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.