Embedded Bulletin | Edition 25 – The NHS Left Shift is reaching the limits of General Practice
The most important story this week is not one policy announcement. It’s the way General Practice is starting to push back on the work being transferred into it.
List cleansing, shared care, Advice and Guidance, neighbourhood contracts, GP premises and pharmacy expansion all point to the same issue. The NHS still wants more care delivered outside hospital but the operating deal for doing that is becoming more contested.
The left shift only works if the receiving part of the system has enough money, workforce, space, governance and trust to take the work safely.
At the moment, General Practice is sending a fairly clear message that it may support the principle, but it’s no longer prepared to absorb unfunded responsibility quietly.
Why NHS GP list cleansing has become a test of trust
Pulse reported that the BMA has demanded urgent discussions with Government over NHS England’s list cleansing drive, warning that hundreds of thousands of patients have been removed from practice lists and that the process is costing around £40m in core GP funding.
NHS Digital data cited in the report showed 458,188 patients had been removed from practice lists in England since October last year.
That is not a small adjustment. It goes straight into the practice business model.
The principle is not difficult. GP lists should be accurate. Practices should not be funded for patients who are no longer registered or living in England. NHS England is right to say funding should follow patients but that isn’t the whole story.
The problem is the way this lands. List size affects practice income, staffing, room use, partner drawings, recruitment decisions, local service appetite and investment confidence. When large numbers of patients are removed quickly, and practices believe the process is blunt or unsafe, it feels like income is being removed while more work is being asked of them.
Pulse has now reported that a group of Local Medical Committees has demanded a parliamentary investigation into how the process has been approved.
Berks, Bucks and Oxon LMCs warned that practices in their area were losing £31,000 on average, and their updated analysis projected a £19.1m annual capitated funding loss across the area.
Separately, the LMC Support Network wrote to the Health Secretary and NHS England asking for the exercise to be paused and for the methodology to be published, with the letter signed by 74 LMCs.
If NHS England can show the methodology is sound, the equality impact has been properly assessed, vulnerable groups are protected, patients are not being removed in error and any recovered money is fairly reinvested, then the argument becomes easier.
If it cannot, this becomes another example of General Practice being asked to trust a national process that has immediate local consequences.
Why GP behaviour changes when trust breaks down
This all comes at exactly the wrong time. Practices are being asked to support neighbourhood care, prevent admissions, manage access, use Advice and Guidance, take on more shared care where appropriate, participate in local services and help keep patients away from hospital.
That requires goodwill. It also requires a basic belief that the system understands the financial mechanics of general practice.
What people sometimes miss is that a GP is not just an NHS front door. It is also a small business carrying NHS risk. If that business feels exposed, it behaves differently.
It becomes more cautious about Local Enhanced Services. It asks harder questions about shared care. It resists unfunded pathway changes. It looks more carefully at whether a pilot is really funded or just politely dressed-up extra work. It challenges A&G when it creates responsibility without capacity.
For industry, this is a very practical market access point. A product or service may be clinically sensible and nationally aligned but if adoption depends on primary care absorbing extra work into an already fragile operating model, it will struggle.
The question is no longer just “does this support NHS policy?” The question is “who is actually paid, staffed and accountable to do the work?”
What to watch
Whether NHS England pauses, modifies or publishes more detail on the list cleansing methodology.
Whether recovered funding is visibly reinvested into General Practice or disappears into the system.
Whether list cleansing becomes another accelerant for collective action and a harder GP stance on unfunded work.
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Neighbourhood health now has to deal with estate, not just intent
Neighbourhood health is moving from the pleasant part of the conversation into the difficult part.
Kent and Medway remains one of the more interesting examples because every GP practice in the area has reportedly signed up to the local PCN DES variation. That suggests practices will engage when the model is local, negotiated, funded and built around existing primary care structures.
That’s the good news. The harder news is that neighbourhood health still needs somewhere to happen.
Pulse reported that NHS England is reviewing GP estate after its chair, Dr Penny Dash, said practices have “about twice as much floor space” as needed and that NHS England is working with every ICB to identify space that could be used for neighbourhood services.
The same report also captured strong pushback from GP leaders, including RCGP survey findings that 64% of partners said they do not have sufficient space to accommodate staff, and 74% of practice managers said they cannot recruit because of a lack of physical space.
That gap is revealing. On paper, estate utilisation sounds like a sensible management question. The NHS cannot afford to build new premises everywhere. If space is genuinely underused, it should be used better, but GP premises are not empty boxes waiting for system strategy to arrive.
A consulting room that looks unused at 12.30 may be used for admin, remote consulting, results, prescriptions, letters, calls, supervision, trainee work, pharmacist clinics, care co-ordination or simply the backlog that keeps the front end moving. The fact that a room is not full of patients every minute of the day does not mean it is spare estate.
This is where neighbourhood planning can become detached from the daily working model of general practice.
The NHS wants neighbourhood services anchored around primary care. That may be right. Patients trust local practices. Practices know their populations. PCNs already create some infrastructure for working at scale, but anchoring new services around General Practice is not the same as assuming General Practice has the spare rooms, management time and workforce to host them.
The bit people are underestimating is how physical this reform is. The left shift is not only about contracts and pathways. It is about rooms, parking, IT, infection control, waiting space, staff bases, storage, supervision, patient flow and who pays for the building work.
If neighbourhood health is going to be serious, each local model needs an estate answer as well as a clinical one. That answer cannot simply be “use the GP premises more efficiently.” Sometimes that may be fair. Often it will be wishful thinking.
For commercial and system partners, this matters. Any offer that depends on neighbourhood delivery must understand the physical site model. Is it practice based? PCN based? Community estate? Trust outreach? Pharmacy? Mobile? Digital? Home based?
If that question is not answered, the pathway is not yet real.
Shared care is becoming the clearest boundary test
The third story is the BMA’s escalation on shared care.
GPs across England have been told to refuse new shared care agreements as part of collective action. The BMA’s position is that practices should refuse informal requests for hospital specialist treatment to be transferred to GPs unless agreements are appropriately resourced, safe, formalised, and clear on specialist support and responsibilities.
This is important because shared care sits right in the middle of the NHS’s preferred future. More care closer to home. More long term condition management outside hospital. More specialist medicines continued in the community. More patients supported without unnecessary hospital attendance.
All sensible, but shared care only works when the word “shared” is real.
Too often, shared care has become a polite phrase for work leaving hospital and landing in General Practice. Prescribing moves. Monitoring moves. Blood tests move. Patient queries move. Risk moves. The resource does not always move with it.
That is why this escalation is more than a contract dispute. It is a boundary being drawn around the left shift. The BMA is not saying care cannot move closer to home. In fact, the comments reported by Pulse recognise that patients with complex needs may be managed closer to home safely by both specialists and GPs. The challenge is whether commissioners have calculated the workload, funded it properly and made the responsibilities explicit. That feels like the right test.
The NHS has spent years assuming General Practice would absorb complexity because it always has. That assumption is weakening.
Advice and Guidance shows the same pattern. North Central London has introduced a system for GPs to alert the ICB if trusts do not respond to A&G requests on time, to bounce back inappropriate workload from secondary care and to report patient safety incidents. Haringey LMC said 570 alerts were sent in the first five weeks and that trust responses were improving.
That is a small but useful signal. It shows the interface is becoming more accountable.
Advice & Guidance should not be a one way valve.
GP shared care agreements should not be about an unfunded transfer. Neighbourhood health should not be a new label for work that nobody has costed.
The practical test is the same across all three:
Has the workload been described properly?
Has the money followed the work?
Is clinical responsibility clear?
Is the pathway safer and simpler for the patient?
If the answer is no, expect more resistance.
For pharma, medtech and device companies, this is particularly important. Many market access strategies rely, directly or indirectly, on primary care adoption. That may still be the right route, but only where the adoption model is credible.
A brand plan that assumes GP prescribing, monitoring, identification, recall, review or follow-up must now show how that work is funded and made manageable.
“GPs will do this” is no longer a plan. It is a risk.
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Advice & Guidance should not be a one way valve.
GP shared care agreements should not be about an unfunded transfer. Neighbourhood health should not be a new label for work that nobody has costed.
The practical test is the same across all three:
Has the workload been described properly?
Has the money followed the work?
Is clinical responsibility clear?
Is the pathway safer and simpler for the patient?
If the answer is no, expect more resistance.
For pharma, medtech and device companies, this is particularly important. Many market access strategies rely, directly or indirectly, on primary care adoption. That may still be the right route, but only where the adoption model is credible.
A brand plan that assumes GP prescribing, monitoring, identification, recall, review or follow-up must now show how that work is funded and made manageable.
“GPs will do this” is no longer a plan. It is a risk.
Worth watching
Pharmacy expansion. Ministers continue to position community pharmacy as a way to ease GP pressure. That may help, but only if records, governance, prescribing responsibility and patient communication are properly joined up. Otherwise, work can come back to practices through the side door.
The online hospital. Pulse reported that the new NHS online hospital will not create extra workload for GPs, according to one of the trust’s directors, with GPs to be consulted on referral pathways. That promise is worth remembering when the pathways arrive.
Single Neighbourhood Provider contracts. The debate about whether these contracts are needed at all is useful. The NHS should be careful not to create a new contractual architecture where a simpler local variation, alliance or service agreement would do the job.
What this means in practice
General Practice will increasingly judge every pathway change by workload, funding, responsibility and safety, not by whether it fits national language.
ICBs need to stop treating primary care capacity as elastic. If work moves, the operating model has to move with it.
Neighbourhood health needs an estate plan. Without rooms, workforce and site level practicality, it remains a diagram.
Shared care, A&G and local service specifications need formal agreements, not informal transfer of responsibility.
Industry needs to design for adoptability. The best propositions will reduce work, clarify accountability and make implementation easier.
Closing
The NHS is not wrong to want more care closer to home. In many pathways, that is exactly where the opportunity sits, but General Practice is now making clear that it will not simply absorb every consequence of that shift.
That is probably uncomfortable for the system, but it may also be useful. It forces the right conversation. Who funds the work? Who carries the risk? Who has the rooms? Who has the staff? Who is accountable when it goes wrong?
That is where the next phase will be decided.
As ever, I would be interested in different local views, especially from practices, ICBs and partners trying to make this work in real life.
Sources
General Practice finance and list cleansing
Neighbourhood health and estate
Shared care, A&G and workload transfer
Wider access and delivery models
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Scott McKenzie helps pharmaceutical, medtech and device companies cut through NHS complexity and get their offers in front of the right decision-makers. In 2023, he helped launch 53 new NHS projects – and added another 28 in 2024. Behind those numbers is a system-level understanding of what actually gets approved, funded and sustained.
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