Are traditional GP partnerships at risk?

In the second of our weeklong daily insights into the NHS 10 year plan, the team ask, “are traditional GP partnerships at risk?”

There are two sections in this insight:

• a look at different partnership models
• the risks and opportunities for practices

There is surprisingly little stated about general practice within the 10 Year Plan (“the Plan”). The focus is on neighbourhood working and the development of services at the neighbourhood scale. With this focus on different size populations it could be interpreted as indicating that smaller traditional practices may not fit within this new model.

The Plan states:

‘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.’

Since publication this message has been reiterated by Wes Streeting MP (Secretary of State for Health and Social Care) and by Dr Amanda Doyle (National Director for Primary Care and Community Services at NHS England).

Mr Streeting has stated in an interview with Pulse that:

‘If you’ve got really effective GP partnerships that work and if you’ve got primary care networks that are working, why would I want to come in and say, “I think my model’s better than yours, so I’m just going to stop you doing something that’s working in order to do something else”?’

‘What we are doing as a neighbourhood health model is inviting GPs to step up and lead a new way of delivering neighbourhood health in a way that I think lots of GPs will be up for including GP partnerships, and those pioneers will show us the way.’

(We won’t replace GP partnerships that are working well, Streeting tells Pulse – Pulse Today)

Dr Doyle provide this further clarity also in Pulse:

‘There’s nothing in this plan about getting acute trusts or community trusts to come in and take over primary care provision.

It’s possible for that to happen where local primary care isn’t stepping up and able to, but it’s not designed in that way, and so it’s really important that people start to think about what the opportunities are, think about how things could be effectively, better delivered out of hospital in the place they work.’

(Hospitals could take on contracts where GPs ‘are not stepping up’, says NHSE lead – Pulse Today)

The message is therefore clear that there is no intention to replace the existing GP partnership model but there is an inherent threat to those practices who are deemed to be failing or to not have ‘stepped up’.

The Plan therefore foresees three options for practices which will be determined based on the size of the practice and the model in which they wish to provide services across their neighbourhood.

1. Traditional model
2. Single Neighbourhood Provider
3. Multi-Neighbourhood Provider

Traditional model

The current model of GP provision through existing core contracts (GMS, PMS or APMS) will remain the default model for all practices for the foreseeable future.

The General Practitioners Committee (“GPC”) and the government will be commencing negotiations for what Mr Streeting has referred to as ‘a new substantive GP contract within this Parliament, without preconditions, based on collaborative work, and in the spirit of mutual trust and good faith’ (sofs-letter-to-bma-gpce-20250318.pdf).  This is unlikely to take effect until 2027 or 2028.

There have been concerns raised by the GPC and by LMCs that there was no reference to these negotiations within the Plan. It may be possible that the new contractual structures, outlined below, will be introduced and in some areas implemented before these negotiations have been completed. It may also be possible that the government did not want to pre-empt the negotiations by making any presumptions within the Plan.

Current contractors may be in a situation in which it will be commercially preferrable to defer making major contractual decisions until they know what all their options are. This could be a limiting factor for the adoption of the new models until the negotiations have been completed. This would further support the notion that traditional models will be the prominent model until 2028, but it is essential that this does not create complacency. The failure to participate and support the development of the Neighbourhood Health Service could place contracts at risk before the new contracts are published.

The role and focus of general practice is likely to change. Where they fit within the ‘neighbourhood’ will need to be clearly defined and there is a risk that they may be required to change how they operate to fit the requirements of the neighbourhood if they do not take a proactive role in shaping this.

There could be a risk to existing enhanced services which could be redesigned to be delivered across a larger geographic scale. Whilst many practices are likely to remain the provider of choice for this work it is not guaranteed. This is particularly important where the Multi Neighbourhood Providers are established and/or where Foundations Trusts are given control over the whole health budget, effectively giving them increased power over how and where funding is spent.

There are some essential steps practices should consider to secure their role and functions:

1. Continue to build collaborative services and to integrate with your neighbouring practices
2. Take a proactive lead in identifying and defining the needs of your neighbourhood
3. Create relationships and contacts with other providers including other primary care services, community services, social services and third sector providers

Practices will continue to have one of the strongest relationships with the patients and this connects them to their communities. Building this strength will ensure that the practices continue to have a key function whilst working at a small scale of the population.

This will not however be achieved alone and working with other practices in your PCN and within neighbouring PCNs will be essential.

Single Neighbourhood Providers

As stated in the quote from the Plan above GPs will be ‘encourage[d]’ to work at the neighbourhood level within providers specifically designed for the delivery of services for populations of approximately 50,000 people.

There will be early adopters of this model, particularly among those practices who already serve populations of this size and of those PCNs who are considering practice mergers to provide services at this scale.

Once this new contract is published practices will have the option of converting their existing core contract into the new format. It is anticipated that this will be designed to make it easier for the new provider entity to secure and run contracts for other services particularly outpatient and community services.

It should be noted that this same objective can already be achieved using the existing NHS contracting models.

The most obvious route would be to merge existing core contracts and to form a single provider. This may be within the structure of a traditional GP partnership working at scale, which many of the ‘super-practices’ have adopted, or there could be the option of ‘incorporating’ and novating the contract into a limited company.

This entity can then enter into a wide range of contracts commissioned using the NHS standard form contracts, NHS standard sub-contracts from Trusts and contracts from other sources such as local councils.

Alternatively, services can be commissioned at this level using the NHS standard form contracts which expressly include schedule 2L which integrates the provisions of APMS contracts. This would allow for a single consolidated general practice contract across the neighbourhood.

If an existing group of practices are interested in taking a lead in developing neighbourhood services there is therefore no need to wait until a new contract is formed. It is necessary to start the work involved in merging practices and designing the services you wish to deliver.

Those who take these steps now will be in a more advanced position to seize the opportunities which may arise from the new contract once it is published and in any event is capable of responding to opportunities at the neighbourhood level without delay. It would also allow them to wait for the outcome of the GPC contract negotiations to undertake a full comparison of the options available to them, without preventing them from the important work of delivering the Neighbourhood Health Service.

Once the ‘early adopters’ have made this transition it will be interesting to see what incentives will be used to ‘encourage’ other GPs to move to this model. This is particularly important in the context of the negotiations regarding the core GP contract and whether the government will attempt to include provisions which will inspire a further round of GP practice mergers and consolidation to form more Single Neighbourhood Providers.

Further advice on mergers is available on our website.

Multi Neighbourhood Providers

The third option available to practices is to seek to consolidate at a larger scale covering a population of approximately 250,000.

Arguably this is the most innovative model being proposed within the Plan, certainly in relation to the provision of general practice. However, this entity is not by default a provider of general practice services.

The core functions are largely administrative which are being removed from the ICBs in accordance with the Model ICB Blueprint (The Model Integrated Care Board Blueprint – key insights – Hempsons). These include services such as overseeing digital transformation, creating shared back-office functions, developing an estates strategy and providing data analytics and quality improvement functions. These entities should therefore be established across the country with the intention of supporting existing practices, and other providers.

The Plan also states that ‘they will actively support and coach individual practices who struggle with either performance or finances – including by stepping in and taking over when needed.’ A lot of focus has been given on this wording as it is clear that practices could be taken over by this type of provider.

Federations and Foundation Trusts are the most likely entities to take on these functions. In particular those which already operate at scale with developed or developing support functions.

In theory there is the option of a new form of NHS Trust to be developed specifically designed to hold and to provide general practice contracts. This is already permissible in existing legislation although the practice of developing such an entity would not be easy. It is certainly an option being discussed and explored in various locations across the country.

As with the single neighbourhood provider option it should be noted that the existing legislation and contracting structures do make this type of scale possible. The primary limitation is that Trusts cannot hold GMS contracts but other entities can. The new contractual structure may be very similar to the one published in 2018 for Accountable Care Organisations (“ACO”) which provided practices the right to opt in which would suspend their core contract with the option of taking it back if they were discontent within the ACO.

Many Trusts and Federations already hold GP practice contracts and there is no reason why they could not expand these services in areas where the traditional GP model is not working. However, if the intention of the government is to focus on the delivery of services within neighbourhoods it would seem unlikely that this level of scale will be the preference over the Single Neighbourhood Practice model.

This type of contract may represent a safety net for many GP practices and in some areas it may be the opportunity to completely redesign services to fully integrate with community and secondary care provision. There is no suggestion that this will be imposed and practices will need to make a decision as to whether this is what they want for the future of general practice services in their neighbourhood.

Where the Multi Neighbourhood Provider is likely to have a bigger impact on practices will be with the commissioning of services. It is highly probable that these entities will hold contracts commissioned by the new, streamlined ICBs, and will sub-contract services across their neighbourhoods. In areas with established Single Neighbourhood Providers this is likely to be a relatively straightforward arrangement. In areas where practices operate in a more traditional and siloed environment some practices may find that they lose revenue streams and opportunities over others.

This could in theory include existing enhanced services which have been traditionally provided at practice level. By way of example, the option for PCNs to collaboratively develop and deliver vaccination hubs has been adopted across many PCNs. This could be made mandatory and could be applied to all services commissioned locally.

Practices must therefore ensure that they have strategies for engaging and working with these entities as they are established in their areas.

The future of traditional GP practices

For how little general practice is referenced within the 10 Year Plan the impact it will have on the future of practices is likely to be the most hotly contested. This is a very political debate as evidenced by the responses from key individuals and organisations within the sector.

However, what is clear is that there will not be an immediate change. Traditional GP partnerships running their local practices will be the standard model for delivery. For some these changes will offer a new opportunity to change how they deliver services, and for others there may be limited evidence of any immediate change.

Ultimately though all practices will be impacted by the implementation of these plans. To prepare for this the practices must stay engaged with the system, work collaboratively with their PCN member practices, ensure they have a high standard of service delivery, maintain high quality standards, and have strong governance. These will place the practices in a secure position ready for when the changes start to take effect.

What are the risks and opportunities for practices?

Due to the relatively limited references to general practice within the Plan it is necessary to consider what objectives within it may have direct, indirect and consequential impacts on practices. The following tables look at some of the risks and opportunities which may not be evident on an initial review of the Plan.

Risks

Opportunities

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