Hot on the heels of the Fuller Report, there is now talk of a reform of general practice funding allocations, all of which is pointing to some big changes coming for how the money flows to general practice.  What exactly do we know, and what is likely to happen?

Let’s start with the Fuller Report.  This says a number of interesting things when it comes to funding.  It reiterates the point made by NHS England recently when it says, “We welcome the clarity from NHS England that staff in post will continue to be treated as part of the core PCN cost base beyond 2023/24 when any future updates to the GMS contract are considered” (p19).

This is welcome, as many had been concerned that general practice would be expected to pick up the staffing bill for the ARRS staff post 2024.  It is noteworthy, perhaps, that the description is of these staff being part of the  “PCN cost base”, given the push for PCN funding to come via ICS’s in future that I will come on to.

The report also indicates that no change is planned to general practice funding until after the current five year contract has run its course – the recommendations on p35 around funding are that they should take place “beyond 2023/24”.  Nikki Kanani’s recent comments were also all about planning for the next contract after the current 5 year one.

However, the big push in the Fuller Report is for primary care funding, including general practice funding, to shift from being nationally to locally driven.  The report states, “National contractual arrangements, including for PCNs, have provided essential foundations including for chronic disease management and prevention. But they can only take you so far. As already highlighted in the report, getting to integrated primary care is all about local relationships, leadership, support and system-led investment in transformation. ICSs putting in place the right support locally will be enabled by maximising what control ICSs have over the direction of discretionary investment. This should be looked at by NHS England as part of the implementation of recommendations.” (p28).

Now in case that was missed by anyone the report was accompanied by a letter from the 42 Chief Executives of the new ICSs which reinforced this very point, repeating it almost verbatim, “National contractual arrangements, including for PCNs, have and will continue to provide essential foundations. But they can only take you so far. Getting to integrated primary care is all about local relationships, leadership, support, and system-led investment in transformation.”

There will undoubtedly be a variation across the ICS CEOs in how they view primary care and the role it can play.  But what they can agree on (unsurprisingly) is that they would like the funding for general practice to come via them rather than via a national contract.  It is hard not to believe that this shift of funds was at least to some extent behind the universal support ICS CEOs displayed for the report.

The extent of this shift is made clear in the annex at the very end of the report.  They want firstly the Additional Role Reimbursement Scheme to be delivered via ICSs not via a national contract (“Specifically consider, with DHSC and HEE, how the (ARRS) scheme should operate after March 2024, including the role of ICSs in working with national colleagues and PCNs in delivering it” p35), and secondly any additional funding for general practice to come under the control of local systems (“Move to greater financial flexibility for systems on primary care… Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35).

The report also sets the context for Nikki Kanani’s comments at the recent NHS Confederation Expo about reviewing the national funding allocation formula as part of the contract negotiations for the next contract from April 2024.  The report says, “It is also generally accepted that the distribution of primary care funding to neighbourhoods is not always well aligned to system allocations and underlying population health needs – and we need a concerted local effort to try and fix this.” (p28).

All of this, then, is pointing to a shift of resources out of the national contract after this 5 year deal expires, with far more to be allocated via ICSs.  The distribution of this additional resource (it seems) will be made by ICSs dependent on population health needs, regardless of the specific local needs of primary care providers.

All of this means there are a number of risks ahead for general practice.  First, ICSs are governed by a requirement to break even across the system, and cannot ringfence funds in the way areas could in the previous system when commissioners held individual contracts with providers, so funding via an ICS cannot be guaranteed in the same way as funding via a national contract.

Second, the allocation of locally distributed funds is likely to be based on population health need, meaning the distribution across practices will vary significantly.  Third, the ability of general practice to influence the direction of funds within a local ICS is far less than its collective ability negotiating a national contract together.  Fourth, there does seem to be some form of play for some of the existing PCN resources to shift out of the national contract and into local control.  And finally once resources are within ICS control they don’t have to come direct to general practice but could come via a partnership mechanism, i.e. via a third party provider of “support” such as an acute or community trust, which would likely further impact on the independence and autonomy of general practice.

My view for what it is worth is that general practice should think extremely carefully about agreeing to any significant shifts of funding from the national contract into local systems, but the GPC appears to be positioning itself badly in this regard with its position on the PCN DES, and so whether the service ends up with any choice in the matter remains to be seen.