29
apr
0

Who Should become an IHO?

Posted by Blogs, The General Practice BlogNo Comments

There was a fascinating session at the PCN Plus Conference in which colleagues from West Essex presented how they are working together.  This included leaders from the acute trust, community services, social care, general practice and the ICB.  What they presented really challenged my thinking about who should become an integrated health organisation (IHO).

Plenty of people working in or with general practice, including myself, bring a healthy scepticism to the notion that an acute trust could or should be identified as an IHO.  Just the idea of the acute trust holding the funding for general practice is enough to bring most people in the sector out in cold sweats.

This is not without good reason.  There is little or no track record of acute trusts investing into general practice and community services.  Those of us with long enough memories remember that community trusts had to be separated from acute trusts only 20 years ago because of the stripping of community resources to fund acute services.

But there is an argument that it would make sense.  If you take any local health community with an acute trust at its centre at least half of the total funding is going to the hospital.  They have the deepest pockets, and are the ones most able to make any shift occur.

The problem is we don’t trust them to do this.  We know the financial pressures acute trusts are under, and expect any widening of their income to be used to ease this pressure – to the detriment of all other providers.

So it was hugely refreshing to hear Thom Lafferty, the CEO of Princess Alexandra Hospital, talk about the need for a shift of resources to primary and community care.  He was clear that the solution to the pressures his hospital is under will only come from a change in the way the whole health community operates, and that this requires a shift of resources out of his acute.

The GP leaders had clearly bought into this.  The GP leaders came across as extremely astute and well informed, and so this isn’t a case of the wool being pulled over their eyes.  Trust has clearly been built, and there were concrete examples of how the Trust is actively trying to support general practice, such as providing estates.

What was even more interesting was the CEO sharing how he was coming under pressure from NHS England because of the challenges they are experiencing with acute operational targets.  When he explained to them that his plan to address these was founded on working across the whole health community (in line with NHS England’s own strategy!) it didn’t sound like this was what NHS England wanted to hear.

This raises a really interesting question.  Which are the best organisations to become IHOs?  Do we want it to be the trusts that have their finances, waiting lists and waiting times under control?  Because won’t they want to protect what they have, and be the ones most likely to continue the historic shift of resources from community to acute care?

Wouldn’t it be better for it to be those acute trusts with performance challenges who genuinely believe the only way out of their current predicament is a change in the way the whole system operates (like Princess Alexandra)?  Surely the key point is not one of operational grip, but rather of a genuine, bought-into strategy to change the way things work by investing in out of hospital care.

From being extremely sceptical about the IHO model, I do now think there is possibility that it could work, and for the benefit of both the whole system and general practice.  At present the potential risks still seem to me to outweigh the potential benefits, but the key will be whether NHS England will let those places like West Essex where the whole system wants to do things differently become IHOs, or whether it insists on focussing on those organisations without financial or operational challenges which feels like a recipe for disaster.  I for one will be watching with interest to see how the story in West Essex unfolds.

15
apr
0

How Will Neighbourhoods Improve Access to General Practice?

Posted by Blogs, The General Practice BlogNo Comments

One of the big claims being made by the government and NHS England is that the introduction of neighbourhoods will improve access to general practice.  But how exactly will the introduction of neighbourhoods achieve such a feat?

This is a question that I don’t think is being asked enough.  It simply is not obvious that the introduction of neighbourhoods will lead to an improvement in GP access.

The idea of neighbourhoods is that they are to solve the problem of services in the community being disjointed and poorly co-ordinated.  Their development is being sold as enabling the left shift of services out of hospitals into the community.

But how does joining up services and enabling services to move out of hospital improve GP access?

Maybe the neighbourhood system will allow more resources to be invested into general practice so that improvements in access can be achieved?  As well as this sounding improbable the document makes it clear that no new resources are coming via neighbourhoods, and the chances of existing providers choosing to give their money to GP practices to improve access does not seem high.

Maybe the new Neighbourhood Health Centres are the answer?  The guidance states that these will bring GP services together “with a mix of community, local authority and civil society sector services” so that services are organised so that they can work together.  But increasing the scope of the demand hardly seems like a mechanism for improving access.  And if GP services are centralised from existing locations to these new centres (I don’t think that is the idea but you never know) then surely the extra distance will just make access worse.

Maybe it is that access to general practice is seen as a precursor to neighbourhood health?  This is implied by what the government’s framework says about it, “General practice is the bedrock of neighbourhood health. Without good access to GPs and their teams, we cannot shift the dial on outcomes, patient experience or sustainability.  As part of building a neighbourhood health service, the NHS will support GP access recovery.”

The logic that neighbourhood working requires improved access to general practice does not really stack up.  If the point of neighbourhood working is agencies working together to improve outcomes for specific cohorts of patients, then access to practices is not going to be a major factor in its success.

But we all know its political and been crowbarred in because it suits political priorities.  Even so, how will access be improved?  There is no new money being given in this year’s contract, yet it still appears as a neighbourhood priority for 26/27.

One of the “minimum basic requirements” of ICBs for this year is to “agree a plan for tackling unwarranted variation and improving access to general practice, ensuring core hours requirements as defined in the national GMS contract are met, including the newly introduced urgent access requirements”.

The plan appears to be as follows. A new non-negotiated requirement for practices to respond to urgent requests on the same day is imposed on practices without any agreement from the service, or without any additional funding.  ICBs are then expected to performance manage any practices not achieving the target.

However, ICBs have been depleted of manpower to the point where direct performance management of practices on any sort of scale seems unlikely.  This, I think, is where the new neighbourhood infrastructure comes in.

PCNs wanting to take on the new SNP contracts will almost certainly be expected to ensure that all its practices are hitting the access targets in order for their bid to be successful.  Once in place the new MNPs will performance manage any SNPs with practices not hitting the access targets.  IHOs will performance manage any MNPs with SNPs and practices not hitting the access targets.

Underneath this plan is the belief that all practices could be hitting these new targets within existing resources, and that those who are not are either not trying hard enough or have poor processes in place.  There is no recognition or understanding of the current realities of general practice, or of the hugely different circumstances that practices operate within.

I have written before about how NHS style performance management is coming to general practice.  If general practice wants to maintain the independence it currently enjoys then this is something it needs to strenuously resist.

25
mar
0

Why Neighbourhoods Mean a Bleak Future for General Practice

Posted by Blogs, The General Practice BlogNo Comments

The Department of Health and NHS England have produced the long-awaited guidance on neighbourhoods.  It is now clear that neighbourhoods are going to have a significant negative impact on general practice.

First of all, general practice funding flows are going to change significantly.  While the core contract is to remain nationally determined, it looks like all other funding (local enhanced services etc) will come via neighbourhoods.  Single Neighbourhood Providers (SNPs) will “enable primary care to take on new neighbourhood services that are not contracted for (through the GMS contract)” – this sounds very much like all local enhanced services are to come via this route.

Worse, all the funding for general practice will in future be held by an Integrated Health Organisation (IHO), “IHO contract holders will subcontract neighbourhood services, most likely through multi-neighbourhood providers (MNP), and take on local contract management responsibility for GMS (or PMS or APMS) general practice contracts, as well as pharmacy, optometry and dentistry, all of which will continue to be determined nationally”.

The funding plan for neighbourhoods appears to work like this.  All the money for primary care and community services will be given to the local acute trust, who will be renamed an IHO.  The expectation is then that local acute trust/IHO will give some of its own funding on top of the funding it receives for primary and community care so that neighbourhoods work.

That’s it.  There is no new funding, no pump priming, no investment in change capacity, just an edict that “neighbourhood health will be funded by rebalancing existing resources rather than relying on new funding”.  Not only is this unlikely to work, it is going to put funding for general practice at extremely high risk.

One of the key outcomes for neighbourhoods is that they will improve access to general practice.  Less clear is how the introduction of neighbourhoods is expected to achieve this, especially when they bring zero additional resources or capacity.  I think the answer is this is expected to come as a result of introducing three layers of bureaucracy above practices:

“The ICB contracts a single integrated health organisation (IHO) for an area. The IHO then contracts a number of multi-neighbourhood providers (MNPs). Each MNP works with multiple single neighbourhood providers (SNPs). Each SNP works closely with all local GP practices in the neighbourhood.”

So, as I read it, first the SNP has to try and performance manage improvement to access targets in its member practices.  If that fails it will be escalated to the MNP, and likewise from there to the IHO.  Beyond “performance management” I cannot think of a single reason why these new arrangements could possibly result in an improvement in access to general practice.

General practice meanwhile looks like it is also expected to pick up what the guidance terms a “25% diversion rate” through (newly mandatory) single points of access/referral management centres (unless there is somewhere else that will pick up this work?).  Remember there will be no new money for this as use of advice and guidance is now part of the core contract.  GPs are also supposed to lead “Integrated Neighbourhood Teams” (INTs) that will keep patients who are frail or have multiple long term conditions out of hospital, as well as taking on at least 10% of the patients who are currently managed as follow ups by the hospital.

PCNs, meanwhile, are going to “evolve into” SNPs.  This means that control over PCNs will most likely shift away from practices and to whoever the new contract-holder ends up being, who in turn will be beholden to the MCP and the IHO.

There is no evidence that introducing neighbourhoods will achieve any of the outcomes that the government and NHS England are suggesting.  Logically it is hard to understand how simply changing contract models and creating “new partnerships and collaborations” can achieve any of the proposed outcomes.  Unfortunately, general practice seems set to suffer the most as a result of these changes as it will certainly lose autonomy, it will lose control of PCNs, and it will be dependent on the acute trust for its funding, while at the same time being set up as the fall guy for when neighbourhoods inevitably fail to deliver the pie in the sky outcomes these documents propose.

11
mar
0

NHS-Style Performance Management is on its way to General Practice

Posted by Blogs, The General Practice BlogNo Comments

The outline of the 2026/27 contract very much looks as though NHS England is looking to roll out its performance management approach into general practice.

Over the last 20 years the NHS has changed.  In that period it has become much more centralised, with the centre taking a much more active role in establishing what it would term as “grip” across the system.

This involves heavy performance management of any NHS organisation not delivering on finance, activity or access targets.  This has expanded to include a requirement to produce plans (by all, not just “failing” organisations) as to how these targets are going to be achieved, and then heavy performance management of these plans (before delivery has even begun).

Where organisations are deemed to be failing or have an inadequate plan NHS England will “intervene”.  This involves insisting on changes of senior leaders, requiring organisations to use expensive management consultants and “turnaround directors” (at their own cost), along with requiring more information as “assurance” that improvement plans are in place and that the changes are on track.

This approach has not worked.  If anything, overall performance is worse than it was 20 years ago.

One of the huge drawbacks of this approach is that it stifles local innovation.  The constant insistence on the production of a plan does not allow any time for the development of innovation or new ways of working to feature within it.  There is an expectation that organisations will look to what is working elsewhere and use that as a route map to improvement.  But because it allows so little time for organisations to tailor changes to what will work locally they end up having at best a diluted effect.

At the same time, where organisations are investing in developing improvement capability or schemes with longer term benefits, these quickly get culled for the sake of short-term savings or to ensure there is sufficient “focus” on the immediate priorities.  Most areas have seen schemes and enhanced services that will deliver medium term benefits or savings be cut for these reasons.

I have first hand experience of this at work.  I worked as a GP federation leader in pre-CCG days and we were leading the way in the development of general practice led innovations in areas such as pro-active care and delivering multi-agency care models.  But when we became a CCG all that stopped.  The NHS performance management regime ensured all local innovation made way for a focus on cutting costs and short-term improvements in performance targets.

The response by the NHS and the government to the failure of the performance management approach has not been to change it, but rather to increase it.  The (clearly flawed) logic appears to be that if heavy performance management is not working, then it needs to be even heavier.

So far (CCGs aside) general practice has largely been immune from the impact of this NHS way of working.  The independent contractor model provides a degree of protection from it, as the NHS has no direct say as to how practices conduct their business.

But what is increasingly apparent, particularly from the contract for 2026/27, is the NHS’s desire to impose this was of working onto general practice, particularly around access.  The contract changes seem primarily designed to set out a list of minimum standards for the service: patients identified as clinically urgent will be seen on the same day; practices are required to provide an appropriate response to non-urgent patients by the end of the next core hours period; a requirement to use advice and guidance prior to or in place of planned care referrals; online consultation requests must not be capped (etc).

Then alongside this there is a new requirement to engage with support from the ICB if there is “unwarranted variation” in performance.  In other words, a requirement to agree to enter the NHS performance management regime.

This threat will not materialise straight away.  The simple fact of the matter is ICBs do not have the capacity or understanding of general practice to undertake performance management on significant numbers of individual practices (although we may see the start of this).  But come neighbourhood contracts (with GP access consistently featuring heavily as a priority for neighbourhoods), then we could very well expect NHS performance management to fall on these providers, and that in turn to fall on practices.

25
feb
0

The 2026/27 Contract: The Danger of Imposition

Posted by Blogs, The General Practice BlogNo Comments

This week NHS England has written to practices and PCNs outlining the changes to the 2026/27 contract.  It is the first time a contract has been produced without any attempt at negotiation with the service.  Instead we have what one presumes will be the first in an annual cycle of contract impositions by the NHS on general practice.

The purpose of this article is not to summarise all the changes that will be made for next year.  It is rather to highlight one specific extremely worrying shift that has taken place within the contract.

This is not (as you might expect) the halving in growth funding practices will receive this year compared to last.  Rather it is that last year practices were invited to take part in a new enhanced service for advice and guidance, through which practices could claim a £20 item of service for pre-referral requests.  But this year the enhanced service has been scrapped and participation made mandatory via the core contract.

Enhanced services have long been a route through which the NHS has been able to introduce new ways of working into general practice.  They work because it puts the onus on the NHS to provide sufficient funding for the new way of working to be affordable for practices.  If insufficient funding is provided then practices will not sign up to the enhanced service, requiring the centre to make further changes to the scheme such as an increase in payment.

There are many practices who considered the £20 item of service payment within the enhanced service and decided that it was insufficient for the amount of work involved, and as such declined to participate.  The work involved in making the request, chasing and understanding the response, potentially recalling the patient and sometimes having to undertake complex further investigations before agreeing a way forward is undoubtedly significant, and it is not a surprise that many deemed £20 as insufficient.

The decision practices were having to make was whether they could absorb this work within their fixed costs (i.e. existing staff levels) and therefore use any money generated to support other costs, or whether the staff were already acting at capacity and that more workload could not be absorbed. The funding may have been insufficient, but at least practices had a choice.

According to NHS England, over 99% practices signed up the DES.  But signing up simply meant practices had the option to claim for any advice and guidance requests they made.  Where there was significantly more variation between practices was in the amount of advice and guidance referrals actually made.

The mechanism NHS England has decided to use to address this variation is not to improve the terms of the DES or make it more attractive, but instead to include it in the core contract and make it mandatory.  The decision-making opportunity for practices as to whether this work makes financial sense has been withdrawn.

We have not seen the wording around this, and are unlikely to before the end of March, but it is hard to envisage it resulting in anything other than a requirement of additional work on practices.  It seems likely that the principle of payment for activity will be replaced by a block payment to include all activity (despite NHSE CEO Jim Mackey describing block contracts as “evil” last year).

To say the funding is now included in core when the overall growth level is half of that provided in the previous year is essentially saying that practices now have to absorb this workload.  And this workload could easily just grow and grow as more and more pathways are put in place.

In previous years this would have been picked up in the negotiation, and some way of coming to a compromise worked out.  But without a negotiation it has just been added to the increasingly unreasonable list of requirements that contractors are now mandated to undertake.

Will practices simply accept this?  Is it okay for NHS England to make unreasonable changes to the contract and simply impose them?  Will there be a reaction, a response?  I hope so, because if there is not I fear for the future of the service, as it sets a precedent that will allow NHS England to make whatever changes it wants to the core contract without regard for the impact on practices.  If NHS England can continue unchecked in this way the independent contractor model of general practice will soon become completely unsustainable.

Page 2 of 88
123488