility.

While the review is finally tackling an issue that has negatively impacted many practices for many years, the risks of doing so, along with its positioning as almost a response to general practice entering dispute with the government, will be of real concern to the profession.

There is a misconception that somehow the new Neighbourhoods will replace PCNs.  This is not the case.  What will be of critical importance, however, will be the relationship between the PCN and the Neighbourhood.  This is likely to be determined by whoever takes on the leadership role for the Neighbourhood.

At its core a Neighbourhood is the coming together of all of the providers across a local community.  One of these providers is general practice.  Neighbourhoods will not function effectively if practices operate as individual providers, and instead need practices to operate as a collective.  This will be via the existing PCNs, as the PCN DES requires practices to work together.

But the PCN will only be one voice around the Neighbourhood table.  There will also be the community provider, mental health providers, social care, voluntary sector, other primary care providers and even the acute trust.  This group will need to decide how any new Neighbourhood services are to be designed, delivered, staffed and funded.  If this funding is to come via a new Neighbourhood contract then this group will need to agree how this funding is to be used and apportioned.

The Neighbourhood, then, will in some respects mirror how PCNs function at present where the different practices come together to make these kinds of decisions, but instead of this being a discussion between the practices it will be a discussion between different organisations and only one of these organisations will be general practice (via the PCN).

Given how hard many PCNs find it to agree decisions across their practices, the challenge facing Neighbourhoods in getting all the different organisations involved to come to an agreement should not be underestimated.

The challenge for the PCN leaders, or whoever ends up representing the PCN in the Neighbourhood discussions, will also be significant, as they will have to come to an agreement that works with the other Neighbourhood providers as well as one that the practices within the PCN will sign up to (particularly where practice delivery is involved).

The opportunity seems to exist at present for general practice via PCNs to take on a leadership responsibility within the new Neighbourhoods.  The question is whether, given the complexity and obvious challenge there will be in getting these Neighbourhoods to work, this is a sensible move?

The problem is that, like it or not, Neighbourhoods are coming.  Neighbourhood contracts are on their way, and any new funding for out of hospital care (including general practice) is highly likely to come via this route in future.  The question, then, is not really whether we like the idea of Neighbourhoods or want to work as delivery partners with our local provider colleagues, but given that Neighbourhoods are coming whether it would be better to have the leadership role or for another organisation to take this leadership role on?

When we think of it like this the answer is obvious – general practice and PCNs have to take this opportunity to lead Neighbourhoods.  The alternative of giving this up and letting others take on the leadership responsibility would allow them to determine what role general practice should play in the Neighbourhood and, crucially, what resources it should receive for doing so.

At present the importance of Neighbourhood working is easy to ignore, because the neighbourhood contracts are not yet in place and no real funding is at stake.  However, this will change in the years to come.  But the opportunity to take on the leadership role is coming now.  What PCNs and general practice must not do is give this opportunity up and let someone else take it on because it doesn’t feel important, because when the financial realities kick in in the coming years it will be too late to have a change of heart as someone else will already be in the driving seat.

A key part of making neighbourhoods work is building relationships with the local provider organisations.  But in many places general practice has struggled to be able to develop any sort of meaningful relationship with the local acute trust.  How can this change now?

In a past life I worked in acute trusts, and at one point was a Director on the Board of a hospital Trust.  This was before I had worked much with general practice.  Looking back, a number of things stand out about how the hospital perceived general practice.

The most noticeable was that there was no understanding within the Trust as to how general practice worked.  Very few people within an acute trust, particularly on the management side, have any sort of experience of working in a general practice environment.  The language of general practice (DES, LES, GMS, PMS, QOF, PCNs etc etc) is daunting and off-putting, and makes the service feel impenetrably complicated.

General practice is also perceived as very difficult to do business with.  When working in an acute trust it feels very hard to identify individuals who can make agreements on behalf of general practice.  Those particularly long in the tooth will remember GP fundholding and how hospitals had to agree contracts with each fundholder individually, and that sense of not being able to pin general practice collectively down to an agreement still remains.

At the same time, general practice can feel that hospitals themselves are distant, focussed only on themselves, and uninterested in general practice and the community.  There is a hostile undercurrent of frustration from GPs with the perceived shifting of (unfunded) work onto their laps.  Any primary to secondary care initiative feels designed to create yet more work for practices (shared care, advice and guidance, referral management etc etc), and so even the incentive for a stronger relationship is not always obvious.

But now the advent of neighbourhoods and the prospect of multi neighbourhood provider contracts has created an urgency for developing this relationship that has maybe been missing in recent years.  But moving forward is not straightforward, so where should we begin?

The best place to start is to identify the person or people within the hospital who are the easiest to do business with.  I remember on my executive team there was a range of individuals, and some were definitely harder to do business with than others.  Not all had the same attitude towards general practice.  Generalisms about the ‘acute trust attitude’ towards general practice are not helpful because different individuals will have different attitudes. The trick is to find those most open to working with general practice, and let them be the ones who work to persuade their less amenable colleagues.

But how do you find them?  Asking senior ICB colleagues is a good place to start.  They will be able to recommend the best people to contact.  You don’t want anyone too junior (because their influence within the acute trust will be too limited). This is the perennial problem with identified “general practice liaison leads” – you can invest time with them, but it can often lead to no tangible changes because they have insufficient clout within their own organisation.

The ideal place to get to is a small group of management and clinical leads from both sides (4-6 people) who can oversee any joint working, and where each side has enough influence to troubleshoot any issues that arise.  Of course this also requires general practice to have established its own way of working collectively so that it can participate effectively in this kind of arrangement.  Otherwise the general practice leaders can end up feeling very exposed!

A priority for this group is to establish a rationale for joint working that both can sign up to.  There will inevitably be a fear from some GPs that the acute trust may want to take over general practice, and so this needs to be explicitly taken off the table.  Recently from the GP side this work has been around reducing the pushing of unnecessary workload from secondary to primary care, and from the acute side about improving the appropriateness of referrals.  With the advent of neighbourhoods this can be expanded to how joint working can enable neighbourhoods to be effective, and of course joint preparations for the multi neighbourhood provider contract when it arrives.

Ultimately, the relationship between general practice and the acute trust will come down to personal, individual relationships.  The mistake that is often made is trying to use big set piece meetings with multiple attendees to develop the relationship.  These are fine, but can only work if they sit on top of some individual relationships. Getting these in place is the most important place to start.

The 10-year plan lacks detail on implementation but still sets some ambitious timelines.  In particular, it states that the roll out of the two new contracts (the Single Neighbourhood Provider and the Multi Neighbourhood Provider contracts) will start next year.  With the threat of other providers being able to take on these contracts, what can PCNs be doing now to prepare for them?

For those PCNs keen to be in a position to take on the new Single Neighbourhood Provider contract the best starting point is an assessment of where they are now against the identified features of the new neighbourhoods in the plan.  A simple review of where they are now and where they want to be in 6 months’ time can form the basis of an action plan as to what is required should these contracts become available next year.

There are 8 areas that I would focus on, which I have outlined below.  It is not an exhaustive list, but it is where I would start.  If much more is included it runs the risk of becoming unwieldy and losing focus on what is important.

Leadership.  Does the PCN CD want to take on a leadership role in the new neighbourhood?  If they do, can they be freed up from the internal running of the PCN (potentially by others stepping up to support with this) so that they can focus on the external work with others that will be required?  If not, can an individual from within the PCN who has both the skills and desire to take this on be identified, and then be supported to start to move towards this role?

External relationships.  Does the PCN have individual, personal relationships in place with the key leaders from the different organisations across the neighbourhood (such as the community trust, the mental health trust, the acute trust, social care and the voluntary sector)?

Governance.  Does (or could) the PCN convene regular meetings of these individuals, which could potentially start to operate as a leadership group for the neighbourhood? There will ultimately be a value to being the organisation that convenes these meetings if the PCN wants to play a leadership role within the neighbourhood.  Is the PCN in a position to be able to hold a contract, should one become available?  If not, what steps does it need to take to be able to do so?

Integrated neighbourhood teams.  Are there any integrated neighbourhood teams in place?  What further teams might be developed?  How are these teams supported and enabled, and how is their impact tracked and success measured?

Population health.  Are the specific needs of the local population understood?  Have groups with similar needs been defined, and specific cohorts of patients been prioritised?  Is there a neighbourhood plan to improve population health and reduce health inequalities? Are partners across the neighbourhood bought into this?

IT, data sharing and information governance.  Can information be shared across the different teams in the neighbourhood?  Are mechanisms in place to allow this to happen?

Neighbourhood health centre.  Has the neighbourhood health centre been identified (given every neighbourhood is to have one)?  If it has, what steps can be taken to develop it?

Voice and influence.  Is the PCN actively influencing the place-based partnership board that is making the key decisions about neighbourhoods, both now and as they develop?  What actions can the PCN take to develop its influence further?

The expectation is not the PCNs will already be operating as full-blown neighbourhoods and be able to answer all of these questions positively.  The opportunity, however, is to understand where the PCN currently is in relation to the neighbourhood, and use the gaps that it identifies as the basis for an action plan for the next 6 months.  It will also mean that at the point in time at which the PCN is asked about its preparedness in relation to the neighbourhood (as this will inevitably come) it will be able to clearly state the actions it is proactively taking, and be in a far better position to take on the single neighbourhood provider contract when it arrives.

By now you are likely to have either read the government’s 10 year plan for the NHS, or at least a summary of it, or picked up from others the key elements of the plan (my take on what the implications of the plan are for general practice is here).  The question now is how should general practice respond to the plan, both nationally and locally?

I recently spoke to Dr Katie Bramall-Stainer, Chair of the GPC, about the plan.  You can listen to our conversation here.  Her view is that the plan is not set in stone, but rather a signal of the start of an iterative process of how the desired reform should be delivered.

She does have real concerns about some of the suggested mechanisms for delivery in the plan, not least of which is integrated health organisations, which she says stands out as “a big red flag” and potentially poses an “existential risk” to general practice.  But rather than come out in opposition to the plan as a whole and risk having reform done to the profession, her view is that it would be far better for general practice to be part of shaping the changes as they develop.

It is hard not to agree with what she is saying.  General practice would run the risk of being sidelined if it decided to withdraw any engagement from the plan.  It would not be hard for the profession to be portrayed as being anti-reform, and the plan has already opened up routes by which change could be imposed on rather than negotiated with general practice.

But equally it will be important that engaging in discussions about shaping the reform are not taken as implicit approval of the ideas Katie has already identified concerns about, such as the integrated health organisations and also the multi-neighbourhood provider contract (specifically how it will be procured).

What general practice will need to do is not only dissect the plan, but also come up with alternative proposals as to how the ambitions of the plan can be realised where the initial proposals cause concern.  It very much feels like an opportunity exists now to shape the future, but simply rejecting the ideas that others put forward on its own will not be sufficient because no change is not going to be an option.

Almost immediately after the publication of the plan NHS England announced a “National Neighbourhood Health Implementation Programme”, and is seeking 42 local place areas to apply.  Given the concerns about the plan, but equally the desire to shape it, does it make sense for general practice to support any local application?

As ever the response is “it depends”, but what it depends on are the assumptions being made locally as part of the application.  What parts of the plan are being taking as a given and what parts are being tested?  For example, is the local area taking a multi-neighbourhood provider as a given and wanting to use the pilot to fast-track its procurement?  In this scenario, I would have serious reservations.  But if we have a trusted local at-scale general practice provider and the aim is to use this to enable effective neighbourhood development then maybe an application would be worth supporting.

What this highlights is that it is not only a national general practice responsibility to react to the plan and develop ideas on how the ambitions of the plan can best be delivered, but also a local one.  The plan correctly identifies that there will not be a one size fits all national solution that can be imposed everywhere.  Local solutions will be needed.  If general practice wants to shape the future locally, and not be a recipient of imposed reform, then it will need to support and potentially lead the development of local alternatives to the ones it has concerns about within the 10-year plan.

The rumour mill is hotting up as the release of the 10 year plan draws closer.  According to the Health Service Journal the plan will be published next week.  They also report that one of the key features of the new plan will be the return of Foundation Trust style freedoms for hospital trusts, and that this will include them being given the entire budget for health and care for a specific population.

This has potentially huge implications for general practice, as it would mean that much (if not all) of its funding could come from the acute trust.

The idea is that hospitals would take on the equivalent of what in other health systems (such as the US) is known as the accountable care organisation role.  Apparently here they will be known as integrated health organisations.

The logic is that if they are incentivised to improve outcomes for the population they in turn will look to improve prevention and early intervention activities, and as a result will invest in primary and community care.  Equally, it will remove the issue of one provider benefiting from the activity in another sector (or, conversely, suffering as a result of failure in another sector) as all local providers will be linked as part of the integrated health organisation.

If the model works, the system could reinvest any surplus how it sees fit, but potentially in those areas that could maximise its outcomes and ability to generate a surplus in future years, i.e. primary and community care.

This would mean, then, that the acute hospital would potentially hold the budget for general practice and contract with them directly.  It may be all of the general practice budget, or it could (more likely) be just those parts of the contract that are outside of core (i.e. enhanced services).  This would, however, most likely include PCN funding and potentially also QOF funding.  In this scenario one would expect the national trend to be to reduce the amount in core funding to maximise the influence/impact of the new integrated health organisation.

This model contains many risks for general practice.  First and foremost, and before there is any discussion of how any surplus is used, it relies on the acute trust/integrated health organisation choosing to use the money it receives for general practice in general practice.  History tells us that hospitals use whatever funding they can to shore up hospital services.  This was the reason community trusts were invented in the first place.

In addition, one assumes because of the pressure on national finances, there will little if any new money with the plan.  According to the HSJ one of the aims of the plan is to stop the expectation of “money being the answer to everything”.     We already know that achieving a shift from secondary to community care requires a period of double running before the benefits start to be realised, and without it difficult decisions will have to be made.  Not ideal, then, if the acute trust is making these decisions.

Where previously the government had made a commitment to increase the share of NHS spending on primary care by 2029 this now has been pushed back (apparently) to the end of the plan period (i.e. 2035).

There is talk of GP Federations, or GP provider organisations operating at the same scale as an acute trust, being able to take on the integrator function.  Whether that materialises remains to be seen, but the lack of investment in any at scale GP infrastructure over the last 6 years since the introduction of PCNs means there are precious few places with organisations in place with anything like what will be the required infrastructure.  We know from the bitter experience of CCGs that accelerated development timelines simply result in a loss of confidence from the rest of the system and ultimately won’t work.

These are, of course, all rumours.  What actually makes it into the plan we will find out shortly.  That said, these rumours are based on claims by individuals claiming to have read drafts of the plan so I doubt they are that far off.  A priority action for general practice for now must be to ensure it has organised itself so that it can have a strong collective voice in system discussions (that may end up being integrated health organisation discussions).  It will need to be on the inside of the decision making of these organisations, not via a token individual GP appointed by the acute trust but via some form of united collective representation.  The future funding of the service may depend on it.

I am sure you have had chance to see the changes to the GP contract for next year by now, the headline of which is an increased investment into general practice for the first time in what feels like a very long time.  But what can we learn from the new contract?  Here are 5 initial observations.

1. This government wants to invest in general practice

Last year when the Labour government came into power they increased the global sum by 7.4% to fund GP and practice staff pay rises worth 6%, and this has been followed up with a 7.2% cash growth on the total contract funding envelope in this year’s settlement.

This is in stark contrast to the previous administration, who steadfastly refused to release any additional funds beyond those agreed in the 2019 contract, despite inflation running into double figures.  Not only that, but overall money is extremely tight, both in the NHS and more widely across government, and so this injection of funding is not in line with what is happening in most other areas.

The government has pledged to shift care from hospitals to the community, and to increase the percentage share of NHS funding that primary care receives, and this settlement indicates that they are looking to make good on these promises.  This is good news for general practice, and holds promise for the future.

2. Life is not going to improve quickly for practices

The less good news is that all of the new investment is likely to get swallowed up by either new or existing cost pressures.  Of the global sum increase of £743M, it is estimated that £300M will be swallowed up by the new employer national insurance contributions and increase in the national living wage, and a further £300M to fund a 2.8% pay uplift for staff.  This only leaves £143M to fund any other new cost pressures, and to try and start to make a dent in the backlog of unfunded cost pressures from previous years.

So while at least things will not get worse financially for practices this year (which in itself is a change from previous years), they also are unlikely to get much better.

3. Access is the priority for general practice

For all the talk about neighbourhoods in recent times, these changes reinforce the priority that the government gives to improving GP access.  The key inclusion into the contract is the requirement for practices to keep their online consultation tools on for the duration of core hours from the 1^st October.

The delayed implementation date and the multiple references to “necessary safeguards” indicate this was a tough part of the contract changes to agree, but one that NHS England was not prepared to back down on.  Given improvements to GP access is also a key priority for the emerging neighbourhoods for this year we should not expect the pressure in this area to ease any time soon.

4. PCNs are not going anywhere

For the GPC’s part, they have clearly worked hard to negotiate more flexibility to the ARRS pot.  A number of concessions have been made such as the caps on numbers of staff being removed, the pot for new GPs no longer being separate, the maximum reimbursable salary for GPs being increased, and the addition of practice nurses to the roles that can be employed.

However, what the GPC really wanted was for the £1.6bn of ARRS funding to be shifted into the core contract.  This was not agreed by NHS England.  There is to be a “joint review on the future of ARRS” through 25/26, but that really just points to an inability to get to an agreement within these contact discussions.

The reality is that while it would have been cost neutral for NHS England to meet this demand, they know that the majority of PCN funding is within the ARRS pot, and that dismantling it would most likely effectively precipitate the demise of PCNs.  PCNs clearly form an important component of the neighbourhoods that we will find more out about in the 10 year plan, and having fought so hard and invested so much in their establishment over the last 6 years NHS England is not prepared to simply let them go.

5. Much bigger change for general practice is on the way

This contract very much has the feel of a holding contract, one that is designed to keep things going, remove the cloud of collective action and suggest positive intent without introducing any major changes.

However, GPC England has been clear that acceptance of this contract is conditional on a commitment from the government to a “full renegotiation of the new national contract, beginning within this parliament”.  The government, meanwhile, is closing in on the publication of its much-touted 10 year plan, and for the shifts it is seeking to achieve changes in general practice are going to be required.

This all points to much bigger changes ahead.  At least now the two sides are talking and have been able to come to an agreement for this year, but any trust that has been built is likely to be needed in the even trickier negotiations that await in the years to come.

While we know the impact of neighbourhoods could potentially be hugely significant for general practice and PCNs, the recently published neighbourhood health guidelines told us very little about them.  This is because the powers that be want them to be locally developed rather than nationally imposed.

But this in itself is important.  It means all of the most important decisions about neighbourhoods are going to be taken locally.  Neighbourhoods in one area could look very different to neighbourhoods in another.  The devil will be in the details.

It almost goes without saying, then, that general practice needs to make sure it is directly involved in the decision making about the local development of neighbourhoods.  According to the guidelines there needs to be, “a mechanism for joint senior leadership, such as a joint neighbourhood health taskforce, in each place to drive integrated working, comprising senior leaders from the constituent organisations across health and care, including the acute hospital”.  General practice needs to make sure it is on whatever this looks like in their local area.

But getting on this group or taskforce is only step one.  Once there, what do general practice leaders need to be seeking to influence?  Here is an initial list of 6 things to look out for:

1. The Configuration of PCNs. The Neighbourhood Health guidelines avoid the question of what the configuration of neighbourhoods should be, instead leaving this for local areas to decide.  While some areas may end up with a configuration that matches the current PCN configuration, many areas will not.  A key question will be how, then, any misalignment between the two should be handled, and whether attempts will be made to alter the configuration of PCNs as a result.

2. Control of PCN Resources. While we may see an investment in the neighbourhood infrastructure via the forthcoming 10 year plan, as it stands the current guidelines do not suggest that there will be any.  Given the lack of additional resources there is a real risk that the system will try to treat PCN resources, and in particular the ARRS staff, as neighbourhood resources rather than resources that belong to general practice.

3. Improving GP Access. It seems somewhat incongruous that neighbourhoods, that are supposedly about joint working between organisations, are to have a focus on improving the performance of one of these organisations (general practice) as an initial priority (“NHS England regional teams… should work with systems to agree locally what specific impacts they will seek to achieve during 2025/26. We expect these to include, as a minimum, improving timely access to general practice”).

One question this raises is how neighbourhoods will seek to achieve this.  The risk to watch out for is that systems via neighbourhoods may choose to adopt a top-down, performance management approach, rather than one that seeks to reduce pressure on practices by maximising the contribution of other local agencies.

4. The Role of PCN CDs. If PCNs are to form one component of neighbourhoods alongside a range of other local providers, an important question will be where PCN CDs end up sitting within the neighbourhood leadership infrastructure (if anywhere).  Will PCN CDs be able to play an influential role in shaping and leading neighbourhoods, or will the local system attempt to sideline them in favour of giving power to others?

5. The “Integrator” Function. All the indications are that an at-scale organisation will be sought to take on what has so far been termed an “integrator” function (for example in North West London – here).  This is where one organisation takes on responsibility for bringing all the providers in the neighbourhood together, which in turn could bestow considerable control of the neighbourhoods to that organisation.  While theoretically this could be a primary care organisation, a community health provider or a local authority, what is important is which of these it ends up being locally.

6. Funding Streams (and link to GP funding streams). If neighbourhoods are to have any kind of authority then they will need to have clear funding streams.  The guidelines, however, do not make clear what these will be.  The concern might be that some systems may choose to set neighbourhoods up as commissioning style organisations, that hold all of the local funding for the local providers, but with the freedom to move it around to “best meet local needs”.  This could potentially put GP and PCN funding at risk.

The other funding stream risk GP leaders will need to be aware of is where finances are predicated on a series of “invest to save” business cases, designed to shift resources from secondary care to the new neighbourhoods.  These have a terrible record of success, largely due to fixed capacity in secondary care and the ongoing increase in overall demand (Joe McManners explained this well on our podcast last year), and so such a design would most likely be setting neighbourhoods up to fail.

These are just some of the initial things for GP leaders to be looking out for.  The most important thing at this stage is to ensure that general practice is represented on the local neighbourhood development group, and that there is effective two way communication between this representation and practices and PCNs.

The shift of activity from secondary to primary care is starting to pick up pace.  Does this represent a threat or an opportunity for general practice?

This government has been clear that it wants to see a shift of activity from hospitals to the community, listing this as one of the three big shifts it is seeking to achieve.  These are intended to form the foundation of the forthcoming 10 year plan for the NHS, but there are early indications of what is to come in the recent Reforming Elective Care for Patients document (which we discussed in a recent podcast here).

This contains the ambition for the number of advice and guidance requests to be increased from 2.4M to 4M, along with more patient initiated follow ups, greater use of the NHS App, and GPs to support patients activating choice of treatment provider.

All of these have workload implications for general practice.  Funding has only been identified for the advice and guidance requests (although even then the £20 per request feels inadequate given the amount of work each request entails), but we await details of the 25/26 GP contract.

It is not just elective care.  A similar plan for reforming urgent and emergency care is due out (a draft has already been leaked to the HSJ), and it is hard to see a scenario in which this does not have further workload implications for general practice.

More is likely to follow once the full 10 year plan is released.

Practices, however, are operating at full capacity.  There is not the workforce or space within practices to cope with the existing work, let alone take on more.  Practices are already undertaking collective action in protest at the underfunding and underinvestment in the service in recent years.  One of the things that has irked the service most has been the unfunded shift of work from hospitals to practices.

The threat that this poses to the existing model of general practice is real.  The government is not going to suddenly reverse its push to shift care from hospitals to the community, and practices cannot magic capacity out of thin air.  Something is going to have to give.

General practice could respond to this threat by scaling up collective action to attempt to make the government reverse its plans to increase the workload on general practice in this way.

But given the government has already announced its intention to invest in general practice beyond the levels it will invest into other sectors, it is hard to see a scenario where choosing to do this ends well for the service.  The government has been insistent on the need for reform to go alongside on additional investment, and clearly has question marks about the current model of general practice.

Instead, are there any opportunities that potentially lie within the shift from secondary to community care for general practice?

The most obvious opportunity lies in the funding.  Even with any uplift that is given, the core GP contract is never going to be funded sufficiently again.  All new money now comes with additional expectations, which means general practice is highly unlikely to ever be able to really thrive again if it is relying solely on this contract.

But funding for the shift of secondary care activity is new.  If general practice can find a way of both working this at a profit and of scaling it sufficiently then it does hold out the promise of a secure new future.

The question, of course, is how can it do this?

Each practice can’t do this on its own.  There is not the physical or workforce capacity.  But by working together or at scale, by accessing the resources that come via the PCN, and by developing an infrastructure beyond that which exists within practices and most PCNs, then the capacity can be put in place.

Historically federations and even PCNs have operated too independently from practices for this type of model to be effective in securing individual practice sustainability.  But if practices can develop a model whereby the at-scale work is a core component of the practice business model, and at the same time the at-scale work can develop to make the most of the coming shift of activity, then there is a scenario where general practice can once again thrive.

The shift of activity from hospitals to the community could end up being the final nail in the coffin for the existing model of general practice.  If the elective reform plan is anything to go by then this could come sooner rather than later.  This threat is real.  But it may also be an opportunity for a brighter future for an evolved model of general practice, where a proper support infrastructure enables practices to make the most of this shift in activity.

All the signs point to “neighbourhoods” as the next priority area of focus for the NHS.  The new government has spoken repeatedly about creating a “neighbourhood health service”, and at the recent NHS providers conference Secretary of State Wes Streeting stated that the role of ICBs should no longer be performance management but instead he said,

“I want ICBs to focus on their job as strategic commissioners and be responsible for one big thing: the development of a new neighbourhood health service.”

So while we await whatever is to be included in the promised 10 year plan, one thing we can be relatively certain of is that neighbourhoods are going to feature front and centre.  At the same time PCNs are getting less and less of a mention, so it also pretty reasonable to assume that while practices operating together at a PCN level will continue, primacy will shift from PCNs to neighbourhoods.

The question, then, is what does this mean for PCNs and practices, and what (if anything) should they be doing now to prepare for this shift?

Here are 5 actions I would recommend:

1. Strengthen PCN working. General practice will still hold a pivotal role in neighbourhood working.  PCNs as group of GP practices within a neighbourhood will be very important and will need to be strong together to be able to shape how the neighbourhood functions.  While there is a temptation right now for practices to retreat into core service delivery and away from PCN working, doing so would fracture the unity of local general practice and reduce its influence within the new neighbourhoods.

2. Match PCNs to neighbourhood boundaries. In recent years the pressure has been on community teams and others to match to PCN boundaries, but the nature of neighbourhoods mapping to both local communities and existing community and social care teams means that the pressure will most likely now come for PCNs to change rather than vice versa.  We have seen this already in the NW London Integrated Neighbourhood Team  It would be sensible where there is not an existing alignment for PCNs to start to think about how they could make this happen in the least disruptive way, before the system imposes its own inevitably heavy-handed approach.

3. Focus on building strong relationships across the local area. Neighbourhood working ultimately relies on local relationships.  Just as effective PCN working requires strong relationships and trust across the practices, the same is true for all the different organisations working across a neighbourhood.  Relationships take time to build, so early investment in them now will pay big dividends in the future.

4. CDs take on a leadership role for cross-organisation working initiatives. Lots of pilots and MDTs are already springing up in local areas, as systems start to gear themselves up for neighbourhoods.  PCNs playing an active role not only within these initiatives but in leading them is extremely sensible preparation for the future, as it will position primary care as the natural leader for these emerging neighbourhoods.

5. Support local at-scale general practice to prepare to become an “integrator”. GP federations have been in and out of favour over the last 10 years, but one important emerging theme in all the publications about neighbourhoods (going right back to the Fuller report) is that there will need to be some form of at-scale support for them.  This could be from general practice (i.e. a federation) or from an NHS or local authority organisation.  If general practice is keen to both be able to influence the way neighbourhoods develop and is keen to protect its on ongoing independent contractor status then there would be a lot of value in the local federation taking on this integrator function.  To do this, however, local PCNs and practices will need to actively support it now so that when the time comes it is in a position to be able to take on this role.

On the podcast recently Joe McManners highlighted that the more government and policy makers talk about shifting resources out of hospital and into primary and community care the less it happens.  Well, we have had the talk in the form of the Darzi report, and now does the budget simply prove his point?

On the bright side, the Chancellor did at least announce new money for the NHS.  £22.6bn was announced over 2 years, but the narrative that she used to go with it was painfully familiar, “Because of this record injection of funding, because of the thousands of additional beds that we have secured, and because of the reforms that we are delivering in our NHS, we can now begin to bring waiting lists down more quickly and move towards our target for waiting times to be no longer than 18 weeks by delivering on our manifesto commitment for 40,000 extra hospital appointments a week.”

It seems the chancellor didn’t get the memo from Darzi.  When we look at the detail of what the money is for (although the Kings Fund have indicated the majority of it will be needed to fund the already published workforce plan) there are specific capital projects identified:

• 40,000 extra operations and acute sector appointments a week
• £1.5 billion for capital for new surgical hubs and scanners and new beds
• £70 million for radiotherapy machines
• Fixing RAAC (reinforced aerated autoclaved concrete) hospitals
• £2 billion to invest in NHS technology and digital – contingent on 2 per cent productivity next year
• A dedicated fund to deliver around 200 upgrades to GP surgeries (£100M “earmarked”)
• £26 million to open new mental health crisis centres

The majority of these are secondary care focussed.  The primary care and mental health items at the end look very much like someone noticed this and added them on at the last minute.  Anyone who has been involved in the development of new GP surgeries will know that half a million does not get you very far, and even 200 developments isn’t going to touch the sides of the need across the 6000+ practices out there.  And of course no one is going to be surprised if even that money comes with caveats about “neighbourhood working”, or if it gets forgotten when NHSE decide they need the money for something else.

In fact general practice does not even get a single mention in the budget.  This does not inspire hope that the service will then be at the front of the queue for investment when the much touted 10 year plan arrives in Spring.

The new government has talked about shifting care from hospital to the community and shifting from treatment to prevention, and has raised our hopes via the Darzi report which called for a “hardwiring of financial flows” to lock in the shift of care closer to home.  So it is somewhat depressing to then receive a budget which ignores this altogether and goes back to funding more activity in hospitals.

But the Prime Minister has continued to insist that the government will focus on reforming public services rather than simply spending more on what we currently have.  It may be that this budget is what is needed as a short-term fix to prevent the NHS deteriorating further, before the promised reform plan is published next year.

Let’s hope that what it is.  If we are being honest we are seeing an early gap develop between the rhetoric and the action, but it feels too early to give up just yet, and hope still remains that this government will provide the investment for primary and community care in future that is needed to prevent the NHS becoming even more hospital-centric.

The PCN DES has been reissued to include the addition of GPs to the Additional Role Reimbursement Scheme.  This contains the details of the new £82M funding that the government previously announced for GPs to be added to the scheme.  What do the details mean for the difference this funding will be able to make?

The good news is that there are relatively few strings attached to the funding.  There were concerns that there would be a relatively tight specification on exactly what these new GPs could be employed to do, but PCNs have been given a relatively free hand in choosing how to make the most of these GPs once they are employed.

It is also good news that PCNs are not being asked to produce a baseline on how many GPs they had, to prove that any employed via this scheme are additional (as, you will no doubt recall, was the case with pharmacists).  The funding cannot be used to continue to fund someone already in post pre-October 2024, but that is more or less the limit of the additionality test.

The bad news is that any GP employed with this funding has to be within their first two years since qualification (at the point at which they start with the PCN).  If they are more than two years post-qualification then this funding cannot be used to employ them.  These GPs cannot be employed as locums, and must be employed or engaged on terms or conditions that are no less favourable than the model terms and conditions for salaried GPs (B.19.4).

This terms and conditions requirement means that there is no chance of PCNs being able to reduce the on-costs of the additional GPs, and raises the important question of what it means in terms of how much funding each PCN will receive.  PCNs will receive £1.303 per weighted population, which means that a PCN with a population of 50,000 will receive an indicative amount of £65k for the six remaining months of 24/25 (that can only be spent on these newly qualified GPs).

The (annual equivalent) maximum reimbursable amount per GP is £92,462 (£95,233 with London weighting).  This falls more or less at the mid-point of the NHS Employers current salaried GP range of £73,113-£110,300, but of course this doesn’t take into account on-costs.  If we assume 9 sessions per week and 28% on-costs it means the maximum reimbursable amount is just over £8,000 per session.

Unfortunately, the available newly qualified GPs are not evenly distributed across the country.  This level of funding is unlikely to be enough on its own to persuade them to move to areas that may already by under-doctored.  Equally where there is competition amongst local PCNs in areas where there are GPs it seems highly possible that PCNs limiting themselves to the maximum reimbursable amount may find it difficult to secure a GP, and may need to dip into (already overstretched) PCN coffers to do so successfully.

When £82M arrives nationally at a single point in time and can only be used for one specific purpose (employing newly qualified GPs) then demand is always likely to exceed supply and so it should not be a surprise if it leads to prices going up.  Good for the newly qualified GPs, bad for the practices.

Overall, the issue with the scheme is that it seems designed to support and help the newly qualified GPs by securing them employment, but not GP practices with the challenges they are facing.  The call for the profession had been that if there is no new funding they need to be able to use some of the ARRS funds for GPs (the more experienced the better) rather than additional roles.  What this does is still maintain the protection on the existing ARRS money, limit the employment of GPs to those who are newly qualified, and most likely create an additional drain on PCN funds.  Of course new money is welcome, but it feels like the challenges practices are experiencing are still neither understood nor being taken seriously at a national level.

The BMA has published its Safe Working in General Practice Guidance, which is in effect its guide to collective action.  It does not appear to be full of any major surprises, and rather provides practical guidance for practices on how they can implement the changes that they have already described.  However, it includes a section on the PCN DES, which raises the question of whether it would be better for practices to leave the PCN DES altogether.

To be clear, the guidance does not come out and outright say that practices should leave the PCN DES.  Instead it is implied.  It states, “Many feel that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS (Additional Roles Reimbursement Scheme) staff.”  It then states, “Practices will need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their wider practice and their present workforce” before going on to outline the mechanism by which practices can choose to opt out.

“Many” is a vague term.  It implies the majority of people, but it can simply mean a large but indefinite number.  If it was true that the majority really thought the requirements of the DES outweighed the benefits the current sign up rate to the PCN DES would not be over 99%.  Many dislike the requirements of the DES, but that is not the same as considering that their practice would be better off financially by not being part of it.

The problem of leaving the PCN DES is not just about losing the resources (both the financial income streams and the ARRS staff).  It would also mean GP practices ceding control of the PCN and these staff.  As the BMA guidance points out, ICSs are obliged to continue to provide PCN services to practice populations, and so the most likely scenario in the event of general practice refusing to take this on is a neighbouring PCN or another provider such as a community or acute trust taking the PCN on.

Strategically, this would be a terrible outcome for local general practice.  While the BMA sees a very clear distinction between investment in core general practice and overall primary care funding (i.e. including PCN funding and other non-core general practice funding), the government do not.  The government has committed to increasing the percentage share of NHS funding that primary care receives, but if general practice loses control of PCN resources it could end up receiving very little if the additional funding comes through that channel.

The BMA don’t believe that another provider would be able to take on the PCN responsibilities if practices withdrew.  But ultimately it is not their livelihoods that they are gambling with if they are wrong.  The BMA wants the funding that goes into PCNs to be shifted to core contracts.  But national policy is firmly against this, and so practices that resign from the DES will be taking a huge personal risk that this is what will happen when the likelihood is that it will not.  There are clearly divisions within general practice as to the value of PCNs, and so there is not going to be a mass resignation from PCNs, meaning those that do leave are going to be very exposed.

At present, practices can work with their PCN to find mutually beneficial ways of ensuring PCN requirements are managed alongside supporting practice sustainability, both through direct financial flows and through PCN services like pharmacists and home visiting teams that support practice work.  But if ties were to be severed, then this link and these opportunities would be lost, and practices in a far worse position than they are now.

NHSE and the government like PCNs, which is why from the BMA perspective resignations from the PCN DES are desirable as a leverage for negotiation.  But the risk to those that take such a step, when the BMA have not come out and explicitly said that this is what they want, is extremely high.  Rather than leaving altogether and losing the opportunity to access the existing and (potentially larger) future resources, it would seem a much more sensible stance for practices to stay within the PCN, keep control, and campaign to be able to access more of the PCN resources in future.

The big policy question of the moment is how general practice can be “integrated” with the rest of the NHS.  But I wonder if this is the wrong way round, and whether the question should really be how the rest of the NHS can be integrated with general practice.

The first problem is of course that it is not universally clear what integration actually means.  While most of us would sign up to integration meaning joining up the delivery of services across organisational boundaries, the term retains a looseness beyond that.

For some it means joining up delivery by removing organisational boundaries, and we see that increasingly across the acute sector with a whole raft of joint Chair and CEO appointments followed by formal merger.  For others it means  operating at a larger scale across organisations, which leads to thinking like mandatory urgent care centres across a whole ICB area.  And for yet others it means putting services in place to cater for those that fall between the gaps between organisations, although sometimes with an assumption that this can somehow be done with no additional investment and so at the expense of the existing core organisational services.

Underlying all of the policy thinking to integrate general practice is the assumption that the independent contractor model operates against it.  This has played out since the inception of Integrated Care Systems in 2022, which was the exact point in time at which any investment into the core contract ceased.  Since then the only new funding for practices has come via PCNs, accompanied with active disinvestment into the core contract with below inflation imposed settlements.

This ‘NHS good, independent general practice bad’ thinking seems to me to be fundamentally flawed.  The NHS is beset by waiting lists and overspends, none of which exist in general practice.  Plenty of organisations exist within the NHS that fail to collaborate or ‘integrate’ with each other.  And you can’t merge them all.

In fact, if what policy makers are really seeking is a ‘Neighbourhood health service’, then the scale at which nearly all NHS organisations operate at actively works against this.  Any practice or PCN that has started to build relationships with their local district nursing team will tell you how one day critical team members get moved to another area because of staffing shortages or issues elsewhere.  Local managers tell you it is outside of their control, and the work either has to start again or (more commonly) collapses.

The scale that NHS organisations work at, and the environment they operate in, means the need for efficiency outweighs the need for effectiveness.  They will always choose to move resources around at the expense of continuity of care and relationships in any local neighbourhood, as the alternative is to incur additional costs for the organisation as a whole.

The only way this can be stopped is if the organisational units delivering joined up care at a neighbourhood level are neighbourhood-sized.  The organisation itself has to have the health of the neighbourhood as its sole focus.  This can’t be done through a series of expensive NHS organisations.  Instead it needs general practice-style organisations, dare I say it independent contractors, who can then use the speed and innovation that are core components of general practice to join up care delivery and achieve the outcomes that an NHS organisational model never could.

Two years in and the integration agenda of ICBs has delivered very little.  While the overriding concept is laudable, many of the underpinning assumptions are flawed, in particular that the independent contractor model of general practice is preventing integration and that NHS organisational models enable it.  But reversing the thinking to consider how NHS services can be integrated with the existing model general practice would be much more likely to deliver real outcomes.

Whilst there is not a whole lot of change in the GP contract for next year, there are a few things that are different and worth watching out for.  All the headlines have (rightly) been about the lack of any additional funding, but that doesn’t mean practices and PCNs should not pay attention to some of the changes that have been squeezed in.  I highlight 3 things it would be wise to keep an eye on below.

1. PCNs to Performance Manage Practices?

One of the changes presented in this year’s PCN DES is that PCN Clinical Directors are now to determine whether the PCN member practices have met the key components of Modern General Practice Access.  It states:

“10.4A.3. The PCN Clinical Director must, prior to 31 March 2025, apply the assessment criteria and determine whether each improvement has been achieved (i.e. whether all assessment criteria for an improvement has been met). When applying the assessment criteria, the PCN Clinical Director must apply the criteria across all Core Network Practices of the PCN.”

This potentially puts Clinical Directors in a tricky position.  Practices will be pushing for them to claim the funding as early as possible, and yet it is down to the Clinical Director to determine whether the practices are eligible.  Without working this through carefully with practices (e.g. how will the PCN make the decision that practices are eligible?) the Clinical Director could unwittingly end up being the performance manager of practices.

2. How will the Digital Telephony data be used?

Alarm bells are also ringing with the new requirement outlined in the contract letter for practices to provide digital telephony data from October:

“In 2024/25 the GP Contract will be amended to require practices to provide data on eight metrics through a national data extraction, for use by PCN Clinical Directors, ICBs and NHS England.  These eight metrics are:

1. call volumes
2. calls abandoned
3. call times to answer
4. missed call volumes
5. wait time before call abandoned
6. call backs requested
7. call backs made
8. average call length time”

While the claim is that this will be used by NHS England and ICBs to “support service improvement and planning” it would not be a huge surprise if the system came down hard on outliers.  What will be interesting will be whether this pressure is exerted on practices directly, or whether it comes via the PCN.

In fact, the subsequent Update and Actions for 24/25 to the delivery plan for recovering access to primary care states,

“Our goals for 2024/25 are … for PCNs to review the key telephony metrics across their practices (including number of calls, average wait, abandonment time, average call length) to support quality improvement in demand management and planning of care navigation. …Separately, we plan to share data on the number of calls to 111 in core hours with PCN clinical directors to support quality improvement.”

If “support quality improvement” really means “performance manage” (because that is how NHS England operates), then pressure on PCN CDs to performance manage their practices really does look like it could become a theme for the year ahead.

3. Neighbourhood Teams: PCN-shaped or community services shaped?

In the 2024/25 Planning Guidance, that was finally released at the end of March, it was no surprise to find access as the priority for general practice.  However, integrated neighbourhood teams also feature, and the guidance states,

“As a step to building integrated neighbourhood teams and to support the integration of primary care and community services, we ask systems to help improve the alignment of relevant community services to the primary care network footprint.” p18

There is a heavy scepticism amongst some as to whether in reality this will mean PCN footprints being forced to align to community service footprints (as opposed to vice versa).  Certainly it is something to watch out for, as the guidance is written with an apparent primacy of the PCN footprint.

But this is not the end of it.  The last page of the planning guidance states,

“We will work with ICBs to ensure that each system has a plan that shows over 3 years how primary care and community organisations will work to shape integrated neighbourhood teams.” p35

While at present integrated neighbourhood teams appear to be random joint working initiatives looking at specific patient cohorts e.g. frail elderly, patients with diabetes etc, the plan for the future seems to be something more substantial.  “Integrated neighbourhood teams” may actually be a euphemism for general practice and community services operating as part of the same organisation, or at least a structured partnership between the two.  Aligning PCNs and community teams looks like it may be the first step on that journey.

The idea of integrated neighbourhood teams (INTs) was introduced over 18 months ago as the centrepiece of the Fuller Report.  Since then this report has gone on to become de facto national policy for general practice, and yet we are seeing little progress when it comes to the development of these teams.  Why is that?

The reason is because this is the way the NHS works.  General practice has been largely shielded from many of the issues that how the NHS operates causes (with the exception of those who worked in CCGs), but INTs provide an example of how the top down nature of the NHS and the many layers within it conspire to stifle innovation and new ways of working.

The Fuller Report introduces INTs as a concept, but without a detailed blueprint of what they are to be.  The closest it gets to a definition is stating that in neighbourhoods of 30-50,000 they are where “teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities.”

The intention is that local areas will develop their own blueprint of an INT to match local needs, as opposed to assuming a one size fits all model will work.  This is difficult for NHS teams, now in the form of ICB teams, because they in turn are unclear of what an INT is, and so are unsure what it is they are supposed to be implementing.  Many PCNs have had the experience of asking their ICB exactly what an INT is and been unable to obtain a clear answer.  Indeed it is not uncommon for practices and PCNs to attend ICB workshops on INTs and still come out none the wiser!

But pressure for progress at the top of the ICB has been building.  ICB primary care leads are asked to report on their ‘progress on Fuller’ with INTs at the top of the list, and performance management down the line becomes increasingly heavy handed with the lack of progress.  So at this point ICB leads have started to pick anything that is happening locally with a vaguely multi-disciplinary feel and calling it ‘their’ INT, so that they can report back up the line about the progress that is being made. It may have been a pre-existing local enhanced service, or a small pilot project that a PCN was undertaking, but before you know it it is being held up as a shining example of integrated neighbourhood working.

As an example a PCN Clinical Director friend of mine was leading a local frailty project, and was surprised to discover that this is now being held up by the ICB as being at the forefront of local INT development.  Across the patch pre-existing projects have suddenly found themselves re-labelled as INTs, and INT development seems to have become more an exercise in communications than improvement.

Up and down the country huge effort is being expended feeding information and progress updates about INTs up and down the NHS line, but with relatively little support for local teams to innovate.  When I worked in a CCG this was exactly what happened, all of the time.  The ability the same group of GPs had had to innovate and implement change before we became a CCG was lost when the layers of NHS England were imposed above us.

For general practice the lessons are twofold.  One is that if anyone can turn the concept of INTs into something that will make a difference for local populations it is front line teams and not those who operate at a distance from care delivery.  If money and resources are going to be put into INTs (whatever they are), then it may be a good idea to identify for yourselves what changes might make the biggest difference locally rather than letting the opportunity be squandered. Two is that the freedom that general practice has, and its ability to act quickly, is one of its greatest strengths, and this is what will be lost if general practice ever does lose its independence and become permanently weighed down by the heavy layers of NHS bureaucracy.

Four and half years into PCNs and it is no surprise that in that time things have not stayed the same.  One thing that has changed more than anything is the role of the PCN Clinical Director.  But has it evolved far enough?  What does the role need to be going forward to ensure future success?

When PCNs first started the role of the PCN Clinical Director was very much about start up, about getting the practices engaged in the PCN and enabling the PCN to take its first steps as a collective unit.  A whole raft of seemingly endless recruitments followed, liberally interspersed with responding to a global pandemic, setting up a vaccination programme, and an ever-increasing set of demands upon these fledgling organisations.

For much of that time the focus of the PCN Clinical Director out of necessity had to be internal.  In many PCNs no other capacity existed, so for anything to get done it was down to the PCN Clinical Director to do it.  But over time, gradually, this has changed.  PCN managers have been appointed, and more recently these have been supplemented by more senior Digital and Transformation Leads.  Throw in some administrative support and some PCNs can now even lay claim to having management teams in place.

With the rapid expansion of the additional roles many PCNs have introduced clinical leads, e.g. to look after the supervision, training and development of the clinical pharmacists or the physiotherapists or the social prescribing link workers, or to lead on some of the many operational components of the PCN DES such as the IIF or the new access requirements.  Meanwhile the role of the PCN Clinical Director has been evolving into one supporting this range of management and clinical leaders, as opposed to one directly delivering the work.

Some PCNs are much further down this road than others, but it is an important journey to take.  Looking into the future what practices will need from their PCN Clinical Director is a much clearer external focus.

The future direction for PCNs is to be part of Integrated Neighbourhood Teams (INTs).  As these have started to develop we can see that the PCN is the unit of general practice operating within these local teams.  A key part of these being successful, or making any form of difference, will be the relationships between the different organisations that are involved.  For PCNs this means that someone has to have the time to invest in building these external relationships, and that in most instances means the PCN Clinical Director.

At the same time the ability of general practice to operate effectively as a collective unit within a local area is becoming more important than ever.  Increasingly we are seeing decision making about general practice being shifted from a primarily national locus to a local one.  It is highly likely that in the coming months much more of the funding for general practice and for PCNs will come through local systems.  PCNs (like it or not) are the main units of general practice within an integrated care system, and so the voice and influence of the PCN Clinical Directors will be hugely important.

PCN Clinical Directors need to have the capacity to build the relationships with external organisations and wider local general practice to be effective going forward.  They will not be able to do this if they are stuck managing the day to day operations of the PCN.  While many have started the journey of releasing the capacity of their CD, for many there is still a long way to go.  Getting as far as possible by March next year is likely to be of critical importance both for the future success of the PCN and of local general practice.

One of the potential scenarios for next year is that the funding for the PCN DES will be shifted from the national contract and given to local Integrated Care Boards (ICBs) to commission locally.  What impact would this have?

I should start by saying I don’t know what is going to happen next year, although as I wrote last week we know more than we sometimes think we do.  I don’t have any inside track or knowledge beyond what anyone else has, but based on what we do know it is possible to hypothesise about what next year might bring.  So to be clear this is a thought experiment on what might happen, not a statement about what will happen.

We know the system is pushing for is greater local control of GP funding.  While there have been some ideas floated previously around QOF potentially being commissioned locally, it would seem to me that a much more likely target would be the PCN DES.  PCNs are the basic unit of integration for local systems, and as such it would actually be surprising if systems did not want more control over them.  PCN DES money is not technically core contract money (despite it now constituting more than a quarter of all funds coming into general practice), and so it may actually be easier to shift to local control than other parts of the contract.

What would happen if such a change was to occur?  The first thing we would see would be an increase in variation across the country.  The national contract brings a degree of standardisation which would be lost with such a shift.  We would most likely see some areas add additional local investment to the PCN DES pot to accelerate the local development of PCNs and the shift to neighbourhood working, while others would most likely view it as another source of funds that could be accessed to cut costs so that the system could get closer to its financial savings targets.

We would probably also see variation in how the PCN DES funding is treated.  Some ICBs would understand the funding to be primarily general practice funding, and be mindful of the role this funding plays in supporting the sustainability of general practice.  Others would see the funding as system funding for neighbourhoods, with general practice being only one part of what constitutes a neighbourhood.  One suspects in those areas it would not be long before the resources within the DES started to be shared across a wider group of providers.

Then there is the ‘infrastructure’ question posed by the Fuller Report.  The report stated that PCNs’ “lack of infrastructure and support has held them back from achieving more ambitious change”.  So where does this infrastructure come from?  According to the Fuller Report this would come from an at scale general practice provider or existing NHS Trust.  Would it be wholly unexpected, then, if ICBs then contracted the PCN DES money via one of these providers?

If you take into account the new provider selection regime, which is due to come in place in the new year (watch out for my forthcoming podcast with Ross Clark from Hempsons for more details on this), then actually making this happen would be relatively easy for ICBs.  Having PCNs being directly contracted by the local community or acute trust does provide the type of structural integration ‘solution’ that the NHS heavily favours.

It all feels like a high risk scenario for general practice.  While it may create local opportunities in some areas, it clearly comes with huge risks.  Of course it may not happen, but it is exactly because scenarios like this are not unrealistic that it is critical general practice in local areas work together to develop their local system voice and influence.  This way at least it is in a position to mitigate some of the bigger risks that such a change would cause.  Even if it does not happen next April the chances are high that this will come at some point, and so being prepared is essential.

Many PCNs are finding the proximity to the end of March when the PCN DES comes to end a real challenge.  Practices are disengaging from the PCN because of the uncertainty as to what is coming next, and it is difficult for PCN leaders to coral the practices into any form of collective action.  Given this situation is a period of limbo inevitable, or can a more productive use of the time remaining be found?

Well the reality is that we are not surrounded only by uncertainty.  There are some things that we do know.  We know that next year there will be a one year “stepping stone” contract, in which we will see a continuation of PCNs more or less as they are, along with some “pointers” as to what may be to come.  There will be an election next year, and so any major changes will not happen until after a new government is in place.

We know that the funding for the ARRS roles will continue.  While we do not know exactly the form that this will take, given that PCNs are to continue then most likely is that the ARRS funding will also continue more or less as is.

We know that there is not going to be any backtracking on the funding for general practice that comes through PCNs.  At present over 25% of funding comes via PCNs, and because the system’s number one goal is to “integrate” general practice with the rest of the system then it is not going to revert from 1250 units (PCNs) to 7000 units (practices).  It simply is not going to happen. We also know financial pressure on individual practices will continue, and there will not suddenly be more GPs.

We know that what is coming next is going to be some version of PCNs working more closely with the other health and social care providers in the local neighbourhoods.  The original PCN DES back in 2019 said that the DES would be “amended from 20/21 to include collaboration with non-GP providers as a requirement”.  While this never happened because of Covid, the Fuller report (now de facto national primary care policy) has outlined exactly this in its description of Integrated Neighbourhood Teams, and it has become clear since that PCNs will operate as the general practice part of these teams rather than become them.

We are also aware of a couple of reasonably significant risks for general practice.  There is pressure in the system for more general practice resource to be controlled locally rather than nationally.  It is also likely that systems will seek to access PCN resources for the sole purpose of neighbourhood working, disregarding their additional function of supporting core general practice.  Both represent significant risks if general practice is not able to influence effectively in local systems.

Given we know all these things there are two actions that are sensible.  The first is for PCNs to create their own plan to manage the end of the PCN DES.  This would include getting the relationships between the practices to a place where the opportunity of the PCN can best be maximised by all (see last week’s blog), and freeing up some of the PCN leadership time to both start the process of building relationships with local providers and to engage in work to strengthen the voice of general practice within the local system.

The second is to refresh the vision for the PCN (if there is one).  I have written previously about this, but essentially unless the practices in the PCN have their own vision for what they want the PCN to achieve then the system is highly likely to impose is its own priorities for the PCN.  With the system changes around integrated care and integrated neighbourhood teams this is more of a risk than ever, so it is critical that practices are clear on the direction they want to take together so that they can shape any future changes into this direction, rather than allowing these changes to determine where they are going.

Working together to create a plan that focusses on those things that you can control and on mitigating the biggest risks is extremely empowering.  It is a much better way of dealing with the uncertainty than taking no action and waiting for a new direction to be imposed, and is one that is much more likely to achieve a better result for both the PCN and its practices.

The NHS Confederation has published a new document entitled, “Supporting General Practice At Scale: Fit for 2024/25 and beyond”.  In it they have, “identified a set of tangible recommendations for the upcoming GP and primary care network (PCN) contracts for 2024/25”.  What are they saying, and what might this mean for next year’s contract?

The first question is why the NHS Confederation are producing such a document at all?  It seems the answer to this lies somewhere in the midst of the fact that discussions between NHS England and the BMA/GPC have not progressed over the last two years (hence two years of imposed contracts) and so NHS England has started to turn elsewhere to have conversations about the future.

Whether the NHS Confederation, an NHS membership organisation that within primary care has PCNs and GP Federations as its members, has legitimacy to talk on behalf of core general practice is questionable, but that hasn’t prevented the publication of this report, and someone, somewhere is funding this work.  The NHS Confederation Primary Care Network is clear that its aim is to “drive the future direction of primary care”, and the report explicitly states that NHS England and DH participated in its production (p9).

The report talks about contracts for practices and PCNs, as if the two are separate.  At present the PCN DES is a part of the national GMS contract, but without explicitly calling for the two to be separated the report does treat them separately.   Are PCNs a group of practices operating together and so an extension of practices, or are they separate entities in their own right?  The gap between at-scale GP organisations and their member practices is what ultimately has caused most of them to fail, and such a separation will likely have disastrous consequences for both practices and PCNs.

The report reinforces the now prevailing belief that next year (2024/25) will be a “stepping stone” contract (p8), ie one with limited change but which will start to point towards a future direction.  It talks about having “Pathfinder” PCNs in 2024/25 to model new ways of working for PCNs that can “demonstrate a level of maturity and innovation” (p19).

The document lays out the “asks” that it says will underpin the future direction for general practice.  Some of these are very specific, including to explore limited liability partnerships holding PMS and GMS contracts, and the contract to rise with a new pay uplift clause.  It also has this as a short term ask, “Explore proven delivery models that will improve practice resilience and sustainability, enabling a mixed economy that continues to support access to services for patients” (p13).  It is not clear what this actually means, but it could be read as a pointer to NHS organisations running practices.

There is also an ask that, “National primary care contracts should be streamlined, retaining a core national focus on areas of high impact” (p19).  Again, it is not clear what this means.  It could mean less prescription on what is required, or it could mean shifting funding out of the national contract and into local contracts, and the problem is people will hear what they want it to mean.

The report contains many of these “asks”.  The report is worth reading to see what they all are.  Many are sensible, some less so, and some have an obvious bias towards at-scale general practice.  The biggest problem, greater than the lack of clarity as to what some of the asks actually mean, is understanding who is asking whom for these things.  Implicit is that primary care is asking NHSE/DH, but there is some considerable distance between the asks in this report and the ‘Call to Action’ document produced by the BMA earlier this year.  I suspect a substantial number of these asks would struggle to gain support if they were presented at the national LMC conference.

But NHSE and the DH want to move forward with their plans for general practice, and if the BMA will not engage with them in a conversation about these plans it is hardly surprising that they are turning to those that will.  This in turn means that despite the mandate issues around this document it potentially could have very significant implications for next year’s contract, and this is probably our first glimpse of the types of things we can expect to see coming.

NHS England has issued an update on next year’s contract.  For the second year running no deal has been reached between the GPC and NHS England, and as a result the 5^th year of the contract agreed in 2019 will be imposed on the service. The update essentially outlines the changes within that contract that NHS England is able to make without it being a formal variation of the contract.

The changes that have been made by NHS England are not the real issue.  What is important is what is missing from the contract.  It is easy to be distracted by the headline noise around access, but the main problem with this contract is the lack of a funding uplift.

The 5 year contract was agreed at the start of 2019.  The inflation rate at the time was 1.8%, and at that point inflation had been low and relatively stable for some time.  The rises to the core practice contract (ie excluding the PCN DES) were set as follows (p51), based on predicted inflation levels:

• 2019/20 – 1.4%
• 2020/21 – 2.3%
• 2021/22 – 2.8%
• 2022/23 – 2.5%
• 2023/24 – 2.7%

Of course what has happened over that time period is that the cost of living has risen significantly beyond what was predicted back in 2019.  Inflation had risen to 8.5% in March 2022, peaked at 11% in October 2022 and currently remains above 10%.

The number one and overriding issue is that the imposition of the contract last year meant a 7-8% real terms cut in funding for the service last year, and means a similar cut this year (because of the difference between the rate of inflation and the agreed rise to the core contract).

The agreed NHS pay rise this year was 4.5%-9.3%, depending on your starting salary.  The little over 2% that was provided to general practice does not cover this kind of rise.  So it is not just GP partners it is all practice staff who are suffering as a result of the refusal of NHS England to negotiate a reasonable level of uplift.

I am sure the counter argument will have been that additional funding beyond the increase to the core contract has been provided via the PCN DES.  But practices know better than anyone else that PCN funding does not pay the staff, or any of the other eye-watering practice bills that are dropping through the surgery door.

General practice cannot survive this year on year cut in funding levels.  All the discussion about access is just noise, obscuring this core issue.  General practice is agile and nimble and can manage the access changes. There are plenty of solutions out there (e.g. here).  The bigger risk is that the access issue, for which general practice will have little or no public support, is allowed to obscure the lack of funding to meet inflation issue, for which support is likely to be much greater.

It is up to the BMA team and national GP leaders to keep the issue focussed on the money, and away from discussions about access.  Losing sight of this is the biggest error general practice could make right now.

A lesson for general practice must also be that 5 year deals have to become a thing of the past.  NHS England have demonstrated quite clearly that they cannot be trusted with the level of variables that 5 years creates.  A trustworthy contract partner would have recognised the discrepancy between predicted and actual inflation and made good on the gap.  Now we know this won’t happen all future deals need to be kept short term.

We wait to see how the GPC and national GP leaders encourage the service to respond to the imposition of next year’s contract.  I don’t think the same quiet acceptance that we saw last year is likely this time round.  A key part of getting the response right will be making sure that whatever it is it is clear, simple to understand and focussed on the cut in funding.