Professor Andy Brooks
Clinical Chair
Liam Loftus
Head of Policy
When NHS England published its consultation on two new contracts for neighbourhood health, the Single Neighbourhood Provider (SNP) and Multi-Neighbourhood Provider (MNP) models, the reaction was a familiar one. Part heart-sink at the prospect of yet another reorganisation, and part recognition that something important might be within reach. In recent weeks, we have listened to many people and organisations who are wrestling with exactly that mix of feelings, and it has left us, on balance, cautiously optimistic. The ambition behind these proposals feels broadly right. The design is still to be worked through, and that’s something we think we can all play a part in.
Gathering Insights
First, we listened. We did this deliberately across a broad cross-section of the system: GP partners and salaried GPs, PCN clinical directors and federation leaders, commissioners and system chief executives, community pharmacy and nursing colleagues, and people whose working lives sit at the often-messy junctions between all of them.
That breadth matters, and it is where we think NAPC is uniquely placed. These are difficult conversations. They touch money, “control,” professional identity and long histories of trust (or indeed, mistrust…) between different parts of the system. Playing our role of constructive, credible and honest broker, we were able to surface and unpick real tensions rather, than wish them away, and to help the whole system find a way through. That is a role we intend to keep playing well beyond this consultation.
The Headlines
So what did we hear? The most consistent message, by some distance, was that a contract should come at the end of the process, not the beginning. Good neighbourhood care grows from knowing a population, from relationships, and from teams that are already developing the first shoots of working well together. Members worried that a contractual form imposed ahead of that function could disturb work already underway, and turn energy that should go into shaping care into energy spent on shaping structures. Contracts, they told us, should protect and further develop good neighbourhood working once it exists, rather than try to manufacture it from the top down. And whichever way this goes, a contract may be necessary, but it is certainly not sufficient, to bring about effective neighbourhood health – there’s much more to neighbourhood health than the contracts that underpin it.
This is not a new lesson for us at NAPC. We have been making the case for this way of working for many years. We have also seen what happens when a promising model is embedded in a contract without the conditions around it that allow it to thrive. As the Primary Care Home evolved into the PCN DES contract, for example, we saw how much of what people had valued was harder to sustain. The creativity did not disappear, but a great deal of it was redirected into meeting the requirements of a contract rather than into improving care. We are determined that this time will be different.
The second theme was that the most effective and inspiring version of neighbourhood health is wider than general practice alone, and indeed, is wider than the NHS. Local government, public health, and the voluntary and community sector, for example, sit largely outside these proposals, and yet they are often the difference between services that merely cope and services that improve lives. The same is true within primary care, too. Community pharmacy, optometry, dentistry and nursing all have far more to offer than a “simple” subcontractor’s role, and neighbourhoods are stronger when each has a real strategic voice.
The third theme is really an observation about timing. Much of what will matter most has not yet been written. The proposals rest on national rules, the Neighbourhood Directions, that will define what these contracts deliver and who can hold them, and at the moment those rules are largely blank. In session after session, this was the hardest thing for people to react to, precisely because there is so little there. Though we do understand the frustration this creates, we see it as a real opportunity. NAPC very much plans to put our members’ voice front and centre in our dialogue with the centre around shaping these Directions.
The risk and reward for general practice
We heard concern about risk, and we’re clear that this concern should be taken seriously – for general practice in particular. We want to see a thriving general practice, alongside other providers, at the heart of neighbourhood health. But there is a real fear of attrition: that enhanced services and the funding attached to them are drawn up into larger structures; that a protected funding floor very quickly becomes a ceiling they can’t go beyond; and that where the contract is held by a body not rooted in primary care, general practice ends up several steps removed from the decisions that matter. The insistence that core general practice is “out of scope” does not fully settle these worries, because so much of what sits around the core is essential for the financial stability of practices. These are not abstract concerns, and we will not pretend otherwise.
But we heard something else too, and it would be a mistake to brush over it. Handled well, these models could give primary care a far stronger hand: a real say over community services, a route to pull resource and decision-making closer to patients, and a chance to lead the integrated, preventative, population-focused care that so many of our members came into their roles to deliver. We recognise it won’t be easy to get there, but we know there’s plenty that can be done both locally and nationally to make that more likely to be the case. And it is here that NAPC will focus.
What do we mean by handled well? In short, to us, it means these contracts aligning with the others in the system, rather than sitting in isolation. It means the right metrics being in place from the outset to reward the proactive and preventative work we know pays off over time. And it means the model being built from the neighbourhood upwards, rather than imposed from the top down.
Looking Ahead
We’re passionate about making sure that not only the risks are mitigated but also the opportunities are grasped with both hands. That’s where we at NAPC, powered by the insight and expertise of our members, can play a real positive role.
Nationally, we have fed directly into the consultation response, which you can read here. But what we heard from members was much richer, and our work on this topic will therefore be much wider. In particular, we and our members have a lot to offer when it comes to shaping elements such as the Neighbourhood Directions, and on the leadership and commissioning capability that systems will need to deliver this transformation, for example. We plan to continue supporting the centre on getting the design right, including the detail still to be written.
Locally, we want to support our members through what will be a genuine journey of development, so that the systems and providers who are ready can seize these opportunities, and those who are not yet ready are supported to get there.
There is hard work ahead: on trust between partners, on making the promised shift of care and resource real rather than rhetorical, and on keeping continuity of care at the heart of it all. None of it is simple, and this hard work is already well underway at NAPC.
But the mood in our rooms, underneath the caution, was one of appetite and possibility, and we share it. We want to step into this cautious optimism, as we would much rather help shape this future than watch it happen to us. If you would like to be part of that conversation, then we would welcome you on board.
