What does the Government’s plan for neighbourhood health mean for GP practices?

The Government has published its framework for neighbourhood health, showing its direction of travel. While a lot of detail is still missing, Anna Colivicchi and Harry Hetherington explore what the plan could mean for GP practices

When the 10-year plan for the NHS was published last year, the Government had promised it would also set out a ‘model neighbourhood framework’, including ‘definitions, goals and scope of neighbourhood health’, along with ‘priority actions’ for 2026/27. But the document that was published last week has left GPs with more questions than answers about what the neighbourhood health model will mean for GP practices.

There are some policy pronouncements: more structural reform, with trusts being given commissioning responsibilities for primary care, using contracts that haven’t been published yet; targets for GP referrals to be sent back to GPs; and it identifies GP access as one of the main points on its ‘reform agenda’, saying that this will be ‘measured by new GP access targets’ as announced at part of the next GP contract. (Perhaps unsurprisingly, there is no extra funding attached to any of this.)

But the definition of ‘neighbourhood health’ which has now been given as part of the framework is as vague as expected: ‘Neighbourhood health puts the person at the centre of how we deliver their health and care by organising services so they can work together to serve a defined population’. So are practices any closer to knowing what this means for them in practice?

Trusts to be given commissioning responsibilities for primary care

The document set out a change in commissioning responsibilities which could have massive implications for GP practices – NHS trusts will be eligible to hold integrated health organisation (IHO) contracts, which were first announced in the 10-year plan. These give providers ‘a whole population health budget for a geographically defined population’.

The guidance released last week said that these IHO contracts will also give trusts delegated commissioning responsibilities for primary care contracts. According to the BMA, this change could have been driven by a Government belief that trusts ‘cannot fail’ and that, as bigger organisations, they are better placed to manage funding flows than individual practices – but GP leaders have raised concerns that this could effectively mean trusts running general practice.

Dr Steve Taylor, the Doctors’ Association UK GP spokesperson, tells Pulse that although the GMS contract remains ‘in theory’, devolving commissioning responsibilities for neighbourhood services to trusts could be ‘problematic’. GP leaders raised concerns when the 10-year plan was released that the neighbourhood contracts could replace GMS in some areas or for specific services. The document doesn’t necessarily allay these concerns – it clarifies that GMS will continue to be ‘determined nationally and commissioned locally’, but this doesn’t preclude new local neighbourhood contracts from including GP services. 

Medical accountant Katie Collin agrees with the concerns, and says that the IHO contracts could effectively mean trusts ‘taking control of primary care funding’ in relation to neighbourhood services, while not being the most appropriate organisations to manage them. ‘A major cause of anxiety is talk of NHS trusts taking control of primary care funding and even being responsible for general practice complaints,’ she says. ‘That’s because, put simply, trusts are massive organisations and their leadership often has little experience of primary care structures or the owner-operator model that underpins general practice. Running a small business, which is effectively what a practice is, requires a very different mindset and there is a lot of concern about how that disconnect in experience could negatively impact funding flows.’ She adds that practices already have their fair share of funding flow challenges to worry about, and adding multiple new organisations to the chain is bound to make them more complex.

While the framework specifically mentions trusts as IHO contract holders, it doesn’t indicate what other organisations could hold these contracts – other than that these will always be ‘NHS organisations’. It seems to imply that PCNs or GP federations could form alliances with trusts to hold the contracts in the future, once the models are established. However, how this will happen or when still remains unclear – while the leading role of trusts in this new model seems to have already been decided.

Government to consult on the new neighbourhood contracts

While the framework refers to new contracts for neighbourhood services as initially set out in the 10-year plan, there are no further details on what these contracts will look like in practice. NHS England said that these will be developed in the next financial year – despite being initially expected at the end of last year. And before publishing these contracts, the Government said that it will consult on them – although we don’t know when.

In terms of what the new commissioning structure will look like, the document said that ICBs will contract a single IHO for an area, and the IHO will then contract a number of multi-neighbourhood providers (covering roughly 250,000 patients), each of which will work with multiple single neighbourhood providers.

‘We’ve seen this play out before – big organisational changes pushed through with little to no consideration of the accounting implications, leaving practices and PCNs with massive cash flow complications,’ Ms Collin adds. ‘The good news is that we’re not quite there yet, and the Government is at least allowing for a consultation period before diving headfirst into launching this new structure. They must listen to a range of voices during this process, considering all of the financial headaches that would come with this organisational shift.’

Both the BMA and the RCGP stressed that general practice needs to be ‘fully involved’ in shaping both the model and its implementation, and with the College adding that success will depend on gaining the trust of GPs and patients, rather than focusing primarily on structural reform.

While we wait for the consultation, NHS England’s own document has given its definition of the contracts, which is the latest we have so far:

• ‘Single neighbourhood providers’ (SNPs) will deliver ‘new services’, through integrated neighbourhood teams, within a defined single neighbourhood.
• SNPs will enable primary care to take on new neighbourhood services that are not contracted for through today’s general practice contracts.
• The SNP contract holder will need to work closely with practices that cover the neighbourhood population to ensure they can deliver services to the registered patient lists in that population.
• ‘Multi-neighbourhood providers’ (MNPs) will co-ordinate the ‘consistent’ delivery of services across multiple neighbourhoods.
• MNPs will use their scale to design and co-ordinate neighbourhood health services within their footprint, which may include delivering services directly at a larger scale than a neighbourhood.

25% of GP referrals to be ‘diverted’ back to GPs

The framework makes reducing ‘variation’ in GP referrals a key measure of its goal to ‘improve patient experience of planned care’, formally setting a target for quarter of referrals to be ‘diverted’ for 10 ‘high volume specialties’ by next March. In other words, a quarter of referrals will be bounced back to GPs as advice and guidance.

It makes clear this is in service of a longer term Government aim to ensure 90% of patients begin treatment within 18 weeks of a referral (known as the referral-to-treatment/RTT standard). 

To meet this goal, the outcome of referrals is being taken out of GPs’ hands entirely through the introduction later this year of a ‘single point of access’ (SpoA). GPs will submit referral requests to the SpoA but secondary care will decide what happens next – whether to refer to a specialist or to ‘divert’ it back to the GP with advice and guidance (A&G). Even using Jess’s Rule will not give GPs an ‘automatic right’ to refer a patient to a specialist, as NHS England’s primary care director Dr Amanda Doyle clarified in an exclusive Pulse op-ed. 

Dr Paul Evans, chair of Gateshead and South Tyneside LMC, tells Pulse announcements on A&G and referrals are contradictory. ‘Taking away GPs’ right to refer to a consultant peer and have the referral reviewed by a consultant peer, as well as the instruction on Jess’s Rule, makes absolutely no sense,’ he says. ‘It’s spectacularly incoherent that the announcements would come within weeks of each other, and it suggests a huge degree of cognitive dissonance.’

While the single point of access change comes as part of an imposed contract, Dr Evans suggests GPs could continue to make referrals to consultants rather than going through the single point of access, placing the onus on them whether to see a patient or ‘collude’ with the new system.  ‘Consultants can absolutely refuse to participate in this,’ he says. ‘If they wish to do so, they can agree to continue to see those patients GPs have referred directly, bypassing the single point of access systems. Of course, they can also choose to reject these referrals, and that’s fine, but in that case, it’s their name that’s on the rejection, therefore medico-legally, they’ve now got a stake in that and not necessarily a stake that they want to have.’

What the framework says about estates

Not much extra detail was revealed on neighbourhood health centres (NHCs) – the buildings that will host neighbourhood health services. The document restates the promise to have 120 NHCs open by 2030, which was first announced in last year’s Government spending review. Of these, 50 NHCs will be created by refurbishing existing NHS buildings. The other 70 will be built from scratch, financed through private finance initiatives (80%) or publicly funded (20%).  

However, it does confirm that the focus for 2026/27 will be on the NHCs that can be created from repurposing the existing estate, starting with premises located ‘in areas of highest deprivation’. Stewart Gregory, a partner at specialist law firm Hempsons, tells Pulse that this will mean ‘the immediate impacts may therefore be on those practices and other users currently occupying such properties. GPs who are not NHSPS or CHP tenants may well wonder how much funding will be left for improvements to their premises. Optimistically, the 10 Year Plan presents an opportunity to turbo charge much needed improvements across the primary care estate but, as always, much will depend on future budget allocations and competing priorities within the system.’ 

On the long term implications of NHCs for GPs, Mr Gregory says: ‘GPs can play a key role in delivering the vision of bringing together their services with a mix of community services and, where appropriate, other services such as urgent care, diagnostics and local authority commissioned social care and public health services.  

‘However, you may think “haven’t we been here before”? There have indeed been attempts to achieve this in the past, but each time the system seems to lurch back to investing in acute rather than primary and community care. Key to making it work this time will be not just investment though, but truly integrated working. All parts of the NHS will need to embrace collaborative working with local authorities and other partners. Commissioning will need to be redesigned to deliver at a local level. GPs are already “on the ground” at a local level and have a real opportunity to influence the design of services in their area through Integrated Neighbourhood Teams.’ 

It’s also worth mentioning that a recent transfer scheme encouraging trusts to take over NHSPS-owned GP premises seemed to be suggesting that the Government wants trusts to run NHCs, putting them in prime position to run neighbourhood health services themselves. 

Reforming ‘out of hours’ services

The document says that the Government will ‘begin reforming out-of-hours’ but gives very little detail on what this reform will look like. It says that we can however it expect to include a review of how OOH works with 111. ‘We will begin reforming out-of-hours services, which are currently fragmented and inefficient, setting a common minimum expectation across all systems, including the relationship to 111. This will be addressed in the upcoming urgent and emergency care strategy,’ the document said.

GP concern over a lack of detail and funding

Since the framework came out last week, GP leaders have pointed out the lack of detail and specific founding attached to the framework. ‘The lack of detail on neighbourhoods is and will continue to be a problem,’ says Dr Taylor. ‘Fixing population sizes to a certain size is unlikely to work in many, if not all cases. The current expectation is for more top down bureaucracy, when freedom is needed. Wes Streeting pledged “no more top down reorganisation”, yet here we are.’

The RCGP says that it ‘supports in principle’ the ambition to deliver more care closer to home, but this will only succeed if any shift of care from hospitals to the community is matched by the necessary shift in resources – which is currently lacking in this framework.

Ms Collin says that the document contained ‘zero operational detail’ as to how the changes would be delivered. ‘That lack of detail, especially around how new neighbourhood organisations would share resources and manage issues like VAT, pensions, and employment law, for example, is definitely causing anxiety across general practice,’ she says. ‘A tough financial backdrop is also already forcing practices to keep more working capital in their practices, impacting their own personal finances, and knowing this could potentially worsen under these new plans inevitably causes many to worry,’ she says. ‘Their concerns will need to be properly represented and addressed over the coming months, or the neighbourhood health transition might not end up improving primary care – it could jeopardise it.’

What’s next?

The Government has indicated its direction of travel with this document, but so many questions still remain unanswered. The consultation on the new contracts will be crucial to decide general practice’s role within the new model.

The BMA says it is looking into the document and will publish specific guidance for LMCs and practices shortly – but the union’s GP committee has previously said that GPs should take leadership roles within neighbourhoods now, rather than wait for the contracts to be published.

The next financial year will be crucial in fleshing what this model means for general practice. NHS England said it will designate the first wave of providers eligible to hold IHO contracts ‘in Spring 2026’ – so it looks like we might know more about what will happen in practice in the next few weeks.