How proposed NHS reforms will impact practices – what we know so far

Following recommendations form NHS England and the publication of a Government white paper on reforming the NHS to deliver more integrated care, Pulse Intelligence takes a look at the key proposals affecting general practice.

The Government recently announced plans to reform the NHS in its white paper ‘Integration and innovation: working together to improve health and social care for all’.

The white paper came after NHS England’s consultation on recommended reforms on integration, published last November. Most – but not all – of the white paper proposals build on the recommendations made by NHS England.

The stated aim of the reforms set out in the white paper is to achieve ‘joined-up care for everyone England’, bringing together every part of the NHS, public health and social care system.

This integration is to be achieved by two elements that will be underpinned by legislation:

1. Removal of boundaries within the NHS system

2. Greater collaboration between the NHS, local authorities and wider ‘delivery partners’. As such, NHS and local authorities will be given a duty to collaborate with each other.

Integrated Care Systems (ICSs) will be made statutory bodies, comprised on an ICS NHS body and an ICS Health and Care Partnership; the NHS body will be responsible for the day-to-day running of the ICS, while the ICS Health and Care Partnership will bring together systems and ‘develop a plan to address the systems’ health, public health and social care needs’.

The proposals involve major changes for general practice, in particular that the ICS NHS bodies will take over commissioning powers, with CCGs set to be abolished altogether.

In addition, where the NHS budget for general practice has historically been ringfenced, the reforms will see ICSs holding a single budget for both primary and secondary care.

The plans have raised concerns that GPs will be sidelined and funding for general practice eroded.

What are the key proposals?

The reforms would see ICSs take over much of the control over commissioning NHS services, with CCGs set to be abolished altogether.

The white paper states that the Government will enact legislation to create two statutory bodies in 44 ‘ICS areas’ across England:

• The ICS NHS body, with a chair, CEO and representatives from NHS trusts, general practice, plus other health bodies to be determined locally. These will be named by geographical location – for example, NHS Nottinghamshire or NHS North West London. Each ICS NHS body will take over the CCGs’ current commissioning responsibilities.
• An ICS Health and Care Partnership, bringing together the NHS, local government and partners such as community health providers.

These build on NHS England’s recommendations for legislation to put ICSs on a statutory footing.

Other key changes the Government has outlined are:

• NHS England and NHS Improvement merged into one ‘NHS England’ body
• Greater powers of direction from Government over this merged body
• Changes to competition law and the system of procurement set up under the Health and Social Care Act 2012, to reduce bureaucracy – with the repeal of ‘Section 75’ and introduction of ‘clearer’ rules around Any Qualified Provider.
• Pooling of budgets between CCGs and NHS England, across CCGs and between CCGs and local authorities.   

NHS England had also made the following proposals:

• ICSs will be in charge of a ‘single pot’ of funding, bringing together current CCG commissioning budgets, primary care budgets and the majority of specialised commissioning spend, as well as budgets for other directly commissioned services, central support or sustainability funding and nationally-held transformation funding.
• All NHS providers will need to join a ‘provider collaborative’. These may be vertical (including primary, community, mental health, and acute hospital services in an area) or horizontal (between providers – for example hospitals providing specialist services – across larger areas).

NHS England planning guidance has since pledged that the reforms will see clinical and professional leadership enhanced, ‘connecting the primary care voice that has been a strong feature of PCNs and CCGs, to clinical and professional leadership from community, acute and mental health providers, public health and social care teams’. It has also indicated that ICS commissioning will be standardised across the different merged CCGs. Delegated CCG primary care commissioning ‘will move automatically into ICS NHS bodies when they are established’.

What are GP leaders saying about the reforms?

The BMA published its official response to NHS England’s proposals just before the Government white paper appeared. It raised concerns at the timing of the reforms and rushed consultation. While welcoming the move towards greater integration and the establishment of ICSs as statutory bodies, it said it has ‘profound reservations’ about other aspects, particularly a ‘lack of clarity’ on how CCG powers will be transferred to ICSs and the introduction of ‘provider collaboratives’.

It also calls for ‘safeguards’ with the pooling of funding streams, arguing that while this will benefit secondary care which has previously been ‘forced into a competitive model’, it is ‘imperative’ that general practice funding for partnerships is kept ‘secure’.

Its response states: ‘We remain clear that core general practice budgets – including core GMS and PMS contract funding, as well as locally agreed arrangements such as those between GP practices and CCGs – must be protected. The partnership model of general practice and GPs’ independent contractor status both play a vital role in the effective provision of primary care and it is imperative that their funding remains secure.

‘Likewise, local arrangements between CCGs and GP practices can provide vital additional funding targeted at those communities most in need, so should be retained if and when ICSs take on CCGs duties.’

BMA GP Committee policy lead for commissioning Dr Chandra Kanneganti told Pulse his concern that GPs could lose out on locally enhanced service contracts.

Dr Kanneganti said: ‘Primary care budgets should not be included in ICS budgets at all. Whatever current income streams are there should always be protected for primary care.’

He added: ‘GP practices’ income relies on the work commissioned through locally agreed non-delegated budgets.’

In addition, the BMA has called for:

• The retention of a strong clinical voice in ICSs, and for formal representation from LMCs and LNCs
• Greater clarity on how ICSs will be held to account
• Legislation on safe staffing levels
• For NHS Foundation Trusts’ financial responsibilities to be reformed, not just CCGs’
• For NHS providers to be ‘preferred providers’.

The RCGP has yet to release an official statement or publish its response to the consultation. RCGP chair Professor Martin Marshall has reportedly also expressed concerns about potential loss of GP influence that general practice funding will be cut in favour of acute hospital budgets.

What do health professional bodies say?

The NHS Confederation has welcomed the strengthening of integration and that ‘use of competition and outsourcing as the main tools to improve quality of care and value for money for taxpayers will be replaced by collaboration and partnership working’, but expressed concerns about greater ministerial control and loss of NHS England’s autonomy, as well as the potential loss of experienced CCG management.

On general practice, it called for primary care network (PCN) leaders to have more resource to be able to get involved at board level on ICSs.

Ruth Rankine, director of the NHS Confederation’s PCN Network, said: ‘Primary care must have a strong voice at a system and place level, so we are pleased to see… there is a mandatory place on ICS boards.’ 

‘While there is a need for a strong primary care voice at this level, clinical directors of primary care networks cannot achieve this on top of their existing commitments without being resourced properly. That means making the increased funding available for clinical directors working on COVID-19 a permanent resource to enable them to play an effective role in place and system-level discussions, planning and delivery of services.

‘We would also expect some of the current funding from clinical commissioning groups that is in place to support PCNs to be transferred into the PCN budget to support effective management and administration.’

Sources

NHS England. Integrating care: Next steps to building strong and effective integrated care systems across England 2021.

DHSC. Integratation and Innovation: working together to improve health and social care for all