The more contentious of the two new contracts proposed in the 10-year plan is the multi-neighbourhood provider contract. Is this an opportunity for real investment in the service for the first time in many years, or does it represent an existential threat to general practice?
There are a couple of lenses we can consider this through. There is the opportunity it could create for investment into general practice, but there is also the impact it could have on the independence of the service.
Neighbourhoods are the centrepiece of the plan. To change the existing trend of ever-increasing investment into secondary care the plan intends to create high functioning neighbourhoods that can shift care into the community. While there are examples of individual areas doing some great things in this regard, the plan does not work if individual neighbourhoods are effective only in isolation. Large scale change is required if there really is to be a shift in costs and investment.
This is where the new multi-neighbourhood providers come in. These organisations are to work and be responsible for delivery across the 250,000+ people. They are to create the framework for individual neighbourhoods to use, as well as having a clear role in supporting delivery across all of them.
We all know the variation that exists between the PCNs in whatever area we are working in. This will be multiplied once joint working across all the organisations in a neighbourhood is added in. The plan will only work if there is some mechanism to tackle this variation and ensure all of the new neighbourhoods are operating at a level sufficient to enable the shift of resources to take place. This mechanism is to be the multi-neighbourhood provider.
But while these new providers may increase the probability of future investment by tackling variation, this ability may in turn impact on practice and PCN autonomy.
Let’s consider how the new multi-neighbourhood providers will operate. Is the intention they will only deliver contracts for additional work beyond the core delivery of the existing providers within the neighbourhoods? Or will the delivery of all of the work within the neighbourhoods, including the core delivery of the existing providers, be part of their remit?
Here is what the document says: 'These larger providers will deliver care that requires working across several different neighbourhoods (e.g. end of life care). Multi-neighbourhood providers will also be responsible for unlocking the advantages and efficiencies possible from greater scale, working across all GP practices and smaller neighbourhood providers in their footprint. They will support sustainability and professional autonomy by delivering a shared back-office function, overseeing digital transformation and estate strategy, and by providing data analytics and a quality improvement function. They will be large enough to create new commercial partnerships, including clinical trials, so that the Neighbourhood Health Service becomes a hotbed for innovation. And they will actively support and coach individual practices who struggle with either performance or finances - including by stepping in and taking over when needed.' (p32, 10-year Health Plan for England)
And then: 'They will convene a diverse mix of professionals into new neighbourhood teams. They will draw on the full talents of the NHS, across primary, community and acute settings - but they will also have the flexibility to include staff from other sectors where they are involved in a patient’s care.' (p33, 10-year Health Plan for England)
The more I read this, the more it seems all of the core delivery across the neighbourhood providers will be included. It reads more like new organisations will be formed that GP practices and other 'smaller neighbourhood providers' will be part of. They will be able to convene teams using staff from each of these organisations. They will create a shared organisational infrastructure and be responsible for their performance.
The document says that these new providers will 'support sustainability and professional autonomy', but it does not say that they will support organisational autonomy. Implicit is that sustainability for practices and other providers will come from being part of these new entities. Earlier on the plan says, 'Where the traditional GP partnership model is working well it should continue, but we will also create an alternative for GPs. We will encourage GPs to work over larger geographies by leading new neighbourhood providers'.(p30)
This is of course disingenuous because the document goes on to say that the government will, 'give integrated care boards freedom to contract with other providers for neighbourhood heath services, including NHS Trusts' (p32, 10-year Health Plan for England). At-scale GP organisations like GP federations could take on these contracts, but equally so could acute trusts. So it seems very much as if we will have multi-neighbourhood providers that GP practices will be part of (and may or may not be leading), alongside the traditional GP partnership model that may or may not be sustainable if all the additional funding goes into these new contracts.
It is hard to see past a scenario whereby these new multi neighbourhood providers present a real threat to the future autonomy of general practice and PCNs. The exact relationship between the two remains to be seen. I strongly suspect at present no clear plan exists anywhere, even within government.
But these new multi-neighbourhood providers are coming. What is important for general practice is that it ends up leading these. For some places this will mean supporting the local federation to get itself into a position where it can take this on, and in others it will mean the PCNs working together to ensure that a collective entity is established that can do the same. If general practice and PCNs can make that happen then they can work out for themselves how to make the neighbourhoods a success and use the opportunity to secure real investment in the future.
Ben Gowland is director and principal consultant at Ockham Healthcare, a think tank and consultancy. He was an NHS chief executive for eight years and has also been a director of Croydon Health Services NHS Trust. He established Nene Commissioning, first as a PBC organisation and then as one of the largest CCGs.