Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.

Stars aligned and wise heads applied themselves to come up with a wide ranging five-year GP contract deal, achieving the balance of keeping the profession happy enough while getting sign up to modernisation.

While 2016’s GP Forward View was a shotgun spray of short-term initiatives and experiments, this is a more systematic and sustained push for integration in primary care.

The striking thing is not the neat policy of a “network contract” but the direct expansion of non-GP staff. Within two or three years, GPs will for the first time be outnumbered by other care staff in their practices.

Though it won’t be easy to find these bodies, it was really important to have this plausible answer on staffing, which was the big hole in the wider NHS long-term plan.

One result though is that many practices and fledgling primary care networks now have a very steep learning curve to be able to properly deploy different staff groups in quite large numbers, as well as being good employers for them.

They will need help. But the contract deal is fairly quiet on the role of the wider NHS (particularly community health providers) in networks – whether as leader, manager, coordinator, partner, recruiting agent, or employer.

Both the long-term plan and the new contract shine a light on the “historic divide between primary and community health services”, but can’t quite describe how to bridge it – a huge task tied up with professional cultures, business models, and more.

Some GP networks might instinctively take an open approach to their development – asking other providers or commissioners to help, and peers for advice – but plenty won’t.

Mishmash

There is a complicated starting point for building networks; a real mishmash of practice friendships and rivalries; alliances and federations often not made up of neighbouring practices; and a smattering of large practices and super-partnerships whose fortunes are as likely to be curbed under primary care networks as enhanced.

Most practices have on paper signed up to a network already, but lots of places will see some argy-bargy over the next few weeks as boundaries are hastily revised.

For community services, it is often forgotten that the biggest providers of these are not locally dedicated community organisations, but trusts whose main business is mental health (often working across a pretty large area) or acute care (normally mistrusted in general practice). Meanwhile, more legislative proposals due this month from NHS England will again raise the distant prospect of creating new “integrated care trusts”.

The two towers

Clinical commissioning groups have a big task on their hands to set PCNs on the right track.

And as thoughts turn to implementing the long-term plan, it hasn’t gone unnoticed that while CCGs are being taken apart, two of the big new actors – PCNs and integrated care systems – don’t exist yet.

Building a new service model for primary and community health will vie with other projects for priority, management attention, delivery support, staff and money; and particularly with the top NHS Improvement objective of restoring trusts’ financial balance. Which task will be the dog and which the tail?

Strategically, local integration and system working (prioritised at NHS England) will sometimes compete with the enthusiasm (more common at NHS Improvement) for getting acute trusts to come together, share services, and, if possible, swallow up community health too.

A lot of expectation is on the seven new NHSE and NHSI joint regional teams to deliver in the next couple of years: Will they have time for primary and community care? How will they they approach their tasks, and juggle the asks put upon them?