What’s in store for General Practice in 2024?

As 2023 draws to a close, general practice is faced with a great deal of uncertainty. The five-year contract agreed back in 2019 comes to an end, and so far there has been no clear indication of what is to come next. But is the uncertainty really that great? Could it be that we know more than we think?

Let’s consider what we actually do know about the future direction of travel, and what might be in store in 2024.

The best place to start is the 2019 NHS Long Term Plan. Chapter 1 of this plan is entitled, ‘A New Service Model for the 21^st Century’, and NHS England’s number one action to deliver this is, ‘We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services.’ (p12)

The overall system goal is to integrate general practice with the rest of the system. We have moved away from the internal market and the idea of purchasers and providers, and now the aim is to enable joint working between providers. General practice is top of the list both because of the key role it plays in coordinating care and because of its independent status that separates it from the rest of the NHS.

The Long Term Plan was also the first place to introduce the idea of primary care networks, as an enabler of this integration between general practice and community services: ‘The result (of PCNs) will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based healthcare’ (p15).

I think it is fair to say that PCNs, so far, have not delivered this goal. But it is clear this ambition still remains. The introduction of ‘Integrated Neighbourhood Teams’ in the 2022 Fuller Stocktake report is essentially an attempt to get PCNs back on track to achieving this. The report was even entitled, ‘Next Steps for Integrating Primary Care’!

So we know this is the overall direction of travel. The main progress made so far has been for the 6500+ practice units to now be working in a much smaller number of neighbourhood groups (i.e. PCNs). There will be no backtracking from this. Funding is not going to shift from PCNs back to practices. If anything, more funding will come via PCNs as the system seeks to further cement this group working.

There is also going to be an election next year. With no new funding commitment for the NHS in place, and no prospect of one before the next election, NHS England are reported as stating that 2024/25 will be a one-year ‘stepping stone’ contract. This means essentially a continuation of what we have now (i.e. PCNs) with some pointers towards the future direction of travel.

We also know Integrated Care Boards (ICBs) are very keen indeed on getting their hands on general practice funding, most of which is currently held nationally. The letter signed by all 42 ICB CEOs that accompanied the Fuller Stocktake report stated that the NHS needs to, ‘Pivot to system-led approaches as the main way of driving up access, experience and outcomes in primary care in this next stage of its development. National commissioning arrangements, including for PCNs… can only take you so far’.

So when we think about the direction of travel and what might be new we can expect two things. We can expect local systems to be pushing for more control of general practice and PCNs and their funding and resources. And we can expect there to be a move towards enabling structural integration, i.e. GP practices being more directly linked with NHS organisations either via these organisations becoming responsible for the contract (like Wolverhampton and Northumbria) or via some form of sub-contracting arrangement between NHS Trusts and GP practices.

But the move towards local system solutions is also positive. It means there is unlikely to be a large top down imposition (like PCNs or CCGs) on general practice. This in turn means the better general practice can influence the system the more palatable the future changes will be. If general practice can shape what neighbourhood working is and how it develops by PCNs becoming more externally focussed and building productive relationships with local providers across the PCN area, then the chances of the system imposing its own solutions are greatly reduced. And if general practice can develop effective at-scale working across ICB place areas then the system will be less inclined to move to a structural solution.

While we don’t know exactly what will happen in 2024, we do know the policy context is closing the gap between primary and community care via PCNs, developing neighbourhood working and, if all else fails, introducing structural solutions. While we might not agree with this direction of travel, understanding it gives us the opportunity to shape the future of general practice rather than simply waiting for someone else to shape it for us.

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.