A whole new raft of documents was published by the government and NHS England at the end of January, and they have significant potential implications for general practice.  What can we learn from this latest batch?

These new publications include the latest “mandate” from the government for NHS England, which outlines the government’s expectations for next year, the Planning Guidance for 25/26 from NHS England to the service, NHS England’s new operating model, and the new Neighbourhood Health Guidelines which outline how neighbourhoods are to develop next year.

There is a consistent theme throughout these documents which will come as no surprise: improving GP access.  The planning guidance lays down the target for systems to improve patients’ access to general practice, including patient experience.  While it does not set out a numerical target it does state that GP access will now be measured by a regular Office for National Statistics survey.

Of the 5 government Mandate objectives for the NHS, one is to “reform to improve primary care access”.  What does this “reform” entail?  In part it is the “tackling unwarranted variation” mantra that never gets anybody anywhere.  Wes Streeting said in an interview with the HSJ that he wants ICBs to target practices “who are coasting at the expense of those who are striving hard”.  According to Wes there are “some practices who are not working as hard as they could and driving improvements as they could for their patients”.

Let’s put aside (if we can) the fallacy of diagnosing variation in access performance as a pure function of individual practice effort, and how offensive this is to all of those practices doing their best with inadequate funding for the vastly different practice populations they serve.  What is more worrying is that NHS England appear to have taken this to heart.

In their new Operating Model NHS England promises that “in the Spring we will provide you with details of a new Commissioning and Transformation Support Programme for GP commissioners that will support ICBs to create the right conditions for improving general practice, including contractual management and transformation leading to benefits for patients and the workforce”.  This has the heavy whiff of using blunt contractual and performance management to tackle variation (based on the diagnosis that the issue is lack of effort).  It is noteworthy that practices themselves are not listed as one of the supposed beneficiaries of this new approach.

In turn in the new Planning Guidance all ICBs are to, “put in place action plans by June 25 to improve contract oversight, commissioning and transformation for general practice, and tackle unwanted variation”, i.e. outline how they will put this new guidance into practice locally.

The other main element of the government’s mandate for the NHS to reform to improve primary care access is that it should, “develop approaches with relevant partners to improve financial flows within health and social care to provide more coordinated services to patients as a step towards building a new neighbourhood health service”.  What does this mean?

Well this is not as clear, because the mandate does not elaborate any further.  The new guidelines on neighbourhoods lack specificity.  They do not say what a neighbourhood is, what size it should be, what population it should cover, or how it should align with existing ICB or PCN structures.  While the official line is that this is to leave freedom for local teams to develop the model that will work best locally, it would be a huge surprise if the 10 year plan once it arrives does not fill in at least some of these blanks.

The neighbourhood guidelines do, however, make a couple of relevant things clear for general practice.  The aim of neighbourhoods (at least in the short term) is to both reduce the pressure on acute hospitals and to help with the immediate financial challenges systems are facing.  This means no new investment has (so far) been identified for them, and (one can’t help feeling) that they are therefore being set up to fail (Joe McManners eloquently explains in this episode of the podcast why neighbourhoods need to be seen as a long term investment in reducing growth in activity rather than a mechanism for reducing activity in the short term).

The relationship between neighbourhoods and general practice is also noteworthy.  General practice is not portrayed as a co-creator of neighbourhoods but rather as a recipient of them.  One of the initial six “core components” of neighbourhoods is “modern general practice”, as something for neighbourhoods to implement.  General practice appears more as a target of neighbourhood activity than as something they will be an integral part of.

This is further reinforced by the fact that it is ICBs and local authorities that are asked to jointly plan a neighbourhood health and care model for their local population.  There is a requirement for, “a mechanism for joint senior leadership such as a joint neighbourhood health taskforce in each place”.

It could even be that neighbourhoods end up being tasked with the role of tackling unwarranted variation in access between practices.  They could potentially then end up being the performance managers of practices and take on a much more directive relationship than we have been expecting.  There is a hint of this in the mandate which states, “improving primary care is essential to support a move to a neighbourhood service”.

PCNs, meanwhile, are conspicuous by their absence.  At this point it seems highly unlikely PCNs will evolve into neighbourhoods, but rather that they will exist within them (and be subservient to them).  Where PCN and neighbourhood boundaries do not align I don’t think it will even be a question when it comes to which one will have to change.

All this points to “reform” of general practice being high on the agenda.  We don’t yet know what the reference to improving financial flows for general practice means from the Mandate.  We don’t yet know what the relationship between practices, PCNs and neighbourhoods will be.  There is, however, quite significant room in what has been said in these documents for big changes to be proposed, but we will only get more clarity on these once next year’s contract and the 10 year plan have been published.

If there is one actionable take away for general practice from these documents, it is this: make sure you are as involved as you can be in the development of neighbourhoods locally.  Make sure that general practice is on the “joint neighbourhood health taskforce” or whatever it is called locally.  Freedom exists for local areas to determine the final nature of neighbourhoods, so it is crucial that general practice is around the table shaping how this should be.  This will be the best (and maybe only) way of mitigating the potential negative impacts of whatever the final guidance ends up being, and once local plans are made it will most likely be too late to do anything about them.