There are a few problems with Labour’s plan for a new network of “Neighbourhood Health Centres” (NHCs), which were the main new element in last year’s 10 Year Plan for the NHS, and for which new guidelines and policies are now being published.
It turns out they won’t cover neighbourhoods; most won’t centralise all the services needed for a ‘one stop shop’ (while those that do so will undermine hospital services); and 80% of the new build NHCs will be financed through ‘Public Private Partnerships’ – giving the private sector a fresh profit stream at the expense of the NHS.
They won’t be as local as claimed because there will be nowhere near enough of them to cover all of the 1,250 neighbourhoods of around 50,000 people (equivalent to the population of whole towns such as Durham, Banbury, Leamington Spa or Yeovil) currently covered by Primary Care Networks.
Indeed, the promised 100-120 NHCs by the end of the current Parliament in 2029 would not even provide one NHC for each of the 150 top-tier councils. Wes Streeting has said that ultimately there should be one “in every community” – without explaining how this could be paid for (or staffed without draining staff from major hospitals).
Only a minority (the larger newly-built ones) will offer anything like the “one stop shop” that Wes Streeting has argued for.
The criteria published last week make it clear that many NHCs will offer little more than existing large-scale joint GP practices and health centres. Each is only required to offer a 12-hour opening 6 days a week, along with an “integrated neighbourhood team.”
There is no requirement for any of them to offer mental health services or an on-site pharmacy. Only the medium-sized and largest are expected to provide urgent or minor-injuries care, and only the largest are required to offer “diagnostic and imaging space” (whatever that might mean).
So when we discard the empty rhetoric, it’s obvious that far from providing care “on your doorstep,” and in “every community,” most people will have further to travel in 2035 to get to one of up to 300 possible NHCs than they currently do to see their GP in one of the 6,000-plus GP practices in England.
This brings us on to another big problem with the new NHCs: relocating the GPs to the new Centres runs the risk of further antagonising and demoralising GPs who are already fighting the most recent contract imposed upon them by Wes Streeting.
GPs have also been protesting for some time that the funding of primary care has not grown to match the increased workload they are required to carry, and are furious that thousands of qualified GPs are out of work because existing practices cannot afford to hire them.
The best GP practices are well-rooted in their local communities: shunting them all into a new, much larger centre could break those roots, and also threaten the continuity of care for their existing patients.
Yet another problem is that the new Neighbourhood Health Framework confirms that no additional NHS capital is being made available to establish or run the promised new centres.
As a result, all of the statements admit that 80 per cent of the capital investment is expected to come from the private sector through new “Public Private Partnership” deals to be hatched up by the National Infrastructure and Service Transformation Authority and the DHSC, but yet to be published.
It’s already clear that almost all of the private capital will go to building new units, with just 20% of new builds funded from public capital, while the NHS mainly uses limited government cash to refurbish and modify existing “public sector” buildings.
However, the “wave 1 pipeline” for 2026 to 2027 will largely focus on repurposing existing NHS buildings – mostly NHS Property Services and sites built through LIFT (NHS Local Improvement Finance Trusts, a variant of the Private Finance Initiative) – in areas with the highest deprivation.
Nor is there any clear explanation of what form the proposed “public-private partnerships” are expected to take – and how close these may be to the notoriously expensive Private Finance Initiative (PFI) that was used by New Labour and Tory governments from 1997 to fund £12 billion worth of new hospitals – at a cumulative cost of upwards of £80 billion, with payments running in to the 2040s.
The ultimate folly of PFI was most thoroughly exposed by the collapse early in 2018 of one of the companies that had led the way in winning NHS contracts, Carillion. The subsequent mess included the costly process of r completing two major hospital projects (Liverpool Royal and Midland Metropolitan in Birmingham), which both required extensive rebuilding to correct construction failures by Carillion, and were only completed years later, at huge extra public expense. Tory Chancellor Philip Hammond responded by announcing that there would be no more use of PFI, despite the fact that it was initially a Conservative Party policy.
But there are more reasons still to be concerned at the Neighbourhood Health Framework.
The more comprehensive the range of services provided in the new NHCs, the more they threaten to disintegrate local hospital services, not least by requiring professional staff who are already hard to recruit and retain. Adding imaging services to NHCs inevitably duplicates provision (which will still be needed in hospitals) – leading to the less efficient use of equipment and a struggle to retain sufficient staff to work in pressurised hospital units.
The less comprehensive the services on offer in NHCs, the more they are exposed as less local centres for primary care, especially in areas where the best GPs have already joined together in health centres that are more accessible than “neighbourhood” level services.
The size and complexity of the buildings, as illustrated in the new government guidelines, underscore the need for substantial investment, with even the smallest requiring 32 patient-facing rooms and the larger NHCs needing 56. This is not far short of the size of the Polyclinic buildings proposed back in 2007 by Professor Sir Ara Darzi, which proved to be so impractical and expensive that only a small handful ever opened, and only for a short period before the experiment (and name ‘polyclinic’) was abandoned.
With no extra funding in the pot to cover the increased costs of the NHCs, it seems unlikely that many of the latest incarnations of polyclinics will be built.
Which brings us to yet another, and for some the most serious, objection to the plan as it stands: it says clearly that new NHCs will from the outset operate as “single points of access,” which have a target of reducing GP referrals for hospital treatment in 10 high-volume specialities by 25% by March 2027.
Under this policy GPs are offered the incentive of £20 for every patient whose referral is diverted into “Advice and Guidance” – with GPs receiving ‘advice’ from hospital staff on alternatives to hospital treatment (and effectively losing their right to refer, just as patients lose the right to be referred.)
The Framework document sets this out in Goal 3: the diversion of potential referrals away from hospital care is seen as key to reducing the waiting list.
“We aim to contribute to a diversion rate of at least 25% by March 2027 for at least 10 high volume specialties, supporting overall RTT trajectories of 70% (of patients receiving treatment within 18 weeks) by March 2027 and 92% by March 2029.”
Under their new contract, all GPs are now obliged to work through the same Single Point of Access (SPoA) system imposed by the government – a policy rejected almost unanimously in a BMA poll of GPs.
So serious was the opposition that the BMA’s GP committee has threatened GP collective action from 30 April unless the Government ‘paused’ its plans around mandated Advice and Guidance.
To make matters worse, when the implementation of this policy was questioned in the Commons by Tory shadow health minister Dr Luke Evans, health minister Stephen Kinnock repeatedly refused to state whether or not GP referrals would be dealt with by consultants – reinforcing concerns that referrals could be blocked by non-medical staff.
There were other warning signs that the policy aimed at rationing care: while £80m has been set aside by the government to be distributed by ICBs to reimburse GPs for each time they divert a patient from a potential referral, the guidelines make clear that if it looks like their budget for this could be running out, ICBs can impose a limit on how many payments it makes:
“the ability for ICBs to introduce a mechanism to cap the number of (monthly, quarterly or annual) advice and guidance requests which can be claimed per practice.”
Update
So strong has been the backlash from GPs and campaigners against this whole system for diverting care away from hospitals that just after the first draft of this Lowdown article was published, the government backed down on the key issue of targets for how many patients should be diverted.
A letter from Dr Amanda Doyle, National Director for Primary Care and Community Services to GPs and primary care leaders on April 22 blames “terminology” for causing the problem. She says:
“I know there have been concerns about the terminology used in the recently published neighbourhood health framework, in particular that SPoA can contribute to a diversion rate of at least 25%.
“But is important to be clear that there is no national target for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care.
“The objective is simply to identify the most appropriate next step for each patient, based on specialist assessment and triage at speciality or sub-specialty level.”
No “national target” of course still leaves scope for local ICBs to impose their own local targets – whether explicit or implied. Dr Doyle goes on to give a barely plausible fig-leaf of an alternative explanation of what the policy was supposed to achieve:
“The figure quoted relates to an estimate of the potential proportion of patients, including those who are the subject of an A&G enquiry, who could be appropriately assessed and supported by a specialist consultant without a hospital outpatient appointment. It is not the proportion of referrals to be sent back to general practice.”
And under the heading “Your clinical judgement remains central” she adds a reassurance:
“You should continue to make a clinical decision to refer for specialist care where that is in the patient’s best interests, and to request specialist advice where that is what you need. The model is intended to support decision‑making, not override it. A GPs clinical decision to refer remains unchanged.”
To complete the retreat, Dr Doyle’s letter also answers the question that Stephen Kinnock refused to answer, about consultants taking charge of advice and guidance requests:
“requests for referral or specialist advice will receive a response from a named consultant. Where a local model is already in place, or is established by local agreement between primary and secondary care, that provides timely specialist clinical assessment with clear accountability and oversight from a named consultant, this may continue.”
Another concern of GPs, that they get lumbered with the task of arranging additional diagnostic tests for patients after consultant guidance is also addressed clearly:
“Where specialist assessment identifies the need for diagnostic tests as part of the specialist pathway, those tests should be organised by secondary care, with results reviewed and acted on by the trust. These tests should not be returned to general practice to arrange. General practice should continue to arrange diagnostic tests that are routinely undertaken as part of assessment or prior to referral.”
While it is reassuring to see the BMA negotiators have managed to force an ungainly retreat on these important issues, the final form of words on Advice and Guidance still need to be clarified in the GP contract and in the guidance for NHCs, As well as other contested issues in the GP contract.
BMA GP Committee England chair Dr Katie Bramall has responded by warning that unless GPs’ wider concerns over “unlimited and unsafe patient demand” are also addressed by April 30, “we reserve the right to escalate to collective action beyond this date.”
Even if the BMA succeeds, and NHCs do not, as threatened, wind up reducing referrals and imposing rationing, questions remain over their cost, usefulness, effectiveness and accessibility.
For so many reasons (including those listed below) NHCs are still not such a wonderful innovation after all.
Not what the Plan promised
The actual proposals for NHCs are a far cry from the ideas spelled out for Neighbourhood Health in last year’s 10 Year Plan. In it the government effectively claims the new approach would:
- “end the 8am scramble … People who need one will be able to get a same-day GP appointment” [Nothing in the NHC Framework would deliver this: it’s far from clear that this extravagant promise can be delivered].
- “… at least double the number of people offered a Personal Health Budget (PHB) by 2028/29, offer 1 million people a Personal Health Budget by 2030” [The NHC Framework makes no mention of PHBs, and the most recent NHS figures show just 150,000 people were receiving PHBs at the end of last year, of whom only 27,000 received direct payments – almost twelve years after (then) NHS England CEO Simon Stevens suggested “north of 5 million” personal budgets (averaging just £1,000 each) might be operational by 2018].
- “… establish a neighbourhood health centre in every community… – a ‘one stop shop’ for patient care [far from a one-stop shop, the guidance specifically suggests many services in the publicly-funded, refurbished buildings would be provided by mobile units, or by “satellite sites,” potentially miles away].
- … increase the role of community pharmacy in the management of long-term conditions … [community pharmacy will be optional even for the largest NHCs]
- improve access to NHS dentistry … [the criteria make no call for dental services to be included in even the biggest centres]
- deliver more urgent care in the community, in people’s homes or through neighbourhood health centres to end hospital outpatients as we know it by 2035. [This is a very confusing mix-up between urgent care and outpatient services – and there is no suggestion in the guidelines that NHCs would or should be built on a scale, or sufficiently equipped, to take over from hospital outpatient departments].
- End the disgraceful spectacle of corridor care and restore the NHS constitutional standard of 92% of patients beginning elective treatment within 18 weeks. [Even those NHCs which provide urgent care services will make no difference at all to the issue of “corridor care,” which has arisen as a result of major hospitals having insufficient beds for the most serious emergency patients who need admission.
- Expand same-day emergency care services and co-located urgent treatment centres [These services have to be located on major hospital sites].
- … invest up to £120 million to develop more dedicated mental health emergency departments, to ensure patients get fast, same-day access to specialist support in an appropriate setting [Specialist mental health units also need to be on hospital sites]
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