The Department of Health and NHS England have produced the long-awaited guidance on neighbourhoods.  It is now clear that neighbourhoods are going to have a significant negative impact on general practice.

First of all, general practice funding flows are going to change significantly.  While the core contract is to remain nationally determined, it looks like all other funding (local enhanced services etc) will come via neighbourhoods.  Single Neighbourhood Providers (SNPs) will “enable primary care to take on new neighbourhood services that are not contracted for (through the GMS contract)” – this sounds very much like all local enhanced services are to come via this route.

Worse, all the funding for general practice will in future be held by an Integrated Health Organisation (IHO), “IHO contract holders will subcontract neighbourhood services, most likely through multi-neighbourhood providers (MNP), and take on local contract management responsibility for GMS (or PMS or APMS) general practice contracts, as well as pharmacy, optometry and dentistry, all of which will continue to be determined nationally”.

The funding plan for neighbourhoods appears to work like this.  All the money for primary care and community services will be given to the local acute trust, who will be renamed an IHO.  The expectation is then that local acute trust/IHO will give some of its own funding on top of the funding it receives for primary and community care so that neighbourhoods work.

That’s it.  There is no new funding, no pump priming, no investment in change capacity, just an edict that “neighbourhood health will be funded by rebalancing existing resources rather than relying on new funding”.  Not only is this unlikely to work, it is going to put funding for general practice at extremely high risk.

One of the key outcomes for neighbourhoods is that they will improve access to general practice.  Less clear is how the introduction of neighbourhoods is expected to achieve this, especially when they bring zero additional resources or capacity.  I think the answer is this is expected to come as a result of introducing three layers of bureaucracy above practices:

“The ICB contracts a single integrated health organisation (IHO) for an area. The IHO then contracts a number of multi-neighbourhood providers (MNPs). Each MNP works with multiple single neighbourhood providers (SNPs). Each SNP works closely with all local GP practices in the neighbourhood.”

So, as I read it, first the SNP has to try and performance manage improvement to access targets in its member practices.  If that fails it will be escalated to the MNP, and likewise from there to the IHO.  Beyond “performance management” I cannot think of a single reason why these new arrangements could possibly result in an improvement in access to general practice.

General practice meanwhile looks like it is also expected to pick up what the guidance terms a “25% diversion rate” through (newly mandatory) single points of access/referral management centres (unless there is somewhere else that will pick up this work?).  Remember there will be no new money for this as use of advice and guidance is now part of the core contract.  GPs are also supposed to lead “Integrated Neighbourhood Teams” (INTs) that will keep patients who are frail or have multiple long term conditions out of hospital, as well as taking on at least 10% of the patients who are currently managed as follow ups by the hospital.

PCNs, meanwhile, are going to “evolve into” SNPs.  This means that control over PCNs will most likely shift away from practices and to whoever the new contract-holder ends up being, who in turn will be beholden to the MCP and the IHO.

There is no evidence that introducing neighbourhoods will achieve any of the outcomes that the government and NHS England are suggesting.  Logically it is hard to understand how simply changing contract models and creating “new partnerships and collaborations” can achieve any of the proposed outcomes.  Unfortunately, general practice seems set to suffer the most as a result of these changes as it will certainly lose autonomy, it will lose control of PCNs, and it will be dependent on the acute trust for its funding, while at the same time being set up as the fall guy for when neighbourhoods inevitably fail to deliver the pie in the sky outcomes these documents propose.