Reflections on a ‘new’ NHS and its impact on general practice

Legislation now quietly going through parliament will significantly impact on the longer-term shape of general practice. Integrated care systems (ICSs) are partnerships of health and care organisations that come together to plan and deliver joined up services to improve the health of people who live and work in their area. They exist to achieve four aims:

• improve population health and healthcare;

• tackle unequal access, experience and outcomes;

• enhance productivity and value for money;

• support broader social and economic development.

Following several years of locally-led development, and based on the recommendations of NHS England and NHS Improvement (NHSE/I), the government has set out plans to put ICSs on a statutory footing. To support this transition, NHS E/I have now published guidance, drawing on learning from all over the country. ICSs will look to help health and care organisations tackle some of the most complex challenges we face, including:

• improving the health of children and young people;

• supporting people to stay well and independent;

• acting sooner to help those with preventable conditions;

• supporting those with long-term conditions or mental health issues;

• caring for those with multiple needs as populations age;

• getting the best from collective resources so people get care as quickly as possible.

A degree of ‘letting go’

What such a ‘systems’ approach through ICSs can achieve for patients and communities when providers work collaboratively is documented in any number of case studies. The response to the COVID-19 pandemic most clearly demonstrated how providers can work together effectively – at scale and pace – to achieve common objectives. General practice has shown what can be delivered if the right resources, and a degree of ‘letting go’ by system management, is allowed.

We now face the substantial challenge of meeting the needs of patients whose care was disrupted or delayed due to the pandemic, while continuing our work to meet NHS Long Term Plan commitments. So, how will we match the true heroics of dealing with COVID with a sustainable culture of partnership working in the future? Or will we revert to previous tribal approaches and batten down the hatches? Does anyone actually know how secondary care views general practice – and vice-versa? What do others think of general practice, and does it matter?

The reality of the purchaser-provider split has meant that the views of others have not really been considered for some time. What the local trust consultants think of local GPs, and the reverse, has been somewhat irrelevant as their respective contracts have been locally managed and arbitrated on by CCGs locally – and there has been a GP presence within the CCG.

Now things are about to change, and there will be some focus on local providers working together to get the resources from the ICS and its ‘place-based’ structures.  The premise of ICSs is that they are built on a collaborative approach between providers who agree between themselves how to design services and deploy the available resources. 

The national GP contract will remain but, increasingly, we are seeing any new resources deployed through primary care networks (PCNs) rather than direct to individual practices; this trend will continue until for the next two-to-three years, and almost certainly beyond that.

The local ICS will be comprised of the various system partners; the acute trust, the community trust, the mental health trust and the local authority will be extremely powerful voices within the new arrangements. So, it will matter, for the first time in many years, how general practice is viewed by these partners.

A joined-up view of the future

In Cheshire we are already working with our CCG, LMC, GP Federations and the PCNs to ensure general practice has a co-ordinated and joined up view of the future, and a common voice at the decision-making tables. This ‘confederation’ approach looks to build on the strengths and talent across all these bodies in order to develop a base for collective thinking and action. The credibility of the senior GP leadership inevitably affects the credibility of the service as a whole.

Therefore, we are working collaboratively with the CCG and our GP Enhanced Training Hub to develop a suite of supportive ‘leadership’ development offers – not only for GPs, but also practice managers and general practice nurses. NHSE/I have provided a number of GP leadership interventions over the last 12-24 months for PCN clinical directors; this has been added to by developing fora for clinical directors to meet and discuss hot topics and form ‘place-based’ approaches to issues. Our CCG has also enabled this work.

Working with PCC Cheshire LMC recently delivered a practice manager leadership programme over an 18-month period. This proved a solid investment and so we have just completed a short leadership programme for general practice nurses which was co-designed with PCC and our training hub. We have already started to see an increase in ‘executive practice manager partners in general practice in Cheshire and we are now starting to see general practice nurses taking up this role also. We will need to explore the dynamics of these changes. LMCs have, historically, represented GPs; who will take on that ‘professional’ local support and representation with the statutory bodies in the new local systems?

In addition, the LMC is leading in developing the dialogue between the two local authorities and general practice. Local councillors will play their elected representative role, no doubt, as it is right they do; but will we see a greater role for practice patient participation groups supporting their practices and holding councillors to account for local health plans?

PCC has supported Cheshire LMC with a number of leadership programmes for primary care professionals and has supported PCNs to work together to start to create a strong voice at system level. For further information go to: www.pcc-cic.org.uk or contact [email protected]