25
jun
0

Hospitals to hold General Practice Funding?

Posted by Blogs, The General Practice BlogNo Comments

The rumour mill is hotting up as the release of the 10 year plan draws closer.  According to the Health Service Journal the plan will be published next week.  They also report that one of the key features of the new plan will be the return of Foundation Trust style freedoms for hospital trusts, and that this will include them being given the entire budget for health and care for a specific population.

This has potentially huge implications for general practice, as it would mean that much (if not all) of its funding could come from the acute trust.

The idea is that hospitals would take on the equivalent of what in other health systems (such as the US) is known as the accountable care organisation role.  Apparently here they will be known as integrated health organisations.

The logic is that if they are incentivised to improve outcomes for the population they in turn will look to improve prevention and early intervention activities, and as a result will invest in primary and community care.  Equally, it will remove the issue of one provider benefiting from the activity in another sector (or, conversely, suffering as a result of failure in another sector) as all local providers will be linked as part of the integrated health organisation.

If the model works, the system could reinvest any surplus how it sees fit, but potentially in those areas that could maximise its outcomes and ability to generate a surplus in future years, i.e. primary and community care.

This would mean, then, that the acute hospital would potentially hold the budget for general practice and contract with them directly.  It may be all of the general practice budget, or it could (more likely) be just those parts of the contract that are outside of core (i.e. enhanced services).  This would, however, most likely include PCN funding and potentially also QOF funding.  In this scenario one would expect the national trend to be to reduce the amount in core funding to maximise the influence/impact of the new integrated health organisation.

This model contains many risks for general practice.  First and foremost, and before there is any discussion of how any surplus is used, it relies on the acute trust/integrated health organisation choosing to use the money it receives for general practice in general practice.  History tells us that hospitals use whatever funding they can to shore up hospital services.  This was the reason community trusts were invented in the first place.

In addition, one assumes because of the pressure on national finances, there will little if any new money with the plan.  According to the HSJ one of the aims of the plan is to stop the expectation of “money being the answer to everything”.     We already know that achieving a shift from secondary to community care requires a period of double running before the benefits start to be realised, and without it difficult decisions will have to be made.  Not ideal, then, if the acute trust is making these decisions.

Where previously the government had made a commitment to increase the share of NHS spending on primary care by 2029 this now has been pushed back (apparently) to the end of the plan period (i.e. 2035).

There is talk of GP Federations, or GP provider organisations operating at the same scale as an acute trust, being able to take on the integrator function.  Whether that materialises remains to be seen, but the lack of investment in any at scale GP infrastructure over the last 6 years since the introduction of PCNs means there are precious few places with organisations in place with anything like what will be the required infrastructure.  We know from the bitter experience of CCGs that accelerated development timelines simply result in a loss of confidence from the rest of the system and ultimately won’t work.

These are, of course, all rumours.  What actually makes it into the plan we will find out shortly.  That said, these rumours are based on claims by individuals claiming to have read drafts of the plan so I doubt they are that far off.  A priority action for general practice for now must be to ensure it has organised itself so that it can have a strong collective voice in system discussions (that may end up being integrated health organisation discussions).  It will need to be on the inside of the decision making of these organisations, not via a token individual GP appointed by the acute trust but via some form of united collective representation.  The future funding of the service may depend on it.

11
jun
0

What the Urgent and Emergency Care Plan Means for General Practice

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NHS England has finally published its Urgent and Emergency Care Plan 2025/26.  This follows on the heels of the elective care plan (summary here), and precedes the imminently expected 10 year plan.  What are the implications of this new plan for general practice?

The good news is that it does not contain the same workload implications as the elective plan (via the advice and guidance expectations).  In fact, there is remarkably little mention of general practice in the document as a whole, a point highlighted in the final section of the document “Detailed actions: roles and responsibilities” in which there are a grand total of zero actions listed for primary care.

It is hard to know what to make of this.  You could argue general practice has been overlooked, but I suspect the alternative of (yet another) set of expectations on the service would have been worse.  However, I think the real implications for general practice sit in the section on neighbourhoods.

We know more is coming about neighbourhoods in the imminent 10 year plan, and a key plank of this strategy is that neighbourhoods as they develop will be able to offer services that reduce hospital demand.

“The Neighbourhood health guidelines published in January 2025 set out the 6 core components of neighbourhood health that all local health and care systems will start to implement systematically this year…  This includes neighbourhood multidisciplinary teams (MDTs) co-ordinating proactive care for population cohorts with complex health and social care needs, integrated intermediate care with a “Home First” approach, and scaled and standardised urgent neighbourhood services for people with an escalating or acute health need.” (33)

“Similarly for patients living with frailty or complex needs, neighbourhood multidisciplinary teams have been shown to reduce demand on hospital-based unplanned care. In Northamptonshire, local integrated teams involving a range of health and care providers are delivering responsive interventions, such as extended GP reviews, peer support groups, clinical-supported decision-making and remote monitoring. In the 18 months to March 2023, this approach resulted in a 9% reduction in hospital attendances for over 65s and a 20% reduction in falls-related acute attendance due to improved rapid response.” (35)

The government and NHS England clearly want neighbourhoods in place quickly, and there is an expectation that these will return tangible system benefits as early as this coming winter.  As it stands, there is no funding identified to support the development of these neighbourhoods, and without it these expectations are clearly ludicrous.  However, it would be a surprise if what is likely to end up being the centrepiece of the 10 year plan is introduced without any corresponding funding, so until we see the plan (and its associated investment) these expectations are hard to judge.

For PCNs and practices, then, the smart move would be to push for the neighbourhood teams that they think will make the most difference to be put in place, and at the same time be clear both about the additional resources required for these to be effective, and what level of expectation is realistic as to what these teams can achieve.

There is an opportunity here for general practice to take a leadership role in implementing changes and integrated working that will actually make a difference, and to secure the resources (once they are announced) to make this happen.  The risk of doing nothing is that others will assume this leadership role, and as a result practices and PCNs could be left with insufficient resources and unrealistic expectations for whatever is planned.

The main takeaway from this document for general practice is that the system is already developing a neighbourhood focus that threatens to subsume general practice, and if the service wants to influence how things develop and how resources are allocated then it will need to get on the front foot with neighbourhoods as quickly as it can.

28
may
0

What A Neighbourhood Health Service for London means for General Practice

Posted by Blogs, The General Practice BlogNo Comments

London have produced what they are terming a “target operating model” for a neighbourhood health service for the region.  What insights does it give us towards the future, and what are the implications for general practice (both within and outside of London)?

The documents are long, somewhat repetitive and it is not easy to get underneath what they mean.  However, I think there are three main areas of interest for general practice: insights into neighbourhoods themselves; implications for PCNs; and what it terms the “integrator function” and its role and relationship with general practice.

Despite the length of the documents ‘neighbourhoods’ remains a somewhat fuzzy concept. There is a confusing relationship between a neighbourhood and an Integrated Neighbourhood Team (INT), one it describes thus:

The neighbourhood health service extends beyond the concept of INTs, but INTs are one of the main delivery vehicles for improving coordination and outcomes of care within each place and neighbourhood. (p13)

The main issue that sits unaddressed throughout the document is the relationship between the core activity of organisations (like GP practices) and the additional partnership work (INTs?) that comprises the ‘neighbourhood work’.  If all core work is neighbourhood work how is it different?  But if neighbourhood work is additional (i.e. through these multiple INTs), how will it be staffed and resourced?  There is no mention of any extra resources throughout this document.

The starting point for PCNs in these documents is that they are deemed to have failed:

Across London, our PCN clinical directors and wider stakeholders have indicated how the development of PCNs has often not delivered on some of the promises, beyond the narrow objective of providing a vehicle for the employment of additional roles. (Case for change p23)

A new primacy is given to the footprint of neighbourhoods, which is to be determined by local place boards.  Should the footprint of PCNs not align to these neighbourhoods then PCNs are expected to either reconfigure so they match, or to develop “arrangements capable of operating effectively across more than one INT”.

Then there is the thorny issue of funding and resources for neighbourhood working.  The document says this:

In the absence of significant additional funding from outside of places and systems, such functions will need to harness existing assets and resources within our core community-based providers and teams. (p26)

This feels like a heavy hint towards ARRS staff, a suspicion that is seemingly confirmed later in the document when in its plan for what will happen in the next 6-12 months it states it will be:

Working with primary care colleagues to maximise the impact of existing resources including the Additional Roles Reimbursement Scheme (ARRS) funding; GPs with Extended Roles (GPwER); current and new community-based roles. (p33)

These decisions are to be made at place-based boards, and so (once again) this highlights the urgency of ensuring PCNs have effective representation and influence on these boards.

The other key area of interest for general practice in these documents is what it says about the “integrator” function (a term we first came across in the Fuller report).  This is an existing local organisation that will be selected by the local place board to host the necessary functions that will enable neighbourhood working across the constituent individual organisations across health and care (including practices).

The document talks at length about the different roles the integrator organisation will have to take on, and I won’t repeat them all here. However, one very specific role that is worthy of mention is:

Having the ability to offer additional support options to any part of the partnership, including at individual practice level, experiencing difficulties which threaten the sustainability of the INT and the local neighbourhood health service as a whole. (p20)

Delivery of core primary care (while not an INT) will apparently fall under the neighbourhood responsibility.  This is explained thus:

An enhanced offer of support to primary care in the context of the neighbourhood health service, is not about attempting to take over contracts or services, mandating specific models of primary care ownership and delivery, or ignoring existing support structures where these are already working well. Nor is it to ignore the role the whole system plays in making each part sustainable, and a good place for health and care professionals to work. However, acknowledging the core role that primary care plays in neighbourhood delivery is also to acknowledge that we cannot proceed with implementing a neighbourhood health service without ensuring that primary care colleagues have access to the right level of support and services, wherever they are based in London, to enable INTs to function and thrive. (p10)

So, integrator organisations are to be identified, and they are immediately to take on this role of providing support at an individual practice level. This makes the decision-making as to who takes on the integrator function extremely important for general practice.  Unfortunately, the organisations listed that could take on this role are limited to “community providers, vertically integrated acute trusts and local authorities or any other existing organisations capable of operating at the scale and with the local connections to support related INTs to succeed”.  Conspicuously absence from this list are GP federations (and, to be fair, acute trusts).

There is some hope, however, as the function may not lie always lie solely with a single organisation:

In some places, these functions will be hosted within a single organisation with the capacity and capability to support neighbourhood working across all neighbourhoods. In others, integrators may work with one or more local partners to provide the range of required support. (p19)

This leaves the door open for GP federations, and maybe even groups of PCNs, to work in partnership with lead integrator organisations.  Indeed, there are not going to be many community providers or local authorities with the skills to provide direct support to practices.  But the integrator organisations are to be identified quickly, so the time to build alliances is short.

This plan may be specifically for London, but similar ones are likely to arise across the country.  If we take this alongside the model ICB blueprint which outlined a shift of responsibility for general practice from ICBs to “Neighbourhood Health Providers” then what all this points to is neighbourhoods and their organisational manifestations (like “integrators”) becoming much more involved in the delivery of general practice, with PCNs increasingly looking like they will be falling down the pecking order.

14
may
0

Why Engage with Neighbourhoods?

Posted by Blogs, The General Practice BlogNo Comments

Neighbourhoods can be a frustrating concept.  Noone seems to be able to define what they are, and they have the feel of the latest initiative, one that will inevitably come and then go, like so many of its predecessors.  Given this, why should PCNs and practice engage with neighbourhoods?

It is an important question.  Too often local areas jump into what neighbourhoods should be doing (risk stratification etc), without taking the time to articulate why the work is important for general practice in the first place.  I understand the frustration with yet another new concept coming along, but I think there are four reasons why practices and PCNs do need to take neighbourhoods seriously.

  1. To join up care for the local population. The frustration of many practices for many years now has been the increasing distance between themselves and community teams such as district nurses and community midwives.  The opportunity that neighbourhoods presents is to bring back those linkages, and ensure all of the local community service provision is joined up.

At present the scope of influence of practices and PCNs is very much limited to the work of the practices themselves.  Neighbourhoods provide an opportunity to shape how all of the services working in the community can operate to deliver the best possible outcomes for the local population.

  1. To shape service delivery models. Too often in recent years practices have been on the receiving end of centrally defined enhanced service specification that they know are not going to achieve the outcomes that are being sought for their own patients.  These one-size-fits-all specifications fail to take into account the nuances of the local care homes, or local population groups, or whatever it is that is specific to the local area.

The opportunity of neighbourhoods is not only to be able to join up care delivery across providers but also to design and tailor service delivery models to the needs of the local population.  The whole point of neighbourhoods is enabling those front-line staff that best understand the needs of their population to create the service models that will have the biggest impact.

Just as a side note on this, not everywhere seems to have grasped this yet.  If your local ICB are still pushing one-size-fits-specifications to be implemented across all the emerging local neighbourhoods then do push back.  Establishing the freedom and autonomy of each neighbourhood to design its own care delivery models is an important first step that needs to be taken as early as possible.

  1. To ensure general practice leads the work. Like them or not, neighbourhoods are coming, and GP practices and PCNs are going to be part of them.  The choice is either to engage early and establish the leadership role that general practice should be playing within them, or to ignore them and let others take up the leadership mantle.

Unsurprisingly, community trusts, mental health trusts, acute trust and councils are all very keen to play a leading role in neighbourhoods.  If practices and PCNs choose not to engage then there are plenty of others who will.  This will result in others controlling how the neighbourhood works and (importantly) how resources are deployed, with potentially hugely negative implications for general practice.

  1. To shape the shift from hospitals to communities. Neighbourhoods are being established as a vehicle to enable the government’s promised shift of services from acute to community.  PCNs and practices need to be at the forefront of their development to prevent a continuation of the unfunded and unthought through shedding of activity by hospitals and turn it into an opportunity to create a prosperous future for general practice.

It very much feels like the future of general practice will be inextricably linked to neighbourhoods and how they develop.  This means the stakes feel too high for them to simply be ignored, and the sensible move right now is to take an active role in shaping them.

30
apr
0

How Can PCNs Prepare for Neighbourhoods?

Posted by Blogs, The General Practice BlogNo Comments

It is a difficult period for PCNs as all the talk is about neighbourhoods, while PCNs themselves are not getting much of a look in.  This in turn is serving to create question marks around the very future of PCNs and creating additional pressure for PCN leaders who are having to manage (yet another) period of uncertainty.

Given this situation, what is the best way for PCNs to prepare for neighbourhoods?

While neighbourhoods still remain largely in the realm of the conceptual, with very few being able to adequately define what they are or what their purpose is, it is easy for PCN leaders to adopt the ‘head in the sand’ approach and ignore them until something more concrete comes along.

But the government has been clear that the development of a ‘Neighbourhood Health Service’ is central to their plans, and there is no doubt that they are going to feature front and centre in the forthcoming 10 year plan (which is now expected in June).  Equally they have been clear that they want their development to be locally led, tailored to local needs, and not be a one size fits all top down imposition.

With this in mind, ignoring their development, and potentially missing out on local conversations as to how they will take shape, runs the risk of allowing others to mould them to their own needs and to diminish the influence of PCNs and practices.

There are two actions I would recommend PCNs take right now.  The first is to identify how they can free up as much of their PCN Clinical Director’s time as possible to build relationships and influence externally.

In the majority of PCNs the CD tends to focus on internal issues and relationships.  They work to maintain the goodwill of the member practices and ensure the delivery of services such as enhanced access and ARRS initiatives like home visiting.  But now CDs need to be freed up from this work by other clinical leads and managers in the PCNs so that they can focus externally.

Exactly how this can happen will vary greatly from PCN to PCN.  But the stage of development that PCNs need to reach is one that some have got to already where there is enough of a leadership infrastructure that means the whole PCN enterprise is not dependent on the CD.

CDs in turn need to focus their efforts on building relationships with other organisations and local leaders across the neighbourhood.  It is not a case of simply attending the ICB-driven meetings (although where they are making decisions about how the neighbourhoods are to develop locally these are important!), but more about building the personal relationships across the local provider network that will strengthen the influence of the PCN in local decision making.

The second action I would recommend is for local PCNs to work with each other, the local federation (if there is one) and the LMC to establish what the NHS Confederation term a primary care collaborative.

While it is not possible for one PCN or CD to do this on their own, it is possible to choose to invest time in building this joint forum for PCNs and practices that once in place can maximise the influence of general practice in the development of neighbourhoods.

Where these fora have developed, sometimes the impetus has come from the PCN CDs, sometimes from the federation, sometimes from the LMC and sometimes even the ICB.  Wherever the energy comes from for PCNs it is about getting behind this, recognising its importance in shaping how the neighbourhoods develop, and investing the time to make it succeed.

While the final shape of neighbourhoods remains outside the control of PCNs, the ability to influence this does not.  This development period that we are in now is the most important as it is when decisions are made that have lasting consequences, and so the immediate priority must be making the influence on these decisions by PCNs and practices as strong as possible.

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