London have produced what they are terming a “target operating model” for a neighbourhood health service for the region.  What insights does it give us towards the future, and what are the implications for general practice (both within and outside of London)?

The documents are long, somewhat repetitive and it is not easy to get underneath what they mean.  However, I think there are three main areas of interest for general practice: insights into neighbourhoods themselves; implications for PCNs; and what it terms the “integrator function” and its role and relationship with general practice.

Despite the length of the documents ‘neighbourhoods’ remains a somewhat fuzzy concept. There is a confusing relationship between a neighbourhood and an Integrated Neighbourhood Team (INT), one it describes thus:

The neighbourhood health service extends beyond the concept of INTs, but INTs are one of the main delivery vehicles for improving coordination and outcomes of care within each place and neighbourhood. (p13)

The main issue that sits unaddressed throughout the document is the relationship between the core activity of organisations (like GP practices) and the additional partnership work (INTs?) that comprises the ‘neighbourhood work’.  If all core work is neighbourhood work how is it different?  But if neighbourhood work is additional (i.e. through these multiple INTs), how will it be staffed and resourced?  There is no mention of any extra resources throughout this document.

The starting point for PCNs in these documents is that they are deemed to have failed:

Across London, our PCN clinical directors and wider stakeholders have indicated how the development of PCNs has often not delivered on some of the promises, beyond the narrow objective of providing a vehicle for the employment of additional roles. (Case for change p23)

A new primacy is given to the footprint of neighbourhoods, which is to be determined by local place boards.  Should the footprint of PCNs not align to these neighbourhoods then PCNs are expected to either reconfigure so they match, or to develop “arrangements capable of operating effectively across more than one INT”.

Then there is the thorny issue of funding and resources for neighbourhood working.  The document says this:

In the absence of significant additional funding from outside of places and systems, such functions will need to harness existing assets and resources within our core community-based providers and teams. (p26)

This feels like a heavy hint towards ARRS staff, a suspicion that is seemingly confirmed later in the document when in its plan for what will happen in the next 6-12 months it states it will be:

Working with primary care colleagues to maximise the impact of existing resources including the Additional Roles Reimbursement Scheme (ARRS) funding; GPs with Extended Roles (GPwER); current and new community-based roles. (p33)

These decisions are to be made at place-based boards, and so (once again) this highlights the urgency of ensuring PCNs have effective representation and influence on these boards.

The other key area of interest for general practice in these documents is what it says about the “integrator” function (a term we first came across in the Fuller report).  This is an existing local organisation that will be selected by the local place board to host the necessary functions that will enable neighbourhood working across the constituent individual organisations across health and care (including practices).

The document talks at length about the different roles the integrator organisation will have to take on, and I won’t repeat them all here. However, one very specific role that is worthy of mention is:

Having the ability to offer additional support options to any part of the partnership, including at individual practice level, experiencing difficulties which threaten the sustainability of the INT and the local neighbourhood health service as a whole. (p20)

Delivery of core primary care (while not an INT) will apparently fall under the neighbourhood responsibility.  This is explained thus:

An enhanced offer of support to primary care in the context of the neighbourhood health service, is not about attempting to take over contracts or services, mandating specific models of primary care ownership and delivery, or ignoring existing support structures where these are already working well. Nor is it to ignore the role the whole system plays in making each part sustainable, and a good place for health and care professionals to work. However, acknowledging the core role that primary care plays in neighbourhood delivery is also to acknowledge that we cannot proceed with implementing a neighbourhood health service without ensuring that primary care colleagues have access to the right level of support and services, wherever they are based in London, to enable INTs to function and thrive. (p10)

So, integrator organisations are to be identified, and they are immediately to take on this role of providing support at an individual practice level. This makes the decision-making as to who takes on the integrator function extremely important for general practice.  Unfortunately, the organisations listed that could take on this role are limited to “community providers, vertically integrated acute trusts and local authorities or any other existing organisations capable of operating at the scale and with the local connections to support related INTs to succeed”.  Conspicuously absence from this list are GP federations (and, to be fair, acute trusts).

There is some hope, however, as the function may not lie always lie solely with a single organisation:

In some places, these functions will be hosted within a single organisation with the capacity and capability to support neighbourhood working across all neighbourhoods. In others, integrators may work with one or more local partners to provide the range of required support. (p19)

This leaves the door open for GP federations, and maybe even groups of PCNs, to work in partnership with lead integrator organisations.  Indeed, there are not going to be many community providers or local authorities with the skills to provide direct support to practices.  But the integrator organisations are to be identified quickly, so the time to build alliances is short.

This plan may be specifically for London, but similar ones are likely to arise across the country.  If we take this alongside the model ICB blueprint which outlined a shift of responsibility for general practice from ICBs to “Neighbourhood Health Providers” then what all this points to is neighbourhoods and their organisational manifestations (like “integrators”) becoming much more involved in the delivery of general practice, with PCNs increasingly looking like they will be falling down the pecking order.

Neighbourhoods can be a frustrating concept.  Noone seems to be able to define what they are, and they have the feel of the latest initiative, one that will inevitably come and then go, like so many of its predecessors.  Given this, why should PCNs and practice engage with neighbourhoods?

It is an important question.  Too often local areas jump into what neighbourhoods should be doing (risk stratification etc), without taking the time to articulate why the work is important for general practice in the first place.  I understand the frustration with yet another new concept coming along, but I think there are four reasons why practices and PCNs do need to take neighbourhoods seriously.

1. To join up care for the local population. The frustration of many practices for many years now has been the increasing distance between themselves and community teams such as district nurses and community midwives.  The opportunity that neighbourhoods presents is to bring back those linkages, and ensure all of the local community service provision is joined up.

At present the scope of influence of practices and PCNs is very much limited to the work of the practices themselves.  Neighbourhoods provide an opportunity to shape how all of the services working in the community can operate to deliver the best possible outcomes for the local population.

2. To shape service delivery models. Too often in recent years practices have been on the receiving end of centrally defined enhanced service specification that they know are not going to achieve the outcomes that are being sought for their own patients.  These one-size-fits-all specifications fail to take into account the nuances of the local care homes, or local population groups, or whatever it is that is specific to the local area.

The opportunity of neighbourhoods is not only to be able to join up care delivery across providers but also to design and tailor service delivery models to the needs of the local population.  The whole point of neighbourhoods is enabling those front-line staff that best understand the needs of their population to create the service models that will have the biggest impact.

Just as a side note on this, not everywhere seems to have grasped this yet.  If your local ICB are still pushing one-size-fits-specifications to be implemented across all the emerging local neighbourhoods then do push back.  Establishing the freedom and autonomy of each neighbourhood to design its own care delivery models is an important first step that needs to be taken as early as possible.

3. To ensure general practice leads the work. Like them or not, neighbourhoods are coming, and GP practices and PCNs are going to be part of them.  The choice is either to engage early and establish the leadership role that general practice should be playing within them, or to ignore them and let others take up the leadership mantle.

Unsurprisingly, community trusts, mental health trusts, acute trust and councils are all very keen to play a leading role in neighbourhoods.  If practices and PCNs choose not to engage then there are plenty of others who will.  This will result in others controlling how the neighbourhood works and (importantly) how resources are deployed, with potentially hugely negative implications for general practice.

4. To shape the shift from hospitals to communities. Neighbourhoods are being established as a vehicle to enable the government’s promised shift of services from acute to community.  PCNs and practices need to be at the forefront of their development to prevent a continuation of the unfunded and unthought through shedding of activity by hospitals and turn it into an opportunity to create a prosperous future for general practice.

It very much feels like the future of general practice will be inextricably linked to neighbourhoods and how they develop.  This means the stakes feel too high for them to simply be ignored, and the sensible move right now is to take an active role in shaping them.

In a tumultuous couple of weeks for the NHS the government announced that NHS England is to be abolished, and that Integrated Care Boards (ICBs) are to reduce costs by 50% by October.  What will these changes mean for general practice?

The BMA does not come out either in favour or against the abolition of NHS England, seeing the potential of the removal of a layer of bureaucracy but expressing concern about the disruption such a change will bring.

The staff affected have already not been well treated by the way the communication has been handled, and the political point scoring around reducing bureaucrats has exacerbated this.  It is inevitable that the changes are going to cause a huge amount of disruption, and I very much feel for those caught up in the middle of all this.

My sense, however, is that the biggest impact on general practice will not be just the turmoil of the coming months.  In the medium to longer term these changes could impact the freedom of local areas, fundamentally change local contracting arrangements and potentially have significant implications for the future of the independent contractor model.

1. The Freedom of Local Areas

The Department of Health insists the changes will lead to more devolution of powers and responsibilities to local areas.  However, concerns have been raised in certain quarters (in particular outgoing ICB Chair and former Secretary of State Patricia Hewitt) that overbearing performance management by ICBs and NHS England regional teams will simply be replaced by (worse) micromanagement direct from the centre.

What remains to be seen is whether as part of these changes the government is prepared to relinquish the notion of “grip” that came to the fore 20 years ago and support local innovation and autonomy, or whether it will simply seek to centralise the mechanism for exercising control.

The status of general practice as independent contractors has largely protected it from the control the NHS machinery inflicts on front line providers and local area teams.  Those GPs who have engaged with CCGs and ICBs will have experienced it, and it is something that has undoubtedly contributed negatively to both NHS performance and staff experience in recent times.

However, it is likely to become much more relevant to general practice because this freedom (or control) will apply to the new neighbourhoods that emerge from the forthcoming 10 year plan, to which the future of general practice seems inextricably linked.  Even in his letter to the GPC confirming the government’s commitment to securing a new substantive GP contract Secretary of State Wes Streeting said he was committed to, “deliver meaningful reform to establish a modern general practice at the heart of a neighbourhood health service”.

The desire for central control has stifled local innovation and freedom to act, and diverted huge amounts of time, resources and energy away from driving local change.  The changes could be positive and mean neighbourhoods have a freedom to shape services to meet local needs that has been absent in recent times, or it may have the opposite impact. We will have to wait and see to find out.

2. Local Contracting Arrangements

The biggest direct role of NHS England and ICBs concerning general practice has been contract management and support via the local primary care teams.   After their dismantling in 2013 when responsibility was shifted from PCTs to NHS England, and then shifted to first CGGs and subsequently ICBs, it is not a surprise these have not been in great shape in recent years (although some have done remarkably well despite all of this).

There has been more of a focus by the centre on the contract itself in recent years, e.g. when primary legislation was passed in May 2023 changing the contract to require practices to respond to patient requests on the day the request is received.  In this year’s planning guidance NHS England promised a new “Commissioning and Transformation Support Programme” to support ICBs to “create the right conditions for improving general practice, including contractual management and transformation”.  This was backed up by Secretary of State condemning “unwarranted variation” in GP performance and exhorting ICBs to target practices who are “coasting”.

So, the question is whether these latest cuts mean all of this will fall by the wayside, or will we see a more distant, impersonal and potentially harsher contract management approach being taken towards general practice?

Meanwhile it is neighbourhoods that have been tasked with improving access to general practice.  What we need to look out for is whether it will be neighbourhoods as they emerge who take on the role of local general practice contract support, or whether we will see a shift to a more formal style of GP contract management from larger more remote ICB teams.

The demise of NHS England and shrinkage of ICBs may even lead to local providers taking on the GP contracting role.  The HSJ has suggested that the changes will inevitably lead to the rise of “local care organisations”, with a lead provider responsible for neighbourhood services.  The predominance of acute trust CEOs on the NHS England transition executive, along with the model already operating in new NHS CEO Jim Mackey’s home patch of Northumbria, may signal a shift to these being led in many places by the local acute trust.

3. The Independent Contractor Model

The lack of anyone to manage the GP contract even raises the question of what the consequences could be for the independent contractor model.  In what is unlikely to be coincidental timing, the Nuffield Trust have just published a report questioning the longer term viability of the partnership model, and called for alternatives to be urgently explored.  The Secretary of State has seemed more positive in recent weeks about the model, but has in the past suggested a wider range of options also need to be considered.

Even if the core national contract remains into the longer term, it does seem there is the very real possibility that local enhanced service contracts will be picked up and managed by lead local providers overseeing the new neighbourhoods.  This in turn could well accelerate the development of other models for general practice, as local areas seek to replicate the type of model in existence in Northumbria.