There is a misconception that somehow the new Neighbourhoods will replace PCNs.  This is not the case.  What will be of critical importance, however, will be the relationship between the PCN and the Neighbourhood.  This is likely to be determined by whoever takes on the leadership role for the Neighbourhood.

At its core a Neighbourhood is the coming together of all of the providers across a local community.  One of these providers is general practice.  Neighbourhoods will not function effectively if practices operate as individual providers, and instead need practices to operate as a collective.  This will be via the existing PCNs, as the PCN DES requires practices to work together.

But the PCN will only be one voice around the Neighbourhood table.  There will also be the community provider, mental health providers, social care, voluntary sector, other primary care providers and even the acute trust.  This group will need to decide how any new Neighbourhood services are to be designed, delivered, staffed and funded.  If this funding is to come via a new Neighbourhood contract then this group will need to agree how this funding is to be used and apportioned.

The Neighbourhood, then, will in some respects mirror how PCNs function at present where the different practices come together to make these kinds of decisions, but instead of this being a discussion between the practices it will be a discussion between different organisations and only one of these organisations will be general practice (via the PCN).

Given how hard many PCNs find it to agree decisions across their practices, the challenge facing Neighbourhoods in getting all the different organisations involved to come to an agreement should not be underestimated.

The challenge for the PCN leaders, or whoever ends up representing the PCN in the Neighbourhood discussions, will also be significant, as they will have to come to an agreement that works with the other Neighbourhood providers as well as one that the practices within the PCN will sign up to (particularly where practice delivery is involved).

The opportunity seems to exist at present for general practice via PCNs to take on a leadership responsibility within the new Neighbourhoods.  The question is whether, given the complexity and obvious challenge there will be in getting these Neighbourhoods to work, this is a sensible move?

The problem is that, like it or not, Neighbourhoods are coming.  Neighbourhood contracts are on their way, and any new funding for out of hospital care (including general practice) is highly likely to come via this route in future.  The question, then, is not really whether we like the idea of Neighbourhoods or want to work as delivery partners with our local provider colleagues, but given that Neighbourhoods are coming whether it would be better to have the leadership role or for another organisation to take this leadership role on?

When we think of it like this the answer is obvious – general practice and PCNs have to take this opportunity to lead Neighbourhoods.  The alternative of giving this up and letting others take on the leadership responsibility would allow them to determine what role general practice should play in the Neighbourhood and, crucially, what resources it should receive for doing so.

At present the importance of Neighbourhood working is easy to ignore, because the neighbourhood contracts are not yet in place and no real funding is at stake.  However, this will change in the years to come.  But the opportunity to take on the leadership role is coming now.  What PCNs and general practice must not do is give this opportunity up and let someone else take it on because it doesn’t feel important, because when the financial realities kick in in the coming years it will be too late to have a change of heart as someone else will already be in the driving seat.

A key part of making neighbourhoods work is building relationships with the local provider organisations.  But in many places general practice has struggled to be able to develop any sort of meaningful relationship with the local acute trust.  How can this change now?

In a past life I worked in acute trusts, and at one point was a Director on the Board of a hospital Trust.  This was before I had worked much with general practice.  Looking back, a number of things stand out about how the hospital perceived general practice.

The most noticeable was that there was no understanding within the Trust as to how general practice worked.  Very few people within an acute trust, particularly on the management side, have any sort of experience of working in a general practice environment.  The language of general practice (DES, LES, GMS, PMS, QOF, PCNs etc etc) is daunting and off-putting, and makes the service feel impenetrably complicated.

General practice is also perceived as very difficult to do business with.  When working in an acute trust it feels very hard to identify individuals who can make agreements on behalf of general practice.  Those particularly long in the tooth will remember GP fundholding and how hospitals had to agree contracts with each fundholder individually, and that sense of not being able to pin general practice collectively down to an agreement still remains.

At the same time, general practice can feel that hospitals themselves are distant, focussed only on themselves, and uninterested in general practice and the community.  There is a hostile undercurrent of frustration from GPs with the perceived shifting of (unfunded) work onto their laps.  Any primary to secondary care initiative feels designed to create yet more work for practices (shared care, advice and guidance, referral management etc etc), and so even the incentive for a stronger relationship is not always obvious.

But now the advent of neighbourhoods and the prospect of multi neighbourhood provider contracts has created an urgency for developing this relationship that has maybe been missing in recent years.  But moving forward is not straightforward, so where should we begin?

The best place to start is to identify the person or people within the hospital who are the easiest to do business with.  I remember on my executive team there was a range of individuals, and some were definitely harder to do business with than others.  Not all had the same attitude towards general practice.  Generalisms about the ‘acute trust attitude’ towards general practice are not helpful because different individuals will have different attitudes. The trick is to find those most open to working with general practice, and let them be the ones who work to persuade their less amenable colleagues.

But how do you find them?  Asking senior ICB colleagues is a good place to start.  They will be able to recommend the best people to contact.  You don’t want anyone too junior (because their influence within the acute trust will be too limited). This is the perennial problem with identified “general practice liaison leads” – you can invest time with them, but it can often lead to no tangible changes because they have insufficient clout within their own organisation.

The ideal place to get to is a small group of management and clinical leads from both sides (4-6 people) who can oversee any joint working, and where each side has enough influence to troubleshoot any issues that arise.  Of course this also requires general practice to have established its own way of working collectively so that it can participate effectively in this kind of arrangement.  Otherwise the general practice leaders can end up feeling very exposed!

A priority for this group is to establish a rationale for joint working that both can sign up to.  There will inevitably be a fear from some GPs that the acute trust may want to take over general practice, and so this needs to be explicitly taken off the table.  Recently from the GP side this work has been around reducing the pushing of unnecessary workload from secondary to primary care, and from the acute side about improving the appropriateness of referrals.  With the advent of neighbourhoods this can be expanded to how joint working can enable neighbourhoods to be effective, and of course joint preparations for the multi neighbourhood provider contract when it arrives.

Ultimately, the relationship between general practice and the acute trust will come down to personal, individual relationships.  The mistake that is often made is trying to use big set piece meetings with multiple attendees to develop the relationship.  These are fine, but can only work if they sit on top of some individual relationships. Getting these in place is the most important place to start.

The 10-year plan lacks detail on implementation but still sets some ambitious timelines.  In particular, it states that the roll out of the two new contracts (the Single Neighbourhood Provider and the Multi Neighbourhood Provider contracts) will start next year.  With the threat of other providers being able to take on these contracts, what can PCNs be doing now to prepare for them?

For those PCNs keen to be in a position to take on the new Single Neighbourhood Provider contract the best starting point is an assessment of where they are now against the identified features of the new neighbourhoods in the plan.  A simple review of where they are now and where they want to be in 6 months’ time can form the basis of an action plan as to what is required should these contracts become available next year.

There are 8 areas that I would focus on, which I have outlined below.  It is not an exhaustive list, but it is where I would start.  If much more is included it runs the risk of becoming unwieldy and losing focus on what is important.

Leadership.  Does the PCN CD want to take on a leadership role in the new neighbourhood?  If they do, can they be freed up from the internal running of the PCN (potentially by others stepping up to support with this) so that they can focus on the external work with others that will be required?  If not, can an individual from within the PCN who has both the skills and desire to take this on be identified, and then be supported to start to move towards this role?

External relationships.  Does the PCN have individual, personal relationships in place with the key leaders from the different organisations across the neighbourhood (such as the community trust, the mental health trust, the acute trust, social care and the voluntary sector)?

Governance.  Does (or could) the PCN convene regular meetings of these individuals, which could potentially start to operate as a leadership group for the neighbourhood? There will ultimately be a value to being the organisation that convenes these meetings if the PCN wants to play a leadership role within the neighbourhood.  Is the PCN in a position to be able to hold a contract, should one become available?  If not, what steps does it need to take to be able to do so?

Integrated neighbourhood teams.  Are there any integrated neighbourhood teams in place?  What further teams might be developed?  How are these teams supported and enabled, and how is their impact tracked and success measured?

Population health.  Are the specific needs of the local population understood?  Have groups with similar needs been defined, and specific cohorts of patients been prioritised?  Is there a neighbourhood plan to improve population health and reduce health inequalities? Are partners across the neighbourhood bought into this?

IT, data sharing and information governance.  Can information be shared across the different teams in the neighbourhood?  Are mechanisms in place to allow this to happen?

Neighbourhood health centre.  Has the neighbourhood health centre been identified (given every neighbourhood is to have one)?  If it has, what steps can be taken to develop it?

Voice and influence.  Is the PCN actively influencing the place-based partnership board that is making the key decisions about neighbourhoods, both now and as they develop?  What actions can the PCN take to develop its influence further?

The expectation is not the PCNs will already be operating as full-blown neighbourhoods and be able to answer all of these questions positively.  The opportunity, however, is to understand where the PCN currently is in relation to the neighbourhood, and use the gaps that it identifies as the basis for an action plan for the next 6 months.  It will also mean that at the point in time at which the PCN is asked about its preparedness in relation to the neighbourhood (as this will inevitably come) it will be able to clearly state the actions it is proactively taking, and be in a far better position to take on the single neighbourhood provider contract when it arrives.

By now you are likely to have either read the government’s 10 year plan for the NHS, or at least a summary of it, or picked up from others the key elements of the plan (my take on what the implications of the plan are for general practice is here).  The question now is how should general practice respond to the plan, both nationally and locally?

I recently spoke to Dr Katie Bramall-Stainer, Chair of the GPC, about the plan.  You can listen to our conversation here.  Her view is that the plan is not set in stone, but rather a signal of the start of an iterative process of how the desired reform should be delivered.

She does have real concerns about some of the suggested mechanisms for delivery in the plan, not least of which is integrated health organisations, which she says stands out as “a big red flag” and potentially poses an “existential risk” to general practice.  But rather than come out in opposition to the plan as a whole and risk having reform done to the profession, her view is that it would be far better for general practice to be part of shaping the changes as they develop.

It is hard not to agree with what she is saying.  General practice would run the risk of being sidelined if it decided to withdraw any engagement from the plan.  It would not be hard for the profession to be portrayed as being anti-reform, and the plan has already opened up routes by which change could be imposed on rather than negotiated with general practice.

But equally it will be important that engaging in discussions about shaping the reform are not taken as implicit approval of the ideas Katie has already identified concerns about, such as the integrated health organisations and also the multi-neighbourhood provider contract (specifically how it will be procured).

What general practice will need to do is not only dissect the plan, but also come up with alternative proposals as to how the ambitions of the plan can be realised where the initial proposals cause concern.  It very much feels like an opportunity exists now to shape the future, but simply rejecting the ideas that others put forward on its own will not be sufficient because no change is not going to be an option.

Almost immediately after the publication of the plan NHS England announced a “National Neighbourhood Health Implementation Programme”, and is seeking 42 local place areas to apply.  Given the concerns about the plan, but equally the desire to shape it, does it make sense for general practice to support any local application?

As ever the response is “it depends”, but what it depends on are the assumptions being made locally as part of the application.  What parts of the plan are being taking as a given and what parts are being tested?  For example, is the local area taking a multi-neighbourhood provider as a given and wanting to use the pilot to fast-track its procurement?  In this scenario, I would have serious reservations.  But if we have a trusted local at-scale general practice provider and the aim is to use this to enable effective neighbourhood development then maybe an application would be worth supporting.

What this highlights is that it is not only a national general practice responsibility to react to the plan and develop ideas on how the ambitions of the plan can best be delivered, but also a local one.  The plan correctly identifies that there will not be a one size fits all national solution that can be imposed everywhere.  Local solutions will be needed.  If general practice wants to shape the future locally, and not be a recipient of imposed reform, then it will need to support and potentially lead the development of local alternatives to the ones it has concerns about within the 10-year plan.