What does the Integration White Paper mean for general practice?

The government recently published its White Paper Joining up Care for People, Places and Populations, describing it as ‘the government’s proposals for health and care integration’

CREDIT: This is an edited version of an article that originally appeared on Ockham

There is no getting away from the meaningless fluff that surrounds descriptions of integration in the paper e.g:

‘Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole.’ p.17). 

The terminology within the paper is both over the top and (at best) confusing.

The paper clarifies (p.18) that a ‘neighbourhood’ is ‘an area covered by, for example, primary care and their community partners’.  You would think this would be called a PCN, but the PCN nomenclature appears to have been dropped within this paper and replaced by ‘neighbourhood’.  A ‘place’ is a locally-defined geographic area, typically of 250-500k population, and a ‘system’ is a larger area with a population of about one million.

In fact, PCNs only get one significant mention in the paper, and that is primarily to signpost the fact that they are being reviewed:

‘GP practices are already working together with community health services, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as primary care networks (PCNs). Building on existing primary care services, they are enabling greater provision of proactive, personalised, co-ordinated and more integrated health and social care for people closer to home. NHS Chief Executive, Amanda Pritchard, has asked Dr Claire Fuller (CEO Surrey Heartlands ICS) to lead a stock take of how systems can enable more integrated primary care at neighbourhood and place, making an even more significant impact on improving the health of their local communities. This will report later in the spring.’

For some reason, PCNs have shifted from being the central plank and foundation of integrated care systems to something that contribute towards the overall ambition for integration – make of that that what you will.

The paper tries to distinguish between what will happen at the system level and at a place level. There is the sticky issue of whether the NHS or local authority is ‘in charge’ at a place level, and the solution the paper comes up with is that, ‘There should be a single person, accountable for shared outcomes, in each place or local area, working with local partners (e.g. an individual with a dual role across health and care or an individual who leads a place-based governance arrangement).’ p.11.

However, ‘These proposals will not change the current local democratic accountability or formal Accountable Officer duties within local authorities or those of the ICB and its Chief Executive’, which does rather beg the question of what power or authority these newly accountable individuals will have.

The suggested governance model for place is via a ‘place board’, ‘a ‘place board’ brings together partner organisations to pool resources, make decisions and plan jointly…In this system the council and ICB would delegate their functions and budgets to the board.’ p.34.

A unified voice is needed

General practice needs to work out how it is able to be an effective member of, and be able to influence, this ‘place board’. This will, inevitably, require the PCNs within a place area to find ways of working together and to be able to create a unified voice.

The autonomy of these place boards is still open to question. Despite a lot of rhetoric about the need for local areas to determine local priorities, the pull of the top-down approach has, once again, proved too difficult to resist, ‘We will set out a framework with a focused set of national priorities and an approach from which places can develop additional local priorities.’ (p.23). A new set of national priorities is on its way for implementation from April 2023. This means places will receive their must-do list which they will, undoubtedly, be heavily performance-managed on – but, of course, they can also set some additional priorities for themselves if they would like to.

That said, the ambition remains for services and spend to be put under the control of place-based arrangements, so I still think it would be wise for general practice to ensure it plays a central role within them. One thing the paper is clear on is that general practice funding is not to be ringfenced from other spending, but rather included within a single system funding envelope (p.36).

There are promises to have fully-integrated, shared, care records across organisations and seamless data flows across all care settings in place by 2024 – but, if the last 20 years has taught us anything, it is ‘Don’t hold your breath’.

There is a whole chapter on workforce integration; what is notable about this is more what it doesn’t say than what it does. It talks about the pivotal role of link workers and care navigators in joining-up care, about pharmacist integration, and about making better use of occupational therapists, but it never once references the additional roles coming into PCNs through the ARRS.

Overall, the paper continues the national drive towards integration, and reinforces the need for general practice to make sure it is playing a central role in the developing place-based arrangements for their areas. 

What is potentially of most concern is the shift away from the importance of PCNs and whatever lies underneath that.