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.