The last couple of months have seen a huge turnover in the people of influence over general practice.  We have a new Prime Minister, a new Secretary of State for Health, and now the National Lead for Neighbourhood Health has resigned.  What will these changes mean for neighbourhoods and for general practice, and will the result be positive or negative for the service?

While it is hard to predict the exact nature of the changes that will follow, we already have some early indications of what might lie in store.  It is clear that the big priority for Andy Burnham is reforming social care.  He wants to put it on an equal footing to the NHS, so that it becomes available to all regardless of ability to pay.

While that may feel one step removed from general practice, underlying such a change is likely to be the removal of the barriers that exist between health and social care.  The new Prime Minister and the new Secretary of State for Health and Social Care Yvette Cooper were both proponents of integrating health and social care when they ran to lead the Labour party in 2015.

This is relevant when it comes to neighbourhoods.  While the basic idea of all services being coordinated together across a neighbourhood, and Labour’s push for a “neighbourhood health service”, are still popular, the interpretation of this is likely to end up with a much more inclusive approach than we are currently seeing.

Indeed, Sir Jim Mackey’s said, as reported in his recent interview with the HSJ, ”Yvette and other ministers have told me directly that they’re worried the NHS has got less good at working with councils, less good with working with partners”.

It is reported that her view is also a concern that neighbourhood teams are not having enough of an impact, particularly on specific groups like young people and the elderly, and that there is too much focus on contracts and “moving structures around”.

If we take this, alongside the lukewarm response from the service to the consultation on the proposed new contracts, and the fact that now, all of a sudden, Claire Fuller has resigned as National Lead for Neighbourhood Health, everything is pointing to what the NHS likes to call a “reset” when it comes to neighbourhoods.

Indeed, the HSJ has mused that neighbourhoods, “Could be recast around the population groups Ms Cooper has named (children and young people, maternity, frailty, older people and end-of-life care), and around government plans on social care and public service reform”.  This does feel likely.

Equally the push for new contracts may fall down the priority list.  The main response from general practice to the recent consultation, in particular from the RCGP, is that it does not make any sense to jump into the new contract models until there is evidence that neighbourhood working actually works.  It sounds like Yvette Cooper is also keen to focus on finding what makes a difference, so she may well have a lot of sympathy for this point of view.

Meanwhile, the GPC, with its new Chair Dr Claire Bannon, has succeeded in getting the government to commit to bilateral negotiations with the GPC, which is an important step forward for the service compared to where it ended up last year.  Maybe more sensible negotiations about general practice funding can follow.

Money is being taken out of the service at an alarming rate (over £100M in the last 10 months according to a GPonline estimate) via the current list cleansing drive, and this could be only a fraction of the total amount that this initiative ends up taking.  Will this money be reinvested?  The review of the Carr-Hill formula, along with decisions about a way forward, is also long overdue.  The importance of general practice having a direct input into these discussions cannot be overestimated.

Neighbourhoods, core practice funding, and negotiating a new contract are all big ticket items for general practice right now.  It feels like we are on the precipice of major changes for each.  The introduction of the new personnel has been broadly positive in this respect so far, but with the caveat that we are at a very early stage and we will have to see how this develops over the coming months.

The recent consultation on the proposed SNP and MNP contracts is underpinned by the belief that it would be better if general practice worked at greater scale.  In fact, to some observers the main outcome of the proposed changes would be to achieve exactly that.  The question is whether this is something that general practice should go along with or actively resist?

While the consultation is at great pains to stress that the core GMS contract is out of the scope of the changes, it then goes onto include these goals in the overall aims (10):

• ensure that enhanced primary medical services can be commissioned alongside other neighbourhood services, where appropriate, within a single contractual framework (i.e. to shift the commissioning of enhanced services from individual GP practices to an at-scale organisation)
• enable an at-scale organisation, working closely with general practice within a neighbourhood, to coordinate the consistent delivery of neighbourhood health services across multiple neighbourhoods (i.e. to develop at-scale provider organisations managing delivery across individual GP practices)
• encourage sustainable primary medical services at scale, including GP-led provider organisations, which have the capability to hold and deliver population-based contracts (i.e. to create at-scale organisations that GP practices will be part of)

It is undeniable, then, that a consequence of the proposed changes will be to reduce individual GP practice autonomy.

The NHS, and in particular NHS England, works under the assumption that it would be better if general practice worked at a greater scale than it does now.  It does not make the case for this.  Instead, it operates on the basis that this assertion is self-evidently true, with no need to justify it.

It is interesting to note recent developments with acute trusts.  Only a few years ago, NHS England did the same thing with them.  They made it clear that it would be better for acute trusts to be operating at greater scale under group models.  It treated the benefits of operating at such scale as self-evident, and trusts were pressured into moving into these arrangements, without any formal policy to this end being put in place.

But now we are seeing these arrangements unravel.  As just one example of many, a review into the group arrangement between Hull and North Lincolnshire and Goole found that “the current partnership arrangements do not provide sufficient clarity of local accountability and organisational focus, while HUTH and NLAG predominantly serve distinct populations and work within different local health and care systems.”  As a result, the arrangements are now being undone.

Meanwhile NHS England distances itself from the failure.  Indeed, it was NHS England that commissioned the review of the arrangements in North Lincolnshire that found them to be lacking.

The lesson, then, is to ensure that any changes that are made stack up in their own right.  Making changes because that is what everyone else is doing or because it seems to be the overall policy direction is not a good enough reason in itself, and is one that is likely to come back to bite practices in future.

The experience of general practice operating at scale to date is that it works most successfully when it generates a real source of additional income for member practices.  Providing a tangible return for practices, whether it is directly via a dividend or additional revenue streams, is the key to success.

The main problem with the NHS England proposals is that while they detail how layers will be introduced above general practice, and so how the independence of individual practices will be taken away, they are extremely light on how (or even whether) any additional income will come to practices.

This is the critical flaw.  Why would practices give up their independence in the ways outlined with nothing coming in return?  While there are hints at how this might enable the much-vaunted shift from secondary to primary care, there are no promises.  A brief glance at history suggests this is not a funding flow that can be relied on.

Operating at scale through SNPs and MNPs is not self-evidently a good thing.  It is no good simply explaining how it will work.  A case needs to be made for it, one that would most likely state how it would result in increased income for practices.  But as it stands this is lacking, and without it the case for actively resisting these proposals is the one that feels most compelling.