What is the Plan?

When we are trying to understand the future for any individual service (like general practice) it is wise to try and understand what the future for the wider NHS looks like, as a framework to understand any potential changes.  So, what is the plan for the NHS?

The existing NHS Plan was entitled the NHS Long Term Plan, and it was published in January 2019.  While the headlines around it talked about it being a 10 year plan for the NHS, the document itself reads like a 5 year plan.  All of the specific commitments are limited to a 5 year time period, and anything else is described as “and beyond” (e.g. “It provides the framework for local planning for the next five years and beyond” p110).

The NHS Long Term Plan is of particular importance to general practice because it was the document that introduced Primary Care Networks (PCNs).  While there is a tendency in the wider NHS to think of PCNs as a general practice initiative, the reality is they were introduced as a cornerstone of the Long Term Plan ambition to “boost out of hospital care and finally dissolve the historic divide between primary and community care services” p12.

Importantly, PCNs were introduced so that, “GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff” p6.  As an aside, and regular readers of this column will know is a personal gripe of mine, the dealing with pressures in primary care part of this does seem to get lost in many ICBs’ interpretation of the role of PCNs.

Much has changed since 2019.  Matt Hancock has gone from being Secretary of State for Health to appearing in Celebrity SAS.  Simon Stevens has been replaced by Amanda Pritchard as Chief Executive of the NHS.  Covid happened.  We are now only 6 months from the end of the 5 year planning horizon indicated by the Long Term Plan, and from the end of the agreed period of the PCN DES.  Is the plan published in 2019 still the one the NHS is working to in September 2023?  Are PCNs still the plan to dissolve the divide between primary and community care services?

What the Long Term Plan was actually signifying was a closing of the internal market chapter of the NHS, that had been running since 1990.  It heralded the legislative changes that marked this closure, along with the formal creation of Integrated Care Systems (ICSs).  The new post-internal market system of ICSs is one based on collaboration and one that seeks to “deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care” (p10).

The fact that since the Long Term Plan was published Claire Fuller was asked to produce a document entitled “Next Steps for Integrating Primary Care” tells us a number of things.   It tells us the overall ambition to break down the perceived divide between primary care and both community and specialist care remains firm and an overriding priority.  It also tells us that the progress towards this so far via PCNs has been deemed as insufficient.

Meanwhile the NHS finds itself in something of a predicament.  The usefulness of the 2019 Long Term Plan has effectively run its course (or will have by March next year), and nothing yet has been produced to succeed it.  A general election is due before January 2025 (and therefore will probably take place next year) which makes the publication of any major new NHS plans (such as a new five year forward view/long term plan) unlikely in the intervening period.

So in this period of limbo most likely is that the status quo will more or less prevail, hence the widespread predictions for a one year rollover contract or similar for general practice next year.  When we look beyond that, the big strategic goal to bring primary care and community care closer together is highly unlikely to change.  This means more (not less) focus on groups of practices working together at PCN/neighbourhood scale, more focus on those groups working with other agencies across those neighbourhoods, and a continued shift away from any kind of focus of working at an individual practice level.

Why Is Practice Sustainability Being Ignored?

When even private providers start backing out of delivering the GP contract, as now Operose Health has done, it does point to a lack of sufficient funding in the contract.  Indeed, it begs the question as to how GP partnerships are able to make a living from the resources that are on offer.

The sustainability of GP practices is more precarious than it has ever been.  The 2019 contract has not served practices well, as it did not provide sufficient funding to cover the inflationary increases of recent years, and most practices are not set up to be able to make the most of the additional resources which are all going via PCNs.  We are now seeing real financial challenges biting in many practices.

The last time this happened in 2016 there was a national response in the form of GP forward view, which did inject some much needed additional funding into the service.  At least the government and NHS England felt the need to act.  Worryingly, we are seeing no such signs now.  The final 2 years of the 2019 contract were imposed on the service by NHS England.  Zero concern has been shown for the financial challenges this would inevitably cause practices.

Why is this situation being allowed to develop?  For as long as I can remember there has not been an imposed, non-agreed contract for general practice, and then suddenly we have two in a row.  What is behind this unwillingness to fund core general practice properly?

I can only hypothesise as to the cause.  The only reasons I can think of are these:

  1. The government may believe general practice has been overfunded. There exists a school of thought that general practice made money out of Covid and the vaccination programme in particular, that the 2019 contract has invested significant funds into the service at a time when very few areas were receiving any new funding, and that additional resources given to practices serve only to line the pockets of practice partners.  It may be that there are some in senior office who, incredulous as it may be to those trying to keep practices afloat, are genuinely holding onto this as a belief, which in turn has led to the lack of any additional monies coming into general practice.


  1. Policy makers may believe by squeezing funding at an individual practice level they can force practices to operate at larger scale. The Fuller Report action on supporting sustainability of primary care states, “Support primary care where it wants to work with other providers at scale, by establishing or joining provider collaboratives, GP federations, supra-PCNs or working with or as part of community mental health and acute providers” p36.  Maybe we have entered an era of stick not carrot for practices to operate at a larger scale, by reducing funding at the level of the individual practice and making the need for shared services unavoidable.


  1. It may be part of an agenda to nationalise general practice. We have seen politicians of both persuasions in recent months declare that the partnership model is coming to the end of its life and that new options need to be introduced. Equally we know that the NHS cannot afford to buy partners out of their existing contracts, and so maybe the plan is to make delivering the existing contract so unattractive and so financially difficult that they create an environment in which partners will choose to willingly give these contracts up.


  1. The centre may want to reduce the amount of funding that has to be transferred to ICBs when general practice funding shifts from national to local. Now there are some pretty big ifs included in this, but we know that the push from the Integrated Care Boards is for general practice funding to come via them (as evidenced by the Fuller Report and accompanying letter) as opposed to via the national contract.  If NHS England is seriously considering this it is likely to want to ensure the amount of funding it has to transfer is minimised, and so squeezing the contract ahead of any such transfer makes sense.


  1. Senior leaders may have confused integrating primary care with the sustainability of core general practice. The Fuller report is striking in that it works to solve a problem that general practice does not know it has (how it is ‘integrated’ with the rest of the system), and explicitly does not concern itself with the level of funding general practice requires (“the existing legislative, contractual, commissioning, and funding frameworks …were out of scope for this stocktake” p27).  Yet when asked what the plan for general practice is, senior leaders will always refer you to the Fuller report.  Somehow the sustainability question may have got lost underneath the current focus on access and neighbourhoods.

I cannot think of any other possible reasons (but do let me know if you can!), so it must be one or a combination of these reasons.  Generally faced with a choice between cock up and conspiracy I generally lean towards the former, as the top of the NHS is not well known for having (never mind delivering) clear strategies.  On the other hand the recent contract impositions and using parliament to enforce changes to the GP contract does seem to signify intention.

Whatever the cause, the reality is that practice sustainability is not a current priority for politicians and senior leaders.  If this does not change in the near future the number of practices getting into financial difficulties is going to escalate.  Maybe that is the point that we will find out the real reason behind the current situation.

What is an Integrated Neighbourhood Team?

This is one of those questions that you feel like you really ought to know the answer to, but I am finding it very difficult to pin down exactly what an integrated neighbourhood team is.

All of the presentations I have seen about integrated neighbourhood teams outline their aims rather than what they are.  I find this unhelpful because while it might describe the problem they are trying to solve it does not actually help me understand what they are.  What I am trying to understand is who is in the team? Who leads the team? Who does the team report to?  Who sets the work programme for the team? Where does the funding for the team come from? What is its relationship to the PCN?  These are the questions I struggle to get answers to.

Even the aims of these teams seem to vary somewhat, with (for example) some places claiming they will improve access to primary and community care for local citizens and others stating they will keep people well and out of hospital.  If each area is coming up with its own definition of what they will achieve it already seems highly unlikely that what they are will be consistent across the country.

Maybe the place to start is the Fuller Report where they were first introduced, as the “heart of the new vision for integrating primary care” (p6).  Despite their proposed importance, the report does not explicitly define what an integrated neighbourhood team is.  The closest it gets is stating that in neighbourhoods of 30-50,000 “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.”

I am not sure that clears it up for me.  I remain uncertain whether an integrated care team is a concept that is designed for local interpretation (and so will result in a whole range of different manifestations) or whether it is something more tangible that at some point in the future we will all be able to look at and immediately recognise as being an integrated neighbourhood team.  If it is the former surely that should be explicit, and surely each ICS would then be clearer on its own definition.

Here is what I am most uncertain about.  Are integrated neighbourhood teams supposed to take on the whole gamut of services that each of the member teams carry out?  So by that I mean if we are bringing primary care, social care, community care (etc) together does that mean we are bringing all of the work they do together (i.e. those services in totality)?  Or does it mean we are bringing work on the edges of each of their core functions together where there is overlap between them (e.g. individuals with multiple long term conditions, requiring community services, with social care needs)?

If the answer is the latter (and I remain unconvinced that there is consistency on this across ICSs) then it means the work of these teams is in addition to existing work.  We have the core work that each team is doing, and now we have the additional ‘joined-up’ work that is the remit of this new integrated neighbourhood team.  I understand the principle that by doing this additional joined up work together the overall work in the system may fall, e.g. less exacerbations of long term conditions, but there is no immediate reduction in the core function of the participating members of these new teams.

This would mean that the work in integrated neighbourhood teams is in addition to the day job for team members.  But what I haven’t seen is any significant funding streams for these new teams, so what am I missing?  Are PCNs the existing significant funding stream?  Is this what “evolving” PCNs into integrated neighbourhood teams means?

Integrated neighbourhood teams still feel conceptual rather than tangible to me.  Whilst at a national level I understand the desire to stimulate rather than stifle local innovation and therefore why you might start with something conceptual, what I don’t understand is the reticence to define what they actually are at a local level.  It feels like what integrated neighbourhood teams are and how they work will be a big deal for general practice in the future, and so it seems entirely reasonable that at this point we should be pushing for much clearer local definitions.

Too Much Liability

One of the main arguments for giving up the independent contractor model is that the level of liability it requires partners to take on has become intolerably high.  Partners would be able to sleep much more easily in their beds at night if they were relieved of this burden in a nationalised model.  But is it really such a black and white choice?

Partners of GP practices take on unlimited liability.  This means that the costs of any successful claims against the practice that are not covered by any insurance that is in place will need to be met by the partners.  This includes via the personal funds and assets of the partners, i.e. including their homes and savings.

In recent years the level of exposure for individual partners has gone up.  There are less partners and so the total value of the businesses is divided between fewer individuals, making personal exposure higher.  Property costs have risen, which means as well as the buy-in costs being much higher now than 20 years ago so too are the associated liabilities.  And lurking away in the background is the risk that any individual partner may become the ‘last man standing’ and be left on their own holding all of the practice liabilities.

Then there is the emergence of PCNs.  Partners remain ultimately liable for the extended work that the PCN takes on (unless the PCN has incorporated), as well as for the actions of the much extended workforce with the introduction of the additional roles.

It is no surprise, then, that this level of liability facing individual GP partners is putting many new GPs off from the prospect of becoming a partner.  This is at just the time when the service desperately needs GPs to take on partnership roles.  So surely moving away from the independent contractor model and bringing GPs into the full indemnity protection of the NHS is the obvious solution?

But freedom to operate independently is a function of taking on liability.  If someone else is ultimately liable then it is their prerogative to determine the actions we must take.  Hence the lack of freedom that many hospital clinicians complain about when working in that environment.  The cost of not having the liability is giving up independence.

So is the independence worth it?  The questions for partners to consider is whether they are being properly compensated for the liabilities they are exposing themselves to, and whether they are prepared to give up the freedom that a reduction in their liability would mean?

But it does not have to be quite so black and white.  Outside of general practice things have evolved considerably.  Now when entrepreneurs in this country set up new companies, they do so under the protection of a limited company, which means their liability is always limited to the level of their capital contribution to the firm.   The personal assets of the entrepreneurs are protected.  Now while there are costs and complications of using a limited company model, traditional partnerships in other sectors such as accountants and solicitors have been replaced by limited liability partnerships, where the liability is similarly limited as for limited companies but with less technical complications.

At present limited liability partnerships are not permitted business vehicles for those holding a GMS or PMS contract.  This seems an archaic and unnecessary restriction, and one that it is encouraging to see the incoming Chair of the GPC already being vocal against.  Making technical changes that enable the liabilities that partners face to be in line with those faced by those working in other sectors feels is not just a step in the right direction, but one that is long overdue.


The level of liability that partners of GP practices are currently faced with is too great.  It is a problem that needs to be addressed, both to support existing partners and to make the profession more attractive to potential new entrants.  The most obvious solution is to enable GP practices to become limited liability partnerships.  A far less obvious solution, and one that would be both more expensive and disruptive to implement, would be to nationalise the service, and it makes no sense for the liability issue to be the main driver for such a move.

Does the Independent Contractor Model Mean More or Less Resources for General Practice?

One question that is largely ignored in the debate as to whether the independent contractor model has run its course for general practice is what the impact of its existence is on the totality of GP resources.  Does the model increase or decrease how much funding goes into the service?

This is a different question from that of whether sufficient resources are being invested into core general practice.  Overall underfunding aside, the question for today is whether the total amount invested would be more likely to go up or down if we were to move away from the independent contractor model.

At present there is national contract for general practice that is agreed with the BMA and the funding at a national level is then ringfenced.  Local areas can introduce local enhanced service contracts that are in addition to the national funding that has been agreed.  For the last two years there has been no negotiated agreement between the BMA and NHS England, but instead the agreement reached in 2019 has stood, and so there remains a ringfenced fund for the service.

Without the independent contractor model this national ringfencing of resources for general practice would be lost.  The funding instead would be transferred to local ICS areas, who would then in turn decide how much of that funding to pass on to general practice.  Or, the funding would go to the host organisation of local general practice, and they in turn would decide how much to pass on to the local practices.

Of course, in both these scenarios the amount passed on to general practice could be greater than the nationally identified total.  The ICS and local plans for a shift of resources from the acutes into primary and community care could result in an even greater investment in general practice, and should such a change occur I am sure promises of this ilk would be made.

However, it has long been a complaint of the system that when system savings have to be made (remember there is now a system financial control total that has to be delivered, rather than ones for individual organisations) that general practice has been exempt from taking “its share of the pain”, because of the way its national funding is protected.  Once this is removed it seems highly likely that cuts to general practice funding would form part of local financial recovery plans, given the system financial pressures that exist.

We have seen this scenario play out with community services many times over the years.  Originally acute and community services were in unified organisations, but were separated in many places when NHS trusts came into being because the resources intended for community services were being sucked in by the hospital services.  Even now as they start to come back together we are yet to see any big new investments into community services, and doubtless that wheel will have to turn again.

While the totality of the investment into general practice through the national contract is clearly lacking, the argument that this investment will be increased with a shift to a model of funding via the local NHS does not hold water.  The ringfencing would be lost, and the system pressure to use the funding elsewhere would be hard to resist.

If the independent contractor model was abandoned individual practices would no longer have the pressure to sustain themselves as organisations.  However, that pressure would still exist up the line at the level of a bigger and more distant organisation, and the most likely result would be a stripping of resources from local practices to meet a corporate cost pressure elsewhere.

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