Health and Care Act 2022: What it means for GP practices

The Health and Care Bill received Royal Assent on 28 April and is now the Health and Care Act 2022. In this article, Justin Cumberlege explores what it might mean for the future of GP practices.

First published in Practice Management in August 2022.

The Health and Care Bill received Royal Assent on 28th April and is now The Health and Care Act 2022. The new structure of the NHS is with 42 Integrated Care Boards (‘ICBs’) replacing all CCGs and so it will be ICBs which commission services across the whole Integrated Care System (‘ICS’), assisted by Integrated Care Partnerships (‘ICPs’) who are to set the strategy. The focus is on integration between providers of health and social care services.

The ‘go live’ date for ICBs was 1 July 2022, although quite a bit of the preparation has been done in the past two years.

One important change has been the introduction of measures to tackle the COVID-19 backlog and rebuild services badly damaged by the pandemic. These are to be funded by the injection of £36 billion over the next three years, raised from the Health and Care Levy (a 1.25% increase in National Insurance contributions which commenced in April).

However, despite the efforts of the House of Lords to amend the Bill, there has been a lack of progress on workforce planning, one of the most significant factors currently affecting the NHS, where there are currently around 110,000 staff vacancies.

Chris Hopson, Chief Executive of NHS Providers, cited this as ‘the major, missed opportunity to introduce a statutory duty to ensure proper long term workforce planning in the NHS’.

As GPs have found when seeking to merge or where they have come together within primary care networks, it takes time to build trust and confidence when working together.’

It’s all about integration

The real underlying challenge is the integration that is required to deliver on the objectives of the new system. This can be considered within the three distinct levels of the ICS:
  • System (whole of ICS): at this level the focus is likely to be on horizontal integration between NHS Trusts to form pan-ICS hospital Trusts or at least to integrate service provision
  • Place (likely to be co-terminus with local authority boundaries): this is where vertical integration is likely to occur, with place-based provider collaboratives agreeing how NHS Trusts (i.e. hospital care) can integrate with the delivery of primary care, mental health, community nursing, social care and the services offered by charity and third-sector organisations
  • Neighbourhoods (co-terminus with PCN areas): this is likely to be the area that is the ‘engine room’ for the delivery of integrated care to patients and will also see a need for horizontal integration between primary care and the other community based providers of health, social and support services.
It is not going to be easy. As GPs have found when seeking to merge or where they have come together within primary care networks, it takes time to build trust and confidence when working together, and this is the cornerstone of good and productive integrated working. Trying to expand the success of PCNs into a wider collaboration with a much broader and more diverse range of providers is a real challenge, especially cutting across through the healthcare (NHS) and social care (local authority) divide.

What now for general practice?

There is the possibility that DES funding will disappear into the general ICS budget at the end of the current five-year contract framework in 2024, and so PCNs will find that they have to justify holding on to that funding as the best organisation to carry out those services.

There are other forces at work on general practice. The 2022 publication by Policy Exchange At Your Service, with a foreword by the former Secretary of State for Health, gives an insight into the possible direction for general practice. In looking at the role of general practice in the future, this publication proposes:
  • ‘Reform is required to ensure it thrives in the future. The current model is neither adequately staffed, nor optimally planned’
  • ‘Reform to the underlying model of general practice should not be regarded as a distraction (from the workforce crisis) … elements of the partnership model and how it is reimbursed contribute to the current challenges’
  • ‘This report calls for a model predicated upon “layers of scale”. The objective is to ensure that the agglomerated benefits of scale … are realised’
  • ‘To achieve this, we envisage the phase-out of the small-scale independent contractor model across much of general practice’
  • ‘This … should be regarded as a ten-year transition, with … alternative contracting models introduced and running in parallel to the 2024/25 five-year framework’
  • ‘Under this arrangement we expect to see an increasing number of GPs salaried or employed by scaled providers.’

In particular, the suggestion of GPs employed by ‘scaled providers’ suggests the vertical integration of general practice in NHS Trusts, unless general practice can build its own at scale models. In the foreword, Sajid Javid cites ‘the potential of the NHS working “as one”’ and claims there is ‘an exciting future for primary care’. He concludes, ‘This report offers some credible ideas and insights … I welcome the report as a pragmatic contribution to this vital debate on the future of the NHS.’

These are only proposals and are not inevitable but the structure of the ICSs under the Health and Care Act 2022 does seem to provide a framework for this to take shape.