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Brief analytical summaries or syntheses #50

Primary care for the 21st century


Many GPs in New Zealand work collaboratively in independent practitioner associations (IPAs). These are networks whose functions include quality control and the delivery of complementary primary health services. This report, published by the U.K.’s Nuffield Trust looks at the evolution of IPA’s role within the health system.


As the National Health Service (NHS) in England prepares to give general practitioners (GPs) a leading role in commissioning local health services, it is clear that general practice itself needs to be strengthened and made into an effective foundation for transformed, integrated care. This report offers insights from the experience of organized general practice in New Zealand.

Over the past two decades, many GPs and other primary care clinicians in New Zealand have worked collaboratively in independent practitioner associations (IPAs). These networks of primary care providers developed in the early 1990s from the grassroots of general practice. Although they have not held budgets on the scale of that planned for clinical commissioning groups in England, they nevertheless demonstrate the significant potential of organized general practice to enable innovation and expansion in the local provision of care.

IPAs have developed networks whose functions include: standard-setting and scrutiny of primary care practice; taking on contracts for delivering new intermediate and extended primary care services; acting as collective budget holders for some local health services; and improving the quality of primary care. They are now an important part of an infrastructure that is aspiring to create new integrated health organizations and networks within New Zealand.

IPAs have had a variety of organizational forms, governance structures and size since they were formed. They have also weathered a succession of shifts in government policy. Their experience of building strong primary care organizations from within and across general practices, while responding to change and reform, provides useful insights for NHS policy-makers, primary care commissioners and all those involved in the provision of general practice services.

Analysis and results

Reform of the English NHS has focused on using GPs as the basis for renewing the commissioning of care. Comparatively little policy attention has been given to the future provision of primary care in terms of quality, service model, or organization.

There are significant challenges facing the quality and organization of primary care in the NHS. The old ‘corner shop’ model of general practice does not work economically for many GPs, struggles to accommodate demand, and lacks the resources and organizational capacity to take on work shifted from hospitals as part of plans to develop more integrated care.

Policy attention needs to focus on establishing strong and sustainable management and organizational infrastructure that can support the development of general practice and primary care in a way that enables it to meet the financial and health challenges ahead.

New Zealand’s IPA experience shows that collectivized general practice has the potential to extend and improve local primary care services. There is much that the English NHS can learn from these autonomous, privately owned non-statutory organizations that bring independent practices together into primary care provider networks.

The New Zealand IPA experience highlights the importance of primary care organizations being clinically led and owned. Some of these organizations have evolved into important and influential bodies, enabling significant capacity for the planning, development and support of local primary care providers. As IPAs have expanded, the retention of strong links to front-line practices and practitioners has been critical to their success.

IPAs demonstrate the potential of GP-owned provider networks to deliver benefits for member practices, while becoming sophisticated primary care development and management organizations at the heart of new integrated health care networks.

Primary care provider networks based on private organizations such as IPAs can pose a threat to senior managers and policy-makers. There is tension between the necessary accountability for public funds and leaving sufficient leeway for local clinicians to innovate in service provision.

The significant devolution of financial and commissioning responsibility to clinical commissioning groups means that they have to be statutory and subject to significant central control, despite the original policy intent. This will compromise their ability to appeal to, and engage, frontline practitioners.

Clinical commissioning groups will have an opportunity to stimulate the development of local federations or networks of general practice and other primary health providers. This would seem to be vital if commissioning groups are to be able to make the changes to primary care required to support ‘transformed’ local care that meets the financial challenge in the NHS and the demands from rising rates of chronic disease.


New Zealand’s experience of bringing GPs into IPAs suggests that it is in the provision, rather than commissioning, of care that the majority of GPs are most likely to engage with new organizations.

This is also the message from 20 years of evaluation of primary care-led commissioning in the NHS, where primary care-led commissioners have consistently turned their attention to the strengthening and extension of primary care provision. So, new primary care provider organizations may be the most enduring legacy of clinical commissioning groups. Clinical commissioning groups therefore stand to gain from exploring how to stimulate new general practice provider networks, capitalizing on New Zealand’s experience of IPAs.

Implications and recommendations

The challenge for the NHS is not to put all the primary care eggs in one basket, and expect clinical commissioning groups to achieve extensive primary care development at the same time as fulfilling the requirements of the new Commissioning Outcomes Framework (National Institute for Health and Clinical Excellence, 2012). Experience has demonstrated that high expectations of commissioning organizations can lead to disappointment and slow progress (Smith and Curry, 2011).

The opportunity for clinical commissioning groups is to build experience and capacity to address the wider range of health priorities, and encourage the development of local primary care provider networks that resemble New Zealand’s IPAs. These should focus on service delivery and practice support that will excite and engage local GPs and their teams, while providing the basis for much more extensive community-based integrated care.


Primary care for the 21st century.