Neighbourhoods could be future PCN taskmasters

Wading through all of the new guidance published by NHS England at the end of January, one thing has become abundantly clear: the plan is not for PCNs to evolve into neighbourhoods.

The system has grand plans for neighbourhoods and PCNs will just be components within them. Instead, there is a new risk: that these new neighbourhoods, once they are in place, will assume some level of direct control over practices and PCNs.

The new Neighbourhood Health Guidelines hardly mention PCNs at all. Instead, the role of establishing neighbourhoods is put firmly within the remit of ICBs and local authorities as it states: ‘ICBs and local authorities are asked to jointly plan a neighbourhood health and care model for their local populations that consistently delivers and connects the initial core components at scale’.

Once established one of the specific impacts the new guidelines expect neighbourhoods to achieve in 2025/26 is ‘improving timely access to general practice’. Six core components of a neighbourhood health service are identified and one of these is ‘Modern General Practice’.  

So now we have the prospect of neighbourhoods that will be established by the system and will be directly concerned with GP access as a priority for next year.

While the optimists amongst us may cling to the lingering hope that the intention is for local systems to find a way of partnering with general practice via these neighbourhoods to support the service to improve access for itself, NHS England in its outline of the new operating model promises to provide in the Spring, ‘Details of a new Commissioning and Transformation Support Programme for GP commissioners which will support ICBs to create the right conditions for improving general practice, including contractual management and transformation’.

It may be that the intention is for ICBs to create strong GP commissioning teams (which do not exist at present) alongside these new neighbourhoods to implement this programme, but far more likely is the intention is for these to be two sides of the same coin.

Meanwhile, the Secretary of State has been talking about the need to tackle ‘unwarranted variation’ between practices and ‘poor performing practices’ who are ‘dragging down’ the service. These comments coincided directly with the publication of the new guidance, and so it seems as though a national effort to somehow ‘get tough’ on practices has been put in motion.

The worry is that the plan is for the new neighbourhoods is part of this effort.

The Labour government has talked consistently about additional funding needing to be accompanied by reform. The government has already promised an additional £889m for general practice but we are still waiting to find out the details of the reform expected in return. However, in the government’s Mandate to NHS England it makes ‘reform to improve primary care access’ one of five national objectives for the service. As part of this it outlines an expectation for NHS England to, ‘Develop approaches with relevant partners to improve financial flows within health and social care to provide more co-ordinated services to patients as a step towards building a new neighbourhood health service.’

The strong implication here is that at least some of the money for general practice (and, one assumes, PCNs) will be tied up within neighbourhoods. It will come as no surprise, then, if we discover either via next year’s contract or the 10 year plan that at least some of the funding for general practice and PCNs is to come via neighbourhoods.

This will then leave us in the position where neighbourhoods are tasked with improving access to practices, managing so-called ‘unwarranted variation’ between practices, using NHS England’s new performance management playbook to achieve this, and potentially having control over funding streams as a lever.

When we consider it like this, then the risk of neighbourhoods becoming the future taskmasters of general practice and PCNs is extremely high. The good news, however, is that how neighbourhoods are to operate in each area is to be locally rather than nationally determined. There is an opportunity now to influence the local development of neighbourhoods, and so it is imperative local general practice and PCNs get involved in system discussions about their establishment and mitigate this risk as much as they can.

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.