Would putting GPs under the command of hospitals work?

Over the weekend a leaked letter from the secretary of state for health and social care suggested GP practices could be “nationalised”.

It would involve a phase-out of independent partnership, in which GPs are contracted by the NHS to deliver the bulk of primary care services. This has been the default approach to general practice since the NHS was formed: the bit that “Nye” Bevan couldn’t bring “in-house”.

These reforms, as described in the media, would see partnerships gradually replaced by “vertical integration”, in which GPs are sub-contracted by hospital trusts who own and operate premises as well as managing contracting and finance.

The chair of the Royal College of GPs described the move as “kite flying and political distraction”. Nationalisation meanwhile may seem a move of last resort for Conservatives – particularly for one such as Javid, a self-described Thatcherite. Is this the mark of a government continuing a trend of spreading its ideological canvas, or the logical solution to a policy conundrum?

The problem is well understood: GPs are seeing more patients than ever before (over 20 million in December 2021 alone), patients have more complex needs, and the workforce has become stretched.

Part of this is to do with the employment status of GPs. From a small share just 10 years ago, salaried GPs now account for a third of the total (excluding locums, registrars and retainers). More are opting for “portfolio” careers.

In his 2019 independent review, which was heavily watered down, Dr Nigel Watson concluded “the partnership model is not dead” but its decline has been hastened in recent years, with numbers decreasing by 22 per cent since 2016. Partnership decline has led to surgery closures: over 800 in the last eight years, with rural locations particularly adversely affected. This trend shows no signs of reversing.

There is also a compelling argument that too much of the NHS budget is locked into the secondary and acute sectors, with only 5 per cent spent on prevention. Despite attempts in the GP Five Year Forward View and NHS Long Term Plan to increase the share of health care spending allocated to general practice, control and power continues to be exerted from hospitals – an approach which will arguably be reinforced by the Health and Care Bill.

“Vertical integration” is one response – an attempt to shift hospital incentives upstream. Where it has been introduced (Tiverton, Chesterfield, Wolverhampton and West Suffolk are examples), vertical integration has enabled practices at risk of closure to stay open. As we look to this week’s publication of the Levelling Up white paper, the ability to shore-up GP numbers, incorporate digital provision, and place practices on a stable footing in areas that are already under-doctored would be of particular significance.

What of clinical outcomes? An initial evaluation of three case study sites found reductions in the rate of unplanned hospital admissions. Given the exceptional pressures on A&E over this current winter it is obvious to see why the government is drawn to the model.

Not all vertical integration should be characterised as a hospital takeover. In 2015, Northumbria Healthcare Foundation Trust launched a venture with local practices offering a range of tiered services: practices could in essence determine whether they required support with governance and compliance, payroll, finances, human resources or with estates management. Since integration, one practice recorded a 76 per cent improvement in routine access times. Another practice saved £6,000 in monthly expenditure.

Would forcing such a model upon a struggling hospital or primary care system elicit the same positive outcomes? Appraisals of pilots suggest that imposition would not work. The primary care landscape is a mixed economy, with a variety of “scaled” forms of general practice emerging over the past 10 years – the most common of which is a form of “horizontal” integration through federations and super-practices. Some of these are highly successful and would be wary of moving towards hospital ownership.

We have been here before, of course. The Vanguard programme of the 2010s led to the creation of primary and acute care systems (PACS), and multi-specialty community providers (MCPs). Yet contractual difficulties stalled the wider rollout, and the models were quietly deprioritised.

The most recent attempt at scale via primary care networks represented a compromise; whilst 98 per cent of practices currently operate on a PCN contract, the mandated population size of 30,000-50,000 means that some benefits of an upper “layer” of scale are unlikely to be realised.

Putting general practice on a sustainable footing will require wholesale change. Vertical integration is just one star in the constellation. Whilst in some areas it may make sense for trusts to take over some practices, international evidence suggests that integrated care systems which are primary care led tend to do better in reducing hospital use.

The ultimate prize for the government here is to link up primary and secondary care provision and commissioning. This could include creating greater parity between professionals working across primary and secondary care and improving care coordination. GPs attending the recent annual LMCs conference proposed a motion to explore changes to the performers’ list regulations to allow consultant staff to deliver care within general practice. This approach was commonplace in the past but has been lost.

Such changes will require re-plumbing of the system, and the government is right to be looking at the GP model within that. There is a widespread acceptance that the adversarial nature of negotiations between the BMA and the government does not benefit either side. There is less consensus on what should replace it. It will be important to learn the lessons from the Vanguard programme if reforms are to be more successful this time around. Central to this must be an acceptance that GPs need to have a stronger and clearer voice in the debate. 

What then should be the principles to deliver improvements to general practice? First, a vision to “level up” general practice and to reduce generational disparities in GP provision across the country; second, the interface between primary and secondary care should be strengthened; third, contracting and reimbursement must be reformed to reflect an evolving service and most important of all, changes which improve the service for consumers.

Policy Exchange welcome the upcoming government review and will shortly be setting out ideas to bring the principles above to life. In the end, reform should not be driven by ideology but a recognition of what matters most to patients and practitioners: choice, convenience, quality, and continuity. The pitfall of trying to design a “one size fits all” model of primary care should be avoided. Form must follow function.

Sean Phillips is a Research Fellow at Policy Exchange 

Robert Ede is Head of Health and Social Care at Policy Exchange