Primary Care at the Heart of Neighbourhood Health

In this follow-up to “Who Owns Neighbourhood Health?”, Matt Carter and Anna Davey argue that the new contract architecture for Neighbourhood Health makes primary care’s positioning one of the defining questions for the model. Drawing on recent work with the GP Essex Collaborative, they explore what “primary care at the heart” actually requires, and the two key risks the design has to be built against.

Picking up the argument

Earlier this year we argued that Neighbourhood Health doesn’t belong to any single organisation. It isn’t owned by NHS providers, by local authorities, or by primary care. It belongs to the quality of leadership at Place; to a relational model where decisions are taken at the lowest appropriate level, within a shared outcomes framework. You can read the original piece here.

That argument has held up well in the conversations we’ve had since: in webinars, with ICB leaders, and most recently working with the GP Essex Collaborative (GPEC), which brings together general practice across six places and around two million patients. But “no single owner” can be read in two very different ways.

One reading is permissive: if nobody owns it, nobody is really accountable. The other is that ownership has to be constructed through partnership, and constructed deliberately, around the part of the system where most patient relationships start and most coordination has to happen.

That part of the system is primary care. And the architecture now being built around Neighbourhood Health (Single Neighbourhood Providers, Multi Neighbourhood Providers, Integrated Health Organisations) makes where primary care sits in this model one of the defining questions for the entire agenda.

Why primary care has to be at the heart

There are around 1.3 million contacts with general practice every working day in England. For most people, most of the time, primary care is the NHS. It is also, uniquely in our system, organised on a registered-list basis, meaning every neighbourhood already has a defined population, with a clinical team that knows it.

The PPL and NHS Alliance report Towards a Model Neighbourhood puts the point well: general practice “sits at the heart of this model, combining clinical leadership with population insight to identify need early and proactively, support continuity of care, and help coordinate responses around individuals and families.” Three things follow from that.

First, continuity. GP teams hold relationships with families that can stretch over decades. No provider Board, however well-governed, can replicate that. Neighbourhood Health needs that continuity as its anchor, particularly for people with long-term conditions, frailty, mental health needs, or complex social circumstances.

Second, population insight. Because primary care is list based, it sees the whole population, not just the people in front of it on a given day. With the right data infrastructure, it can identify who isn’t being reached, who is at rising risk, and where early intervention will have the most effect.

Third, coordination. The patient who needs housing support, a social prescribing referral and a respiratory review in the same week doesn’t need each of those to come from primary care. But they almost certainly need primary care to know they are happening, to make the picture coherent, and to be the constant when other services come and go.

“Primary care at the heart” is therefore not sentiment. It is architecture.

The new contract landscape makes this urgent

The Fit for the Future implementation blueprint sets out three new contract forms: Single Neighbourhood Providers (covering roughly 50,000 people), Multi-Neighbourhood Providers (250,000-plus), and Integrated Health Organisations holding whole-population budgets. PCNs may, the blueprint signals, evolve into SNPs.

GMS, PMS and APMS contracts are preserved. But primacy is not. Growth in neighbourhood services, i.e., the activity through which the “left shift” actually happens, is being commissioned through the new contract forms, alongside, rather than within, the core GP contract. And the additional investment to fund that growth isn’t guaranteed: in most places it will depend on whoever holds the larger contracts redirecting acute spend through risk and gain-sharing.

This is the architectural reality in which the next decade for primary care will be settled. It is also the architecture in which two familiar risks are most likely to play out.

The first is absorption. Primary care ends up as a service provider into someone else’s neighbourhood model. The MNP holds the contract, designs the pathway, runs the integrated neighbourhood team, and general practice is asked to triage, refer and signpost into it. Neighbourhood Health, in this version, becomes a community services and frailty model with a primary care interface, rather than something built around the patient list.

The second is overload. Primary care is asked to lead Neighbourhood Health on top of its current operating model. Access targets, single points of access for ten or more specialties, INT plans, the same-day urgent care commitment, layered onto a workforce that is already working at the edge of capacity, in estates that often aren’t fit for the model, with digital infrastructure that still doesn’t talk to the rest of the neighbourhood. The result is no progress on either the day job or the transformation.

The instinctive concern among GPs about “being taken over” by larger institutions is sometimes characterised as defensive. It isn’t. It is a clear-eyed reading of how previous waves of integration have gone, change framed as partnership, experienced as absorption. Any credible neighbourhood model has to be designed against that pattern, not in spite of it.

The generalist question

Underneath the structural risks sits something more personal: a growing identity crisis for GPs. Years of rising demand, the partnership model under strain, work moving into and out of the core contract, and now a reorganisation that asks general practice to be everything from urgent-access provider to neighbourhood coordinator. It is reasonable for GPs to ask what, in all of this, they are actually for.

The answer that Neighbourhood Health should give back is the expert generalist. The value of general practice has never been a single specialism; it is the ability to hold the whole person, across conditions, over time, and to know when the breathlessness is a chest infection, a failing heart, or a panic attack rooted in a housing crisis. That generalist judgement is exactly what a model built around proactive, coordinated, person-centred care depends on. It is also what the rest of the system most often lacks.

This isn’t unique to general practice. Generalist clinicians in other settings, including the acute geriatricians and general physicians in our Trusts, bring the same value; Neighbourhood Health works best when it draws their expertise towards the neighbourhood rather than leaving it stranded in the hospital. But general practice is where the expert generalist has always lived. Far from diluting the GP role, Neighbourhood Health, done well, is the model that finally puts a name and a value on the thing general practice has always done. The risk is a model that treats the GP as a triage point into specialist pathways, and in doing so discards the very generalism that makes primary care worth building around.

What primary care at the heart looks like

Primary care is broader than general practice. Community pharmacy, dentistry and optometry all have a role; the universal primary care offer has to include them. But general practice plays a specific coordinating role that the others don’t, and the design has to recognise that.

Making this real depends on the unglamorous things: primary care estate, workforce, digital infrastructure, time. None of these can be left as separate workstreams “to follow.” They are the conditions that determine whether the model works.

The Essex example: GPEC

The GP Essex Collaborative is a useful worked example of what organised primary care looks like at the start of this journey.

GPEC brings together every general practice across the six Places of Essex (South East Essex, Mid Essex, Basildon and Brentwood, West Essex, Thurrock and North East Essex) spanning around two million patients and forty Primary Care Networks. The System Board has twelve nominated GP representatives, two from each Place, with the LMC and operational leads as standing invitees and the chair rotating six-monthly.

What’s striking is the deliberate choice GPEC has made about its own role. It is explicitly not a separate legal entity. It cannot bind member practices. It has positioned itself to contribute “through leadership, design, engagement and assurance, rather than contract holding or direct operational control.”

This is exactly the right starting move. GPEC is building the muscle of organised primary care voice, ensuring credibility at system level, before reaching for contractual leadership. It is working alongside PCNs, federations and the existing primary care provider companies, not displacing them. It is preserving the LMC’s statutory representative role. And it is engaging directly with the design of the Essex Joint Health and Wellbeing Strategy 2026–29, whose Neighbourhood Health model is the Strategy’s most significant structural commitment.

That last point matters. The window in which primary care can shape Neighbourhood Health design in Essex is open now. SNP and MNP contract consultations are coming. The PCN DES is up for review. Local Government Reorganisation is reshaping the local authority landscape just as the model is meant to bed in. The architectural choices being made in 2026/27 will set the conditions for primary care’s role for the next decade.

Organised, credible, in the room while the design is open, that is what “primary care at the heart” looks like in practice.

Three things this means for systems

For strategic commissioning. Outcomes frameworks have to recognise primary care’s coordinating role, not only its access metrics. Funding has to be multi-year, so primary care can invest with confidence. And the enablers (estate, digital, workforce) have to be addressed alongside transformation, not sequenced after it.

For Place leadership. Primary care needs an executive voice at the Place table, not a consultation. That means GP collaboratives, federations or equivalent organised vehicles have to be supported to operate credibly at Place scale, with the time and capacity to do the design work. A seat at the table only matters if the person in it has had the chance to read the papers.

For integrator design. A GP federation or collaborative can be the integrator where it has the organisational maturity to act against its own interest when the wider neighbourhood requires it. Where it isn’t ready, the integrator function can sit elsewhere (Trust, Council, partnership vehicle) provided primary care has real authority within the model, not just representation on a subgroup.

Heart, not head

Primary care at the heart of Neighbourhood Health isn’t a claim to control. It is a recognition that without primary care working well, in close partnership with everything around it, with the architecture and resources that allow it to do so, Neighbourhood Health cannot deliver.

That is the real prize, and the real test of whether we’re getting this right. The contract architecture is being built now. The Place delivery plans are being written now. The window is open now. For primary care, and for the patients and communities it serves, the moment to be in the room is this one.

If you’re working through these questions in your own system, whether from primary care, an ICB, a Place partnership or a provider, we’d love to hear from you.

Drop Matt a line, Matt.carter@mutualventures.co.uk.

Matt Carter, Principal Consultant, Mutual Ventures

Anna Davey, Associate Medical Director Neighbourhood Health, Essex ICB