Is this really A Neighbourhood Consultation?

On 16 July, NHS England published its consultation on new contracting models for neighbourhood health. It sets out three options for a single neighbourhood of around 50,000 people, four routes once you count staying on the PCN DES unchanged. There is no new national funding. It closes on 10 September.

To inform our own thinking, Michael Lennox of the National Pharmacy Association and I brought together primary care leaders working across community pharmacy, general practice and LMCs, optometry, primary care networks, federations and practice management.

The session was held under the Chatham House rule. No position was agreed, and none is offered here.

Together, 18 came together on really short notice, which is a positive and important note. Primary care has an appetite to engage with this properly rather than react to it, and the questions and conversation below are offered in that spirit.

(Please note, this blog or meeting does not claim to represent all 4 pillars of primary care in its entirety, and not everyone who was invited could make it.

Is the neighbourhood consultation asking the right questions?

We asked leaders to score their clarity on the proposed models from 1 to 5, with 5 meaning expert. 15 people answered. The average was two. Nobody scored five.

This raised the question: without the detail, can we contribute meaningfully?

The overall structures appear clear enough.

The contracting mechanisms, the governance, and the options, including finance and resources, are not.

One reading offered was that the absence of detail is deliberate. Leave it permissive, and the choice gets made locally.

Which prompted another point. One likely outcome could be no local variation at all.

The commissioner decides what gets decommissioned and how, so the four routes may not be ours to pick from.

What questions do you feel need to be addressed which are not in the consultation?

Why now, and what is this really about?

Why now? The answer that drew no disagreement was money.

The NHS is carrying deficits it cannot close, and the argument put was that this is about financial sustainability rather than about care.

Working together is better for patients, but that is the altruistic case. The practical case is that the system has to find savings and needs a mechanism that forces collaboration in order to deliver them.

Some felt that the money which arrives will not add resources. It will be a top slice taken from existing pots and handed back as a joint incentive, and the result is that they are made to work together for less.

Is this any different from what came before?

The group looked for what separates this from the Five Year Forward View and the multispecialty community providers, which came and went, and the Long Term Plan and the arrival of PCNs.

Some argued that the absence of funding is precisely what makes this attempt land.

Others read the four routes as less radical than expected. Keeping the current network contract, or varying it locally, is evolution rather than starting again from 2019.

On that point, PCNs have had five or six years, and most of that was COVID, so the argument put was that they have not had a fair run.

The opportunity named most was finishing what PCNs started. Bringing in wider primary care was always meant to be the next step.

The second opportunity named was prevention and population health, built through collaboration and partnership rather than contract form. Greater Manchester is running England's first prevention demonstrator, a test of moving from sickness to prevention, with primary care leading population health and local service design.

Others framed it more directly as a chance to respond to population need, forming consortia around the pathways that do not currently work.

Underneath all of it sat a simpler point. The focus on community care and the search for solutions is itself the opportunity.

What would have to be true for this attempt to work where the others did not, and is what is on offer here a reset?

What is a neighbourhood?

We asked the group to define one in their own words rather than repeat the national description.

Some separated the geography from the culture. A neighbourhood is a place; neighbourhood health is a way of working. Others questioned whether geography is the right frame at all.

One primary care network covers a tenth of its integrated care board population across three separate areas. Somebody described practices in the same building that will not work with each other, and they sit in the same neighbourhood.

A practice on the corner of three PCNs and three hospital trusts already finds geography working against collaboration.

From a patient's position, a neighbourhood is where you work, live, shop, and get care. The optician, the pharmacy, the school, the supermarket, your local hospital (if you have one).

Whatever the answer, it drives the footprint, the partners and the contract.

Should the question be what a neighbourhood is, or what neighbourhood health is? Which one is most important and why?

How do we play a game where we cannot see or trust the rules?

There is always scepticism when a policy consultation lands.

Is this a consultation, or an engagement process designed to make us feel part of a journey that has already been mapped?

And if you do not trust the process, is choosing not to engage a reasonable position, or does it simply guarantee the outcome you were worried about?

Nobody in the group argued for standing back.

Instead, we discussed:

1. Should we instead work together as a lobbying force? Not as a neighbourhood, but as a sector. The government has never seen general practice, community pharmacy, dentistry and optometry sit down together, say this does not work, and set out what should happen instead.

   
   

2. Others framed this as a game that is based on relationships. If everyone can agree on what the right thing is, the argument about defining a neighbourhood matters less because we all get on. (Wouldn't that be great!)

   
   

3. Do we disengage and risk being done to?

   
   

   This raised a further question. If the model is permissive, the choice gets made locally, so who exactly are we trying to influence? Is this still a national conversation, or has it already become one for integrated care boards?

A note of caution sat alongside all of it. Someone recalled Sir John Oldham telling a GP and pharmacy conference that NHS England is largely made up of hospital leaders, and that in a crisis it reverts to what it knows.

Which means we need to be mindful of this, work together differently, and provide constructive challenge.

There was some optimism about integrated care boards as allies. Where their workforce has shrunk, they need people alongside them, and there is an opportunity to understand the hoops they have to jump through before asking them to do anything. We need to remember we are on the same team. (Aren't we?)

There was also a reminder that we need to be clear on what we want, not just what we don't want.

The national lead for neighbourhoods asked one of us recently what the pharmacy sector actually wanted. The response:

1. A national contract that does considerably more than it does now.

2. A menu of optional services that will not fit inside a national contract but could be commissioned locally.

3. The chance to play into delivery wherever the skill exists.

Who do we actually need to influence, and are we ready with an answer when they ask?

Where does the money come from, and what makes change last?

One argument is that the shift of care out of hospital cannot happen, because trusts will not release staff or budget while carrying their own deficits. The other is that it will happen precisely because there is no money.

Either way, left shift has to come with a staff shift, not just a funding shift, and that is a different game again.

Three points could sit alongside this:

1. The mechanism will be a top slice returned as an incentive, which means working together for less.

2. Money should instead follow the work, commissioned around outcomes, with leadership held jointly.

3. Outcome-based incentives move financial risk onto providers.

People also described collaboration already working with no contract behind it.

One area focused on frailty and urgent care admissions and achieved a reduction, on goodwill alone. When reform came, the people went.

Elsewhere, a strong relationship with a commissioner delivered workforce, analytics and digital work across a federation, but the collaborative working stopped when one party left.

Where collaboration lasted, an infrastructure was built around it. In one system, which has six neighbourhoods, clinical and management leadership and care coordination are in place.

In another area, a trust put a million pounds into practices affected by the Carr-Hill formula, which sets core practice funding, worked up with the local medical committee.

We need stability, proactive relationships with succession planning, aligned incentives, systems and processes to foster lasting change.

One model offered for thinking about relationships came from matrix working. A bow tie has one person in each organisation talking to one person in the other. A diamond has bonds running across both.

The complication now is that integrated care boards have lost so many people that, in places, there is no interface left to build either one from.

However, the model describes two organisations. A neighbourhood is not two organisations, and the patient sits in the middle of it all.

We also asked where neighbourhood working is going well, and whether that learning can be shared.

The national neighbourhood implementation programme was assumed to be the place to look, on the understanding that its purpose was to test, shape and define what the future could look like. For those inside it, that is not how it feels on the ground.

In one area, it has been hard for community pharmacy to secure a voice at the table at all.

In another, nine months in, the first meeting attended was still going round the room asking each organisation what it might contribute. Some areas are only getting started.

Others are badging work they were already doing as neighbourhood working, which is not necessarily a bad thing, though it tends to tell other people about the work rather than deliver it with them.

Where money has gone in, it has largely funded neighbourhood coach roles hosted by trusts.

What has to be in place for collaboration to survive the people who started it?

Who has the infrastructure to take part?

Eligibility to hold a single neighbourhood provider contract is expected to rest on access to the registered patient list.

That places pharmacy, optometry and dentistry outside it, reaching a neighbourhood by sub-contract or as part of a consortium. The minimum funding floor, the requirement on ICBs to keep investing at least the equivalent of the PCN DES, including ARRS, applies to the single neighbourhood provider alone.

The group put it more practically. General practice has had years of investment in clinical directors, managers and additional roles. Community pharmacy covers a large patch with a small team.

One leader raised the balance between consistency and permissiveness, and flagged it as most acute for the sectors without a registered list.

If a sector has no registered list and no infrastructure, what does taking part actually look like?

Which contract carries the opportunity?

A clear split emerged on this.

The shift of activity and resources out of acute and into community feels like it sits with the multi-neighbourhood provider rather than the single neighbourhood provider.

Despite the reassurance given to PCNs, the expectation in the room was that the direction of travel is towards the single neighbourhood provider over the medium to long term, with the multi-neighbourhood contract as the space where left shift happens.

Which carried a warning. Primary care could spend the next year lost in the detail of the smaller contract, while the bigger decisions are taken above it, at place and integrated care board footprints.

We also discussed whether the opportunity depended on local need and on whether secondary care is willing or able to shift capacity out, as there is no new money to move.

Which contract are you preparing for?

Who ends up holding the contract?

The multi-neighbourhood provider contract can be held by any single legal entity, so one view was to be the commissioner rather than wait to be commissioned. Do not wait for somebody to hand you a contract. Decide what goes in it.

In practice, that means organising now across all disciplines, assessing readiness, exploring incorporation, and preparing provider vehicles. Otherwise the integrated health organisation becomes the vehicle, and somebody else holds it.

In one integrated trust, a third of the GP practices in the county are now run by the trust.

Alongside that sat an argument for designing something simpler.

The GP contract runs to 265 pages, which nobody thought was a sensible model for community care.

If a simpler contract is what is needed, somebody has to write it, and commissioners were not felt to understand how community care works, which is an opportunity rather than a complaint.

The framing, which was helpful, was to ask what dish each of us brings.

General practice, community pharmacy, optometry and dentistry each arriving with part of a solution, rather than each arriving with objections.

One area had an integrated health organisation mapped out, with other partners involved and commissioners willing to travel with them. It stopped because GPs went into their silos to protect their own patch and their own share.

If primary care cannot align, nobody hands it a contract.

Do we want to hold the contract, and are we ready to?

Where this leaves us

The image that closed the conversation was a seesaw, and the question of how we can work together as a balanced system. At present, primary care can feel like it's always sitting on the light end of the seesaw, and in some areas, the seesaw is broken.

None of this is an argument for standing back. The routes are permissive, which means much of what happens next gets decided locally, by people who will not wait for the sector to reach a view.

What made the session useful was taking the space to challenge the questions rather than rushing to answer them. What do we actually want? Why do we want it? What do we each mean by the same word? People in the same room interpreted the same question differently, and some of the questions that mattered most were not being asked at all.

These are the six we would take into any local conversation about neighbourhood health.

1.    How do you want to engage?

2.    How are you leading?

3.    How are you behaving?

4.    What language are you using?

5.    Are you creating the space to think?

6.    Is there diversity of thought in your network?

If these questions are live where you are, they are worth putting in your own response before the consultation closes on 10 September.

Who convened this?

Michael Lennox, National Pharmacy Association. A pharmacist of forty years, working across community pharmacy, pharmaceutical care and integrated primary care.

Tara Humphrey, with eleven years of experience working with primary care networks, has supported more than 300 across England. Currently an interim PCN business manager on the Isle of Wight. Hosts The Business of Healthcare podcast. MBA in leadership and management in healthcare.

Feel free to contact either of us via email at m.lennox@npa.co.uk and admin@thcprimarycare.co.uk