16
jul
0

How Should General Practice Respond to the 10 Year Plan?

Posted by Blogs, The General Practice BlogNo Comments

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.

9
jul
0

The End of the Independent Contractor

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The 10 Year Health Plan has finally been published.  While the plan is about the NHS as a whole, it is clear that a key component of the plan is a “fundamental reform” of general practice,

“However, truly revitalised general practice will depend on more fundamental reform. Having served us well for decades, the status quo of small, independent practices is struggling to deal with 21st century levels of population ageing and rising need. Without economies of scale, many dedicated GPs are finding it difficult to cope with rising workloads… Where the traditional GP partnership model is working well it should continue, but we will also create an alternative for GPs. We will encourage GPs to work over larger geographies by leading new neighbourhood providers. These providers will convene teams of skilled professionals, to provide truly personalised care for groups of people with similar needs.” (30)

While the plan is rarely explicit about the reform it will impose on general practice, and seems to go to great lengths to be careful in the language that it uses (doubtless because having GPs on board will be crucial to the plan’s success), change to general practice sits at the heart of this plan.

General practice will no longer operate as standalone organisations, but as components of neighbourhoods.  This is a huge change.  While practices have had to work together as part of the PCN DES in recent years, it has for the most part been joint working around the edges.  The core business of the practice has always been separate and remained clearly within the domain of the practice.

This plan is clear that practices will operate as part of the incoming neighbourhoods.  Improving access to the practices within the neighbourhood is a priority part of the neighbourhood activities.  The NHS App will be enhanced to take on much of the first contact work that practices currently undertake.  The work of neighbourhoods will not be restricted to practices activities outside of core work.

A large part of practice funding will come via the neighbourhood.  While core funding will still come direct to the practice, it very much appears that all other funding – local enhanced services, PCN DES funding (or whatever that becomes), vaccination and immunisation funding, potentially even QOF funding, along with any new money – will come via the neighbourhood.  Neighbourhoods will be impossible for practices to ignore.

Neighbourhoods, in turn, will be run by at-scale organisations.  In the best case scenario they will be run by groups of practices working together as an entity, either an enhanced PCN-type organisation or federation.  But the plan is clear that neighbourhoods will not solely be in the domain of general practice, “We will also give integrated care boards (ICBs) freedom to contract with other providers for neighbourhood health services, including NHS Trusts” (32).

Those running neighbourhoods will be those who are awarded the two new contracts the plan introduces – the single neighbourhood provider, and the multi-neighbourhood provider.  It appears both contracts can be operational in the same area, with multi-neighbourhood providers, “responsible for unlocking the advantages and efficiencies possible from greater scale, working across all GP practices and smaller neighbourhood providers in their footprint” (32). Both, it seems, will be directly involved in the work and functioning of individual practices.

Part of the plan is also to reinvent Foundation Trusts.  Its intention is to, “Create a new opportunity for the very best FTs to hold the whole health budget for a defined local population as an integrated health organisation (IHO). Our intention is to designate a small number of these IHOs in 2026, with a view to them becoming operational in 2027. Over time they will become the norm” (13).  It very much seems, then, that the plan is for these two new contracts to ultimately be commissioned by these FT-run “integrated health organisations”.

So the plan seems to herald the end of the independent contractor model for general practice.  While practices can remain contractors, it does not seem that they will be able to remain independent.  Instead, they will become part of the fabric of the new neighbourhoods, with a whole series of new masters (the single neighbourhood provider, the multi-neighbourhood provider and the integrated health organisation).

There is opportunity in the changes for general practice, but there are also huge risks, not least of which is the opportunity for NHS Trusts to gain such direct influence and even take over GP practices.  The status quo, however, does not feel like it will be an option, and so active involvement in shaping the changes as they occur must become a top priority for practices.

25
jun
0

Hospitals to hold General Practice Funding?

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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

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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.

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