Supplementary written evidence submitted by The Health Foundation (FGP0396)


Thank you for inviting me to give evidence to the Select Committee on Tuesday 15th March, as part of your inquiry on the future of general practice.

Thank you also for requesting a follow-up letter on the potential impact of the dissolution of CCGs on the future of general practice. The Health Foundation previously published a paper on the implications for primary care networks of NHS reform1. We also hosted an event exploring the potential impacts of the Health and Care Bill on general practice, and my colleague Hugh Alderwick gave evidence to the Select Committee during your inquiry on the Department's White Paper on health and social care.

This note briefly sets out some background on local support and oversight for primary care in England, how this is changing under the current reforms, and implications for the future.

Local support for primary care
Although core contracts for general practices are nationally negotiated, the support, oversight and management of primary care services in England has long been undertaken by local organisations. From Family Practitioner Committees, through a variety of incarnations to Clinical Commissioning Groups (CCGs), the organisations responsible for supporting local general practice have typically covered similar scales: populations of around 200,000 - 400,000 people, and between 30-50 general practices. The roles undertaken by these organisations have remained relatively constant over time, and are vital.

CCGs support contract management for general practice and administer payments. They monitor service quality and manage poor performance – including offering remedial support where needed. They commission additional ‘local’ services to meet community needs, and they oversee primary care estates. Other less formal roles – such as supporting GP partnerships through difficult times – are vital in a sector where many providers are small and lack resilience. Since 2019, CCGs have also played a central role in Primary Care Network set up and development2.

Research highlights the importance of the roles currently held by CCGs. Strong local knowledge, trusting relationships and detailed understanding of some of the more esoteric aspects of primary care finance and estates are essential in ensuring that the bedrock of the NHS functions effectively and, importantly, without interruption3.

Current changes and implications
The Health and Care Bill removes CCGs, drawing their functions in to Integrated Care Boards (ICBs). These are to have a duty ‘to arrange primary medical services’, alongside other oversight functions for Integrated Care Systems (ICSs). This is a significant shift. ICSs and their boards cover populations of 1-3 million people – much larger than the populations historically covered by primary care commissioning organisations. The Bill, accompanying design framework and explanatory notes contain relatively little detail regarding how the necessary support and oversight of general practice will be provided.

This overhaul of support structures behind general practice coincides with a particularly vulnerable time for the service. General practice is losing doctors faster than it can recruit; workload is rising. Lack of transformation or organisational development support already threatens some aspects of PCN implementation, including the additional roles reimbursement scheme4. Clarity is needed on the future of operational and managerial support functions for GPs previously undertaken by CCGs. This should include consideration of which functions should be held at ICS level, and which should be devolved to ‘place’ level. For example, smaller ‘place’ based geographical communities may offer greater potential for individual GP practices to have relationships with relevant managers.

The right arrangements are likely to differ depending on local context (for example, centralisation of some support functions may make sense for smaller ICSs). But lack of clarity over key support functions for primary care brings clear risks. Differences in local arrangements may complicate the management of a national contract for general practice. Practices in some areas may receive insufficient oversight and support. And wide variation in approaches between ICSs could inadvertently widen inequities in the performance of general practice. Providing ICSs sufficient flexibility to adapt to local needs, while guaranteeing high quality support services for general practice is an important balance to get right.  

Role of integrated care boards in improving equity in general practice

We were pleased to share evidence with the committee regarding inequity in the provision of general practice services across England. GP practices in more deprived areas of England are relatively underfunded, under-doctored and perform less well on a range of quality indicators compared with practices in wealthier areas5. The introduction of ICBs should be used as an opportunity to improve equity in the provision of high-quality general practice. We have previously recommended that integrated care boards should be required to develop plans to reduce inequities in the provision of high-quality GP services. This should include clear goals for improvement and how they will be measured. Integrated care boards should also produce plans for data collection and analysis to effectively monitor general practice provision relative to need.

National policymakers can do more to address the problem of inequitable supply of general practice in England. The measures outlined above should sit alongside an independent review of general practice funding allocations, and consideration of mechanisms to more equitably distribute the primary care workforce. Analysis of previous attempts to tackle inequities in the supply of GP services in England, and recommendations for further action can be found in our recent report: Tackling the inverse care law: Analysis of policies to improve general practice in deprived areas since 19906.

I hope this is note is helpful as the Committee continues its inquiry. Please do let us know if we can be of further assistance.


Dr Rebecca Fisher

Senior Policy Fellow

March 2022





  1.                                                                                                                                                                                                           Fisher R, Smith J, Sidhu M, Parkinson S, Alderwick H. NHS reform: Five key questions about the future of primary care networks in England. The Health Foundation, January 2021.
  2.                                                                                                                                                                                                           Warwick-Giles L, Hammond J, Bailey S, Checkland K. Exploring commissioners’ understandings of early Primary Care Network development: qualitative interview study. British Journal of General Practice. 2021.
  3.                                                                                                                                                                                                           McDermott, I., L. Warwick-Giles, O. Gore, V. Moran, D. Bramwell, A. Coleman and K. Checkland. Understanding Primary Care Co-Commissioning: Uptake, Development, and Impacts (Final Report). LHSTM, Policy Research Unit in Commissioning and the Healthcare System. 2018.
  4.                                                                                                                                                                                                           Baird B, Lamming L, Bhatt R, Beech J, Dale V. Integrating additional roles in to primary care networks. The Kings Fund. Feb 2022
  5.                                                                                                                                                                                                           Fisher R, Dunn P, Asaria M, Thorlby R. Level or not. Comparing general practice in areas of high and low socioeconomic deprivation in England. The Health Foundation, September 2020.
  6.                                                                                                                                                                                                           Fisher R, Allen L, Malhotra A, Alderwick H. Tackling the inverse care law: Analysis of policies to improve general practice in deprived areas since 1990. The Health Foundation, January 2022