It has been reported that the Neighbourhood Contracts announced in the 10-year health plan will be subject to a public consultation, with the results feeding into the development of future annual GP contracts. The very earliest they could be implemented is 2027-28. What should we read into these delays, and what might they mean for PCNs and the future of neighbourhoods?
Ahead of the publication of a promised ‘model neighbourhood ‘document there has been some interesting mood music coming out of the centre. NHS England CEO Sir Jim Mackey, talking on the Prevention is the New Cure podcast, raised the issue of historic investment in out of hospital services not having enough impact for hospitals to ‘feel ‘ the difference.
This speaks to a nervousness within NHS England around the shift of care from hospital to community - one of the three key shifts within the 10-year plan. If investment in the community does not result in a reduction of expenditure in secondary care the worry is the NHS will be in even greater financial turmoil.
So far, this government has made little or no investment in either community or primary care. Financial control and stability is the current priority, which is most likely why the pace of change is not matching the 10-year plan’s announcement that the new neighbourhood contracts would start in 26/27.
This is not news for general practice. The rhetoric of a ‘left shift ‘ has been around for a very long time and has never yet translated into reality. The prioritisation of the financial stability of hospitals when GP partners have to put their own houses on the line is a source of huge irritation across the service.
I am not sure, however, that this means neighbourhoods are dead in the water or that no change is coming. Sir Jim Mackey also talked about the need for disruptive change. The ambition of the shift from hospital to community is not that the same activity is carried out for less cost, but rather that services are completely redesigned. He wants a step change in results and outcomes. He talks about the outpatient model being ripe for such reinvention, along with how frailty services are delivered.
This is different from how we have traditionally thought about this shift in general practice. Here we talk about how the work can be carried out cheaper out of hospital because of lower overhead and operating costs. But the challenge is not for marginal gains, but for step changes both in managing demand and improving outcomes.
This is where neighbourhoods come in. In Sir Jim’s mind it is the neighbourhood that is to be this disruptor, something that is ‘not about delivering the old world better, but about delivering a new world ‘.
When discussing neighbourhoods and how they could function in this way, he said they only work if they are fully integrated teams, including council, acute, community, primary care and mental health from the start, that are jointly led. When NHS England chair Dr Penny Dash was recently asked what aspect of neighbourhoods need most attention, she responded that they haven’t ‘got quite that rigour of management behind it that you might want to see‘.
So NHS England seems to be envisaging something that is significantly different from the current reality of neighbourhoods. At present they feel like a series of well-intentioned projects that are an add-on to the day job, without the resource or the priority to make any real difference.
If NHS England want fully integrated teams with strong management then this will not work as a loose collaboration between organisational partners trying to fit neighbourhood working in alongside everything else. They will require both investment and organisational commitment from all partners, including general practice.
This is most likely where the new neighbourhood contracts will come in. It looks like these are being envisaged as enablers of a structural integration to empower neighbourhoods to be genuinely disruptive. The signs are that they will require fundamentally different ways of working from all sides. This would also explain why NHS England now feel the need to consult on them before they are introduced.
The implications of this for PCNs are potentially huge. The independence of general practice and PCNs is not something the centre values. It is very hard to see independence in the way we understand it now being able to continue, as the very premise of neighbourhoods is integration. Given what we have heard, I would very much expect PCNs and potentially even general practice to have to enter into integrated structures in order to participate in these contracts.
Much of this remains at the level of speculation, and maybe the ‘model neighbourhood ‘ document will provide some much-needed clarity. But it looks like things will change. If they do, ignoring neighbourhoods will put PCNs and general practice on the back foot once more concrete guidance appears. Instead using the management and leadership capacity provided by PCNs to work out what they need to do and what partnerships they need to put in place to take on the ‘lead disruptor‘ role within the system would be the place to focus now.
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.