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

Uttering the words “GP”, “contract” and “reform” in the same breath has, in the last couple of years, been avoided by all but the most unabashed policy agitators.

It has in recent times tended to summon up professional frets of privatisation by accountable care, or acute trust takeover, neither of which go down well at all with GPs.

For NHS leaders there’s been frustration with the long promised and not yet finalised “accountable care contract” or “multispecialty community provider contract” – designed to codify the Five Year Forward View’s proposed “future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals”.

Some with longer memories are also haunted by the last genuine major GP contract shake up, in 2004, which introduced the quality and outcomes framework (which had some big pluses but is now considered outmoded), allowed out of hours opt outs, and cost a lot of money including some for GP pay (particularly vexing for the Treasury).

Yet GP contract reform is now exactly what’s being shouted from the rooftops, as floated at last month’s NHS England board meeting and expanded upon today in a paper headed “developing the NHS long term plan: primary care reform”.

Several bits of work related to the core contract have been initiated in recent months and years, including reviews of the GP partnership model itself, QoF, GP premises, indemnity, and of funding for digital primary care.

The unusual thing this summer is a strong suggestion they could actually come to a head and lead – coinciding with the NHS long term plan – to substantive changes to core contracts, in some sort of coherent way.

Changes could begin in 2019, the just published QoF review is in time to inform negotiations, but would likely be spread over several years.

The direction appears to have pretty enthusiastic support – by the standards of these things, and at this early stage – of the British Medical Association’s GP committee.

Its chair Richard Vautrey said significant changes were possible and told HSJ: “All of these are major pieces of work and have an interrelationship [with the contract], particularly the partnership review. They could set a series of directions that would have major implications.”

He said it was an “opportunity to resolve many of the issues which we’ve been highlighting over recent months and years”.

Why so? Chiefly, the various reviews have been supported by the profession and in the first instance are about trying to address its (substantial) problems. There’s an acknowledgement that doing so requires some contract change.

Second, there is no clear threat here to the independent contractor (partnership) model. An update on the partnership review this week, from its chair Nigel Watson, repeatedly stresses that this traditional “model of general practice has not reached the end of the road”, despite detailing the major strains on it.

The “primary care network” will endure in the NHS long-term plan as the main unit of GP reform (resonating with the “neighbourhoods” now featuring in many integration/prevention plans). It is much less threatening than “accountable care organisation” and even “new care model”, as it implies GP practices will keep their independence rather than being taken over or dominated.

Some will question whether evolution of the core GP contract, rather than revolution of the model, is sufficient to deliver the change needed in general practices – will this not require takeover by hospital trusts, or large and corporately organised primary care providers?

These approaches don’t necessarily have to be off the table altogether. The ACO contract has not been banished altogether; a notable recent Institute for Public Policy Research review showed the idea of new “integrated care trusts” is alive; and who’s to say where the partnership review will lead? Meanwhile, traditional primary care has no immunity from new digital entrants, one stop shop diagnostics, direct access therapies, or inescapable population and workforce trends.

But the more common question about the new direction will be how much resource will come with it. Enough to genuinely build substantial new capacity in community based services?

A 2004 style pouring in of cash via the GP contract is inconceivable.

The trick will be to ride on the coattails of the top priorities in the long term plan – cancer and mental health – which require better primary care. Promising delivery on these, and other expanded provision at “network” level, is seen as a possible route to unlocking more workforce, capital and revenue investment.

  • We have renamed The Commissioner to The Integrator. It will continue to cover integration, system working, commissioning, and primary and community care.