The new government has been very clear in its desire to shift resources out of hospitals and into communities, to increase the focus on prevention, and to establish a “neighbourhood NHS”.  But the question we are very much left with, and one that seems to be at the heart of what the government is grappling with, is whether the infrastructure exists in primary and community care for this so-called “left-shift” to take place.

The parlous state of the general practice estate was highlighted by the Darzi report.  The government recognise there can’t be a wholesale shift of activity if there is neither the space nor the facilities for this activity to be carried out in.

Equally, the need for a new operating model was stressed.  Ever since the Darzi report was published with its promise of a greater share of NHS funding for primary and community care the government has been insistent that there will be no new money without reform.

PCNs and GP federations, despite being the place where practices work together to enable just the kind of shift the government has been looking for, have been largely ignored.  They hardly get a mention in the Darzi report, and while Mr Streeting has been keen to stress that independent GP practices will still have a role to play, he has been less forthcoming about PCNs.

We may have the first inkling as to why in the recent IPPR report.  This was reportedly warmly welcomed by Wes Streeting, and it calls for the government to, “Create Neighbourhood structures: PCNs are not working to put primary and community care in the lead of the NHS’ future. We need to found the neighbourhood NHS – by investing in a hub and spoke model of general practice, and by setting up Neighbourhood Care Providers to lead strategy, invest in population health and revitalise the NHS’ relationship with real communities.” (Summary report, p37)

This report argues that GP practices being outside of the NHS means they are rarely a priority for investment, encourages them to operate at small scale, creates a barrier between primary and secondary care, shifts too much risk onto GP partners, and makes the profession unpopular to junior doctors (Full report, p99).  It argues for a shift away from the “loosely federated partnerships” that are PCNs, and towards a model of what it terms “Neighbourhood Care Providers”, which are to be accompanied by Neighbourhood Health Centres requiring a capital outlay of £12.5bn(!) spread over 10 years.

The report ends up in more or less the exact same place the Fuller Report did when talking about Integrated Neighbourhood Teams, “NCPs could either be newly created or formed by existing community trusts, more advanced PCNs or multi-speciality community providers (MCPs). Over time these NCPs should take on the contracts for primary, mental health and community care.”  (Full report, p101).

The IPPR report is not a policy document.  But IPPR is a left-leaning think tank, and it was set up in the 1990s to “provide theoretical analysis for modernisers in the UK Labour Party”.  Given Labour’s manifesto pledge was to set up a neighbourhood health service, this report has the feel of one designed to provide ideas as to how this could be achieved, and it would not be a surprise to see at least some of this thinking appear in the forthcoming 10 year plan.

What all this means is that the policy question is not whether the independent contractor model is good or bad, but rather how the necessary infrastructure in the community can be developed to enable the desired shift of activity to occur.  This report raises the question of whether the independent contractor model is in fact a barrier to the development of this infrastructure.  This needs to be actively refuted, and what general practice should be doing (rather than setting itself against a government that has clearly stated it wants to invest in and support general practice) is come up with its own view of how this shift could be achieved in a way that builds on the core strengths of independent general practice rather than destroying it.