What influence does general practice have on integrated care systems?

Ben Gowland discusses the impact of the shift from CCGs to integrated care systems

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

The shift to integrated care systems(ICSs) is going to be a difficult one for general practice. The luxury of clinical commissioning groups (CCGs) – whatever you might think of them – was that they put general practice at the forefront of decision-making. Of course, that is not really how they worked out in practice, but at least their existence ensured a strong presence for general practice in any system-wide decision-making.

That, however, is all about to change. It may well be that the statutory change to integrated care systems, and the formal abolition of CCGs, is not due to take place until July, but these changes are already being made and the new system will be up-and-running sooner rather than later. The statutory representation of general practice will then fall to a solitary GP on the ICS Board – and they will have no requirement to be there in a representative capacity for the profession.

In a recent podcast with Dr Jaweeda Idoo, from Greater Manchester, where devolution has accelerated the ICS agenda, it became clear that there are numerous levels between any individual practice and the ICS Board there. Each practice is in a PCN, and each PCN works together with other PCNs in a ‘place’ area. The 10 place areas across general practice work together in a general practice board for Greater Manchester. Representatives from the general practice board are on the primary care board (incorporating wider primary care partners such as pharmacists, opticians and dentists). Representatives from the primary care board sit on the provider board. The full ICS board then also includes CCG and local authority representatives.

There are a lot of layers, making the distance between a practice and the ICS seems vast. In Greater Manchester general practice has retained a voice, but this seems to be due to the influence of certain individuals, such as Manchester LMC CEO Dr Tracey Vell, and a seemingly shared belief in the pivotal role general practice plays within the system.

However, ICSs are not being designed to maximise the voice of general practice; instead we have this sense of predatory hospital trusts, encouraged by the secretary of state, considering how they can bring general practice under their wing and keep their needs central within ICS discussions. Practices in areas more dismissive of the role of general practice than Greater Manchester may find themselves even further down the pecking order.

What, then, is general practice to do? There is a school of thought that the only way to increase the influence of general practice is to make the service more relevant to the system discussions; by doing more to impact the system – such as taking on outpatient and more minor procedures from the acute environment, or managing cohorts of the unwell at home – it then forces the system to listen.

There is another school of thought that general practice has not only to react to proposals put forward by others – which appears to be the default system position – but must also proactively generate ideas and strategies of its own in order to increase its sway in the discussions; by bringing new things to the table general practice can create its own relevance.

While either of these things may or may not turn out to be true, my sense remains that the starting point has to be the development of a sense of unity, and collective identity, across general practice in any area. At present general practice often feels divided between practice GPs, PCN CDs, federation directors, CCG GPs, LMC GPs, and even CCG primary care teams. In the new system, however general practice chooses to work to generate influence, it has to do it together; there can only be one general practice ‘team’, and everyone has to be in it.

For leaders in general practice preparing for the shift to ICSs the most pressing priority right now has to be working to create this unity. Divisions in the service sometimes run deep, but it is in everyone’s interests to put these to one side, to bring together all the skills and expertise that exist across the service, and work to unite these to give general practice the best possible chance of meaningful influence in the new system.