What will neighbourhoods and a new Prime Minister mean for GP local enhanced services?
In the final piece of Pulse’s investigation into local enhanced services, Harry Hetherington looks at the future of LESs and how they might fit into the Government’s plan for neighbourhood health
Like with many other aspects of GPs’ day-to-day work, future developments for LESs are bound up in the Government’s flagship policy for the NHS, the shift towards ‘neighbourhood health’.
NHS England has changed the PCN contract to allow for neighbourhood services to be created locally, and experts fear this could be the end for LESs, with practices potentially losing access to the money they rely on to stay open. And some ICBs are turning LESs into a ‘take-it-or-leave-it’ package, with several risks for practices.
With a new Prime Minister taking office next week, who is a former health secretary and mayor who oversaw health devolution in Manchester, the plot thickens.
So what does the future look like for local enhanced services within neighbourhood structures?
Neighbourhood model threatening loss of LES income for GP practices
The Government’s empowering of local commissioners to vary the PCN contract locally to facilitate neighbourhoods may significantly alter LESs, or even threaten their existence.
Earlier this year NHS England updated the Network Contract Directed Enhanced Service (DES) to allow local variation of the contract, and said that ICBs could use this to create neighbourhood services.
Experts warned this could lead to commissioners channelling local services through a contract variation rather than a LES, making the local offer effectively mandatory rather than optional, while also distancing GP practices from the money. There are fears that the PCN DES will become a ‘PCN LES’, negating actual LESs.
Specialist medical accountant Andy Pow tells Pulse the contract change allows PCNs ‘to do more locally focused things’, with commissioners thinking about ‘chucking the local enhanced services into that pot of money as well’.
‘This is all very well’, he says, ‘as long as it comes back to general practice. If the money gets diverted elsewhere or the hospital trust sets up a service, from the general practice side it will have to reduce its costs somehow and the majority of its costs are staff, so it’s going to be difficult. On the opposite side, it could lead to more investment going in, we just don’t know.’
Katie Collin, a partner at specialist medical accountancy firm Ramsay Brown, says she has gauged ‘quite a lot of fear’ from GPs around neighbourhood contracts because ‘there’s been a lot of talk about LESs coming out of practices and going into neighbourhoods’.
‘We’ve got practices who focus a huge amount of their effort on LESs, because that’s where they generate a significant amount of their income,’ she says. ‘If that moves into a neighbourhood and doesn’t become accessible to them, that’s going to financially jeopardise their practice. It might make them even potentially unsustainable because their staffing models and the way they’ve structured themselves is to focus on that, because that is what they’ve been told to do.’
She concurs with Mr Pow that there is little clarity on neighbourhood funding on a national level. ‘At the moment, there is very little consistency in how LESs are managed across different regions, and that will likely remain the case in the near term.’
Indeed, neighbourhood contracts announced as part of the 10-year plan were expected at the end of last year, but they have not been published yet and NHS England could not commit to a specific timeline for them as recently as last month.
The current political uncertainty could also be a reason for the delay in the contracts, as pointed out by the new chair of the BMA’s GP committee Dr Clare Bannon, who recently told Pulse that progress has been ‘slow’ because the Government and NHS England ‘haven’t had a very clear picture of where they’re going’ with the contracts, and that with a significant change in Government over the coming months things could change again.
What a new (devolution-focused) Prime Minister might mean for the future of LESs
The ascension of Andy Burnham to Prime Minister brings the direction of neighbourhoods into sharper focus. Speaking after winning the Makerfield by-election, he gave sparse details of his plans for the NHS but set out a broad vision for greater devolution of powers to local areas.
As a Westminster politician Mr Burnham served as the health secretary and then shadow health secretary, and as Greater Manchester mayor he oversaw a devolved health system. Starting in 2016, central Government devolved decision-making on health and social care, worth around £6bn in the first year, and Burnham was elected inaugural mayor of Greater Manchester Combined Authority in 2017. This has been followed by further devolution including the creation of a health commissioner to drive improvements to population health, directly accountable to the mayor.
Sir John Oldham worked with Mr Burnham for three years chairing the Commission on Whole Person Care, which published its report in 2014, when Burnham was shadow health secretary. Sir John tells Pulse a Burnham premiership could ‘change the trajectory’ of neighbourhoods – which risks failing without a course correction, he says.
Neighbourhoods are the latest in a series of numerous attempts at ‘left shift’ from hospital to community over the past 15 years, he says, all of which have failed because of ‘failure of design, of definition about what we want, of implementation’.
Chiefly to blame is the ‘institutionalised ignorance of primary and community care in NHS England’, according to Sir John, who says recent indicators of this include NHS England chair Penny Dash’s recent comment that GP practices have ‘about twice as much floor space’ as needed, as well as the ‘haemorrhage of organisational knowledge’ caused by ongoing restructuring of ICBs.
Sir John speculates that Mr Burnham will not be ‘comfortable with the direction of travel’ of neighbourhoods. Burnham is someone who will recognise that demand is largely by driven by people with more and more complex needs – those with multiple long-term conditions, people with enduring mental illness, people who feel they can’t work. ‘Burnham will instinctively, in my view, understand that creating relationships and empowering people at a local level is vital to addressing those problems within an overall framework of strategic direction, accountability, financial flows, and all the other mechanisms,’ he says. ‘Creating the mechanisms first and then making everything fit, which NHS England are currently doing with neighbourhood health, it’s about flipping that on its head, and I think instinctively he’ll get that.’
Dr Tracey Vell, who is the chief officer of Greater Manchester Primary Care Provider Board, tells Pulse Mr Burnham’s time overseeing devolution of health in Greater Manchester could also provide some clues about the future of both LESs and neighbourhoods.
Changes for GPs in Greater Manchester over the last decade included a change in enhanced service offerings for GPs. An example of this is that responding to a ‘differential’ LES offering across the region, the Greater Manchester Integrated Care Partnership created the Beyond Core Contract Reviews service programme to enable GP practices to identify patients at risk of heart attacks, strokes, and complications from diabetes.
Dr Vell tells Pulse: ‘We’ve got more of a standardised rollout to make sure that we had more equity in what we were commissioning. I think that’s probably what you need to watch in the rollout of neighbourhoods – that one neighbourhood doesn’t invest massively more than the next.’
Manchester GP Dr Steve Taylor, the GP co-lead for Doctors’ Association UK, said that since devolution, ‘the collaboration side of things has got better’ for GPs on the ground in Greater Manchester. ‘The general feel in Manchester is that although it’s not perfect by any means, the ability to work across social care and other sectors has been helpful, albeit still under the national problem of not quite having enough funding to do it all.’
He puts this more down to ‘systems working better’ such as patient data systems that do not rely on the federated data platform (Greater Manchester is the only region in England not to join it), rather than creating physical centres of collaboration, which the 250 planned neighbourhood health centres are aiming to achieve.
Dr Taylor says the spirit of devolution is apparent in Burnham’s leadership style too, describing him as a ‘figurehead manager’ and ‘collaborator’ who has a ‘less top-down approach’. Sir John similarly describes Burnham as ‘instinctively someone who devolves power’.
Dr Vell concurs. When Greater Manchester Live Well (a health prevention-based programme that Dr Vell says is similar to a ‘neighbourhood structure’) was introduced, Dr Vell says Burnham took seriously the role of primary care, fulfilled the ‘listening’ role of a mayor. ‘When Live Well came, he said “Live Well is going to save X amount of GP time”. We managed to talk to him to say, “let us understand how that’s going to going to work, and let’s work with you”, and he immediately funded primary care to be able to engage in that work.’
But for GPs and LESs to thrive within neighbourhoods, the NHS needs to change its ‘bad culture’ or risk hospital trusts ‘dominating’ neighbourhoods, Dr Vell says. ‘Locally commissioned services are the additionality beyond the core, we need to ringfence an overall increase in primary care investment by this move – and not the typical reduction that it has been over the years because the trusts own all the power and therefore the finances. The power dynamic has to shift, which is cultural over the NHS. If we don’t break that, we’ve no chance.’
If this ‘culture’ is changed, Sir John predicts that neighbourhood health ‘could be the salvation for general practice’. He hopes the abolition of NHS England will offer the opportunity for this change. ‘Who they choose to lead in neighbourhood health will be quite crucial to refresh the concept itself,’ he says.
The risk of LESs turned into ‘take-it-or-leave it’ packages
A recent trend towards ‘baskets’ of services indicates how LESs overall, and GPs themselves, will fare within these anticipated neighbourhood structures.
Our analysis of exclusive data has shown that GPs in many areas have seen individual services replaced with larger basket offers, often grouped according to clinical area, local population need, or the preferences of the commissioner.
The data obtained by Pulse, which represents the most comprehensive comparison of LESs in England, cataloguing more than 1,500 services, indicate that in some ICB areas these offers take up sizeable proportions of the overall LES budget and have absorbed many different (and sometimes disparate) services into one, ‘take-it-or-leave-it’ package.
The all-or-nothing nature of some basket offers means that some practices risk losing all of their LES income if they are not prepared to do everything.
For example, the data shows that in Birmingham and Solihull, the ICB allocated more than 99% of its entire LES budget last year to one ‘single enhanced offer’ basket – £19,289,787 out of £19,471,114.
The basket includes very different services, such as phlebotomy, wound care, ECGs, diabetes injectable initiation, medicines optimisation, cancer follow-up and immunisations. For this, GP practices received a maximum payment £11.80 per weighted patient during the year, with the threat of clawback from practices that were ‘not able to demonstrate compliance’ with several objectives including access.
For many practices, the risks and workload involved outweigh the benefits of a single offer. Dr Elizabeth Lynch, a GP partner and clinical director at Brownlow Health PCN in Liverpool, says her PCN has a young patient population, skewed by a large student presence in the area, as well as higher levels of deprivation and associated comorbidities. For the GP practices in that area, there would be a risk that a single, uniform LES would include services they would not want to be involved in, because they don’t reflect population, or because the practice doesn’t have the skillset to deliver them.
The move to LES baskets may be because both commissioners and providers see benefits to this model, according to Ruth Rankine, director of primary, community and neighbourhood health at the NHS Alliance. She tells Pulse baskets could be the result of greater scrutiny of LES offers by GPs and LMCs, which has highlighted discrepancies in LES funding and commissioning arrangements. ‘In many areas, this has prompted efforts to develop a more standardised LES offer, creating opportunities for constructive discussions about the true cost of delivering these services’, she says.
Many services currently delivered through LESs will likely sit within neighbourhoods, according to Ms Rankine. She points to the inclusion of 24-hour phlebotomy provision in NHS England’s plans for the larger neighbourhood health centres as an example of a service that already sits within many LES offers. Many LES basket offers, including in Birmingham & Solihull, Nottingham & Nottinghamshire, North East & North Cumbria, and Devon ICB areas offered baskets worth millions of pounds that included phlebotomy services in 2025/26, according to Pulse’s data.
Commissioners will need to consider how they ‘ensure these services are incorporated into neighbourhood offers’ rather than operating as ‘separate and potentially fragmented elements of care, or duplicating services’, she says. ‘LES income often represents a larger proportion of practice income than funding received through QOF. As a result, careful consideration is needed to ensure that both the funding and delivery of these services continue to support patients effectively. For many practices, LES-funded services are not supplementary activities but a vital part of their financial sustainability and day-to-day operations.’
The only way the shift to neighbourhoods will ‘strengthen, rather than inadvertently weaken’ general practice is if GP practices form primary care provider collaboratives with PCNs and other primary care providers, she says. Their existence will help ensure that primary care is not simply consulted on neighbourhood development but is an active partner in the design and delivery of neighbourhood health services.
What next?
We are seeing local enhanced services rolling into universal basket offers, but the destiny of LESs overall lies in neighbourhoods. The main fear for GPs is not that LESs will not survive neighbourhoods, but that GPs will be cut off from providing them once neighbourhoods are up and running.
To ensure the funding and services remain available for GPs to provide to patients, commissioners and central Government will need to back up their rhetoric on neighbourhoods by seeing to it that GP practices are their ‘cornerstone’. If LES baskets are absorbed into neighbourhoods where the provider is not a GP practice, the effect could be disastrous.
