NHS England has published a number of documents recently that shed a bit more light on how the NHS architecture is changing.  What are the main changes, and what are the implications of these for general practice?

The documents in question are the Strategic Commissioning Framework and the Advanced Foundation Trust Programme.  They are significant because they set out a clear shift in the way the NHS is to function.  In recent years we have seen a move away from the purchaser provider split, with ICBs being given the role of system integrators aiming to bring the system together to collectively decide how to make the best use of the limited resources.  These documents, however, represent a shift away from this thinking.

Instead, we have a return to the purchaser provider split.  The role of ICBs is now to be very clearly demarcated as that of “strategic commissioners”.  Strategic commissioning, it turns out, is the updated term for what became “world class commissioning”.  The document lists out the seven features or characteristics of strategic commissioning, in very much the same way world class commissioning identified 11 competencies when it was launched in 2007.

ICBs are expected to make this change quickly, “A strategic commissioning development programme will be in place from April 2026 to support ICBs and others who commission NHS services to develop as strategic commissioners. As part of this we expect ICBs to carry out a baseline assessment against this framework in March 2026 to inform the development support they need. We plan to incorporate elements of the framework in the assessment of each ICB as a strategic commissioner that NHS England is required to undertake from 2026/27.”

The difference this time round to 2007 is that ICBs are expected to do this both with far less staff and resources, and it is not the purpose for which they were originally established.  How able ICBs will be to adapt and take on this new role remains to be seen, but given the inability of the NHS to produce effective commissioners in the past the odds don’t look good.  This change in role may or may not be what has been behind the recent exodus of a large number of ICB leaders.

Just as ICBs are to become the new commissioners, NHS Trusts are to once again become foundation trusts, only this time they will be called “Advanced Foundation Trusts”.  As in the past, NHS Trusts will be able to secure more operational and financial freedoms once they achieve this status.  The main difference this time is that the role of system integrators is also effectively being shifted from ICBs to them.

Once an NHS Trust has achieved advanced foundation trust status it can take on an integrated health organisation contract, whereby it can hold the health budget for a defined local population.  It will not be expected to provide all services under the scope of the contract directly, but rather will need to work with other providers (including general practice) to deliver these services.

So the new delineation is quite distinct: ICBs are to become very clearly defined as commissioners, and NHS trusts as both autonomous providers and the integrators of providers across the system.  The question is where all of this leaves general practice?

The indications are that the impact could be significant.  We get a strong hint of this in the Strategic Commissioning Framework, which states that,

“The 10 Year Health Plan sets out a new provider system architecture for neighbourhood health. This – for the first time since the creation of the purchaser–provider split in 1991 – has the potential to shift the majority of NHS provision from a ‘receive and treat’ model to a population-based model. Individual GP practices, single neighbourhood providers (SNPs) and multi-neighbourhood providers (MNPs) are all population-based entities.” (5.2)

ICBs are exhorted to “shape the development of providers and use of novel contract models to create the right provider landscape to deliver population health improvement”.  It very much seems as though the main lever that will be used to influence general practice will be the new neighbourhood contracts.

This was reinforced by Wes Streeting who suggested that these new contracts would be the tool to enact a “fundamental modernisation” of general practice in his speech to NHS Providers on 12^th November,

“But the bright future that general practice deserves will only come through fundamental modernisation. That’s why we’re introducing two new neighbourhood contracts. A single neighbourhood provider contract for the delivery of enhanced services, for patients, through expert, multi-disciplinary teams and a multi-neighbourhood provider contract to lead the Neighbourhood Health Service at scale.”

This appears to suggest that enhanced services may be commissioned in future via the single neighbourhood contract, a concern that GPC Chair Katie Bramall-Stainer also raised at the recent LMC conference.  If this ends up being the case practices will get tied into neighbourhoods in very much the same way as they have with PCNs, as being without the enhanced service funding will be simply unaffordable.

According to the Strategic Commissioning Framework, “Primary care leaders are working with their ICBs to explore how best to organise their work, including through horizontal and vertical integration with other parts of the NHS, so that patients receive the appropriate care, whether episodic or ongoing co-ordinated care or part of a wider pathway of care. They are also playing a leading role in the development of neighbourhood health.” (5.1).  In reality I suspect very few primary care leaders on the ground are looking to horizontal and vertical integration, but it seems likely that this is the agenda at a national level.  All three of the new contracts (single neighbourhood, multi neighbourhood and integrated health organisation) may well end up pushing general practice in this direction.

This makes the guidance (promised in November in the medium term planning framework) on these new contracts extremely important indeed for general practice.  The NHS is changing rapidly, and general practice will need to work hard to establish its place and maintain its independence in this new architecture.

NHS England has released planning guidance for the next three years (2026/27 to 2028/29), in a move away from the traditional one-year planning guidance.  It also appears as if (although this is not explicit) this is the promised implementation plan for the 10 Year Plan.  What does it mean for general practice?

Unsurprisingly, the focus for general practice is (yet again) on access.  A new target is even introduced, “Improve access to primary care, including reducing unwarranted variation in access. Ensure 90% of clinically urgent patients are seen on the same day. We will consult with the profession on this new ambition and approach.”

Bear in mind the NHS’s recent history of consulting with the profession is not strong, with broken promises around the changes introduced on 1^st October and the lack of BMA involvement in the Carr Hill review obvious examples.

For 2026/27, ICBs are specifically instructed to “identify GP practices where demand is above capacity and create a plan to help decompress or support to improve access and reduce unwarranted variation”.   Who will actually do this (given the downsizing of ICBs) remains to be seen.

It could fall to neighbourhoods.  These feature heavily in the document, and the expectation that began in the 10-year plan that neighbourhoods will be the golden bullet to solve all the NHS’s ills continues, e.g. “The delivery of neighbourhood care has to be a priority for every leader in the NHS because it will create more space to do elective work, reduce waiting times, improve the quality of care and make headroom for leaders to focus on innovation”.

Unfortunately, as has been the case with all references to neighbourhoods so far, details about them remain scarce.  The most concrete guidance the document contains about neighbourhoods is this:

“Starting now and accelerating over the next 3 years, we want to deliver even more care in our neighbourhoods, providing more joined up care for high-priority cohorts through integrated neighbourhood teams (INTs), and make a material difference to patient experience and hospital demand. In implementing neighbourhood health, the immediate focus must be on:

• improving and tackling unwarranted variation in GP access for the whole population
• reducing unnecessary non-elective admissions and bed days from high priority cohorts – people who have moderate to severe frailty, people living in a care home, people who are housebound or at the end of life
• enabling patients requiring planned care to receive specialised support closer to home”

It remains unclear to me how the concept of neighbourhood working is expected to impact on GP access.  However, there is to be a “Model Neighbourhood Framework” which is “expected in November”.  This will “set out the definitions, goals and scope of neighbourhood health, along with priority actions for 2026/27”.  Maybe this will provide more clarity?

There will also be a “model neighbourhood health centres archetypes, which will describe different archetypes of provision of neighbourhood health services that can be used to inform the better utilisation and enhancement of existing estates, together with new-build solutions, where appropriate”.  I think this means guidance as to how the 10-year plan promise of a physical hub for every neighbourhood is to be realised, although the language used to describe it already suggests it may be less than useful.

“Archetypes” is clearly the vogue word of the moment, as also to come in November is “a system archetypes blueprint explaining the interplay of the new contract models set out in the 10 Year Health Plan (integrated health organisations, multi neighbourhood provider contracts and single neighbourhood provider contracts) and a draft integrated health organisation blueprint.”

This document characterises integrated health organisations as a contract model.  Rather than it being a goal for acute/foundation trusts to aspire to (the implication within the 10-year plan) it is now a contract.  The big question is whether this will include the funding for general practice.  What the document says is, “IHOs will work with the wider provider landscape to deliver high-quality care efficiently, including through sub-contracting arrangements and, where appropriate, delegation of commissioning”.

Does this mean sub-contracting arrangements from the acutes to general practice to fund the right to left shift of services, or acutes having a greater say as to what general practice does through its main contracts?  We don’t know yet, but it is clearly a concern.

Indeed, the big question for general practice is whether the new contract types will sit alongside the existing core contract or replace it.  A sceptic may look at the Carr-Hill review as an opportunity for the NHS to force many practices (i.e. the 50% of practices who will lose out as a result of it) to move onto whatever alternative option these contracts may present.

For general practice, then, it feels like significant changes are coming but we still don’t know what they are.  The key questions around the relationship between PCNs and neighbourhoods, and between the new contracts and the core GP contract, remain unanswered.  All eyes are on the promised November documents, although history has taught us that we rarely get straight answers, and we should not be surprised if yet more ambiguity is what we end up with.

The government has announced that there will be a review of the Carr-Hill funding formula.  What are the implications of this review for the profession, and could it mean that the future of the GMS contract is potentially under threat?

In the government’s announcement it states,

“The 6-month review will launch today (9 October) and will be conducted by the National Institute for Health and Care Research (NIHR).  The review will:

• identify a new allocation formula
• assess the impact and feasibility of implementing it while ensuring it aligns to the government’s 10 Year Health Plan
• make an overall recommendation to replace the outdated Carr-Hill formula”

Noone disagrees that the funding formula needs to be reviewed.  However, doing this in isolation poses a number of risks for the profession.

The first and most obvious risk is that if the funding formula is changed without an injection of additional money then some practices will receive more funding at the expense of other practices receiving less.  Practices that are already struggling to make ends meet are not going to be able to take another financial hit if their practice is one that will lose out.

The review does say it will look at the impact and feasibility of implementing it but that does not necessarily mean removing funding from practices won’t happen.  The minimum practice income guarantee (MPIG) was used to protect practices when the move to the global sum was first introduced, but that wasn’t pain free for practices (particularly as it was removed).  If there is no additional money announced (and the BMA have reportedly been told that the review may need to be cost-neutral) it is hard to see how such a guarantee could be introduced this time round.

It is noteworthy that the review of the Carr-Hill formula has been announced as a standalone exercise.  It has not been included as part of a total review of the GMS contract.  The GPC has been insisting on this review and only signed up to this year’s contract on the basis that this would happen, and yet no plans for this review have been put in place other than this review of the funding formula.

It also appears that the GPC and BMA were not consulted on the launch of the review and are not part of the review group.  Maybe the timing of the announcement coming only 9 days after the GPC announced it was entering dispute over the contract changes was not coincidental.  As I wrote about last time, one of the risks of entering dispute is the potential loss of voice and ability to influence policy and in particular the role of general practice within neighbourhoods.

But the biggest potential risk of this review is how it may link in with the new Neighbourhood Provider contracts.  Of course there may be no link at all, and the timing of this review to finish just as the contracts for next year are to be introduced could be entirely coincidental.  But there is the possibility that this review may be part of a wider change, and a move away from the existing GP standalone contract.  A scenario whereby this review recommends that potential “losers” on whatever comes out of the funding formula review shift to the neighbourhood contract instead to mitigate any loss does not feel totally outside of the realms of possibility.

While the review is finally tackling an issue that has negatively impacted many practices for many years, the risks of doing so, along with its positioning as almost a response to general practice entering dispute with the government, will be of real concern to the profession.