It is Time to Stand Together

One of the big complaints the system has with general practice is that they say it is impossible to do with business with 6,500 different individual businesses.  Indeed, one of the main rationales around PCNs was to reduce that number down and create units of general practice that mapped onto local neighbourhoods.

But the reality is the system does not have to deal with 6,500 GP practices individually.  There is one contract for all of those practices, and so dealing with general practice is far more efficient than all of the local contract negotiations that take place individually with each of the provider trusts.

While general practice absorbs its own risk and never returns a deficit to the system, the rest of the NHS is running up debts of £1.5bn a year.  What general practice has to do is absorb its costs, often by partners, GPs and the staff working in practices having to do so much that their own health starts to be affected.  Despite the year on year cuts to funding with the recent below inflation contract impositions, activity across general practice has continued to rise.

An outsider might expect the system to be grateful.  At least one part of the system is living within its means and not adding to the wider financial woes of the NHS.  But that is not how the system is reacting.  Instead what we have is a purported offer to increase the core contract by 1.9% next year. This is well below inflation, and so represents a further cut on top of all those experienced in recent years.

A local commissioner would not get away with such an offer to its local hospital trust.  Threats of cuts to essential services and (if necessary) some gentle winding up of the local MP and newspaper would soon force the commissioner into a more reasonable offer.  Yet for some reason NHS England thinks it can get away with making this offer to general practice.

Why is that? Is it because each practice is so small that individually they are not able to make the kind of noise that actually matters?  Is it because the dispersal across 6,500 different practices means the individual impact is hard to quantify and turn into patient stories?  Is it because the pain of the junior doctor and consultant strikes is worse than any that is likely to be caused by GPs, and so general practice is seen as a soft target?

The government’s response to criticisms of its failure to invest in general practice is to point to its overall increase in investment in the NHS.  While the overspend is so big not everyone can receive additional money, and so it very much looks like general practice has been identified as an area where spending can be tightened to relieve pressures elsewhere.

So general practice has to stop being a soft target.  At present it is too easy to cut money from the service, because while it is the pain is only going to continue.

The way to do that is to stand together.  A voice that is spread across 6,500 practices is not powerful.  But a single voice across those practices is.  The system might think general practice is a diverse group, but practices come together every year via the GPC to negotiate a single contract.  And the stronger the unity across the group, the greater the negotiating power.

The system wants to move to local negotiation for general practice because it understands the latent power the national collective holds.  It has been quite some time since the service has exercised this power, but now is the time.  Practices need to make sure they are all members of the BMA (whatever they think of the BMA, because unity is power), and back Katie Bramall-Stainer and the leaders of the GPC to the hilt.  Now is the time to stand together, and demonstrate to the NHS that general practice is not a soft target.

Who Should Fund GP Representation in ICSs and Neighbourhoods?

The question of who should fund GP representation in ICSs and neighbourhoods was raised with me recently, in the context of concerns that locally the funding for this currently provided by the ICS might be reduced or even stopped.  If ICSs won’t fund it should practices or PCNs fund this themselves?

The immediate reaction to a question like this is that there is insufficient capacity at practice level as it is, and so any other demands are unlikely to be able to be met, especially if they are not funded.  It is hard enough meeting the time demands PCNs place on practices, let alone anything beyond that.

But I am not sure it is quite so simple.  Taking a head in the sand approach to anything that happens outside of the walls of the practice could end up meaning that the practice is not able to survive as it is into the medium or longer term.  We know there is a push for more general practice funding to be held and controlled within local systems (rather than via the national contract), and part of neighbourhoods is about how the system and general practice work together.  Leaving decisions to others about how funding is to be used and how this integration should develop feels extremely risky indeed.

Part of the problem is that many of the ‘primary care leadership groups’ that have been set up up and down the country have been established by the ICS rather than by general practice itself.  The group has an ICS legitimacy, but not one that runs from practices up to the people sitting round the table ‘representing’ general practice.  The danger with this scenario is that it becomes a group where general practice is informed of decisions that the ICS has made (rather than actively participating in the decision making), and a place where the rest of the system can come and tell general practice all of things it wants general practice to do.

So actually any reduction or cessation of funding by the ICS for this work may represent something of an opportunity.  The choice is not a binary one of either continuing to attend system meetings or not.  If general practice is going to have to pay for this itself (most likely through development, PCN or federation resources) then it can design for itself how this is going to work.

This is unlikely to continue to involve mass attendance at ICS-controlled meetings.  Instead it is more likely to be meetings that bring general practice itself together (PCNs, LMC, federation etc) to identify priorities and coordinate (likely much smaller) representation elsewhere.

Funded or otherwise there is a need for general practice within each local area to find a way of working together as a collective and organising itself.  Since the demise of CCGs there are no longer any obvious system advocates for general practices outside of practices themselves, and a collective strategy of hoping the system sees sense is not going to be sufficient.

Ultimately it also works in the system’s interest to have a collective general practice voice so I would still expect the majority of places to be open to providing at least some level of funding for this.  But if they don’t then local GP leaders need to access whatever resources they can and get creative in building mechanisms to ensure the local GP voice is heard.



Katie Bramall-Stainer gave us an interesting insight into the state of contract discussions when she revealed that the push back on including GPs in the Additional Role Reimbursement Scheme (ARRS) is because of the challenge of demonstrating that these GPs are “additional”.  The quote from the Pulse interview is this,

The challenge that is given back [from the Government and NHSE] is: how does that prove additionality? The comeback to that is that GPs aren’t additional. Then let’s describe a number of GP roles which will absolutely be additional and which would bring [NHSE] what they want from a neighbourhood integrated team angle and what we would need, for the work that we’re already doing in practices, but that actually falls outside the contract.”

At the same time GP partner income has fallen 20% this year and the financial challenges GP partners are experiencing is leading some to the position where they are even having to lay off GPs.   So now we are in the position where there are insufficient GPs (6,000 short by the government’s own reckoning), but practices cannot afford to employ the ones they have.

I am not sure there is any need to rehearse here the reason for the current financial situation, but suffice to say the last two annual contracts have been imposed on general practice with an inflationary uplift agreed in 2019 of less than 3% when actual inflation was running at over 10%.  Less money has been invested into general practice than any other part of the NHS in the last three years, to the extent that now the general practice percentage of NHS expenditure is lower than it has been since 2015 (ie the disinvestment has undone any of the 2016 GP Forward View and 2019 contract investment and we are now back at a worse position than when the crisis in general practice was first acknowledged 8 years’ ago).

The idea of demonstrating ‘additionality’ can only be relevant in the context of overall investment.  It comes from the (unfounded yet persistent) fear government/NHS England have that any investment into general practice will end up as additional profits for practice partners rather than in benefits for patients.  But in the context of disinvestment the notion of additionality becomes redundant, as the most that practices can do is try and maintain service provision within the reduced resource envelope.

70% of GP practice costs are staff costs.  Inevitably, then, when practices need to reduce costs they need to review staffing and skill mix (like any organisation).  A significant amount of funding for staffing is now contained within the ARRS, which cannot currently be used for GPs and instead can only be used for a determined list of additional roles.  No surprise then that practices are starting to have to replace GPs with the cheaper, funded roles.

Allowing practices to use ARRS funding for GPs would put a stop to this crazy situation.  Demonstrating we have additional numbers of pharmacists and physiotherapists to the numbers we had before is not additionality if at the same time we are having to sacrifice GPs and other members of the core practice team.

Without investing additional funds the concept of additionality is null and void.  Money is required not for GPs identified as being additional to practice work, but just for GPs full stop.  What is really needed is sufficient investment into the core contract to the point where it really is additional (as opposed to replacing recent cuts).  Enabling the ARRS funding to be used for GPs is just common sense given how unlikely such a rise is, and should come without any additionality caveats.

Integrated Neighbourhood Teams: A lesson in how the NHS functions

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.

Guest Blog: Paul Conroy: The Danger of Making GP Practices LLPs

The NHS Confederation document Supporting General Practice At Scale: Fit for 2024/25 and beyond recommends that Limited Liability Partnerships (LLPs) should be able to hold GMS and PMS contracts and limit GP partner liability “helping to modernise the partnership offer”.  But this, and the document’s use of the use of the word ‘devolution’, got me thinking.

In 1985 the optical market was deregulated – meaning that you no longer had to be an optician to run an optical business, and Doug and Mary Perkins set up Specsavers. By 2012 they represented 42% of the UK market, and the top three multiples held 66% of the market. With a growing online offer, independent businesses had already shrunk to 28% of services.

In 1999 the same thing happened to Vets, with Vets4Pets, the in-store service for Pets at Home, scooping up a vast market share amid a scramble of venture capital investment.

In 2003 Dentists were next, and Oasis Dental consolidated much of the market, aided by a team of senior leaders and investors who’d cut their teeth in the earlier professional market consolidations.

Similar stories play out in Pharmacy, Accountancy and Solicitors, with traditional models swept aside by larger corporates with a near identical structure;

  • A Joint venture partnership model at local branch level, where the professionals delivering the service are partners with the ‘head office’ in owning and sharing the profits of the site, often as an LLP.
  • A powerful head office function, with a strong brand, buying power to drive the cost of stock and consumables down and a franchise-like approach, drawing profits from being a partner at local level.
  • Separate estates arms held as a real estate investment trust (REIT), allowing the property element of the business to be funded by stock exchange investors.

In 2013 it appeared our time in General Practice had come. The shift in NHS pensions directions and a decision by NHSE that all future contracts would go out as APMS, rather than GMS certainly looked like a deregulation event. Plenty of corporates have tried in the decade since. A number of major players have come and gone, though none with joint venture partnership models to retain the professional involvement at practice level. Some have seen pretty ugly examples of quality and safety. The number of practices owned by ‘multiples’ has grown, the average size of practices has doubled in the last decade, and the number of practices open in England has slumped by a quarter in the last five years. Is this a slow burn or a false dawn? We would do well to watch for signs of history repeating itself, and whether LLPs might be the spark.

But context is everything. The Confed piece is overwhelmingly more focused on vertical integration with existing NHS providers – the acute trusts that make up the traditional core of their membership. And Acute trusts are as likely to benefit from LLPs and indeed, the Specsavers approach as corporates, with JVPs as a useful way for Foundation Trusts to extract value, leverage their purchasing power and burnish their brands. The approach doesn’t stipulate who the consolidator will be, just how it has previously been structured. Perhaps the theoretical independence of Foundation Trusts will come to the fore at this point – ironically when we are supposed to be moving away from the internal market.

But it was the use of the word ‘devolution’ that really caught my eye. Call me a cynic, but it seems to me the political examples of devolution in Wales, Scotland and the English cities and regions have largely been about outsourcing the blame for financial control that doesn’t follow with the responsibility. As talk of localising the GP contract and removing QoF in favour of local priorities grows, we must keep an eye on who becomes the scapegoat for the cuts that inevitably follow from stalling investment in services.


Paul Conroy

Practice Business Manager, Denmark Street Surgery, Darlington

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