Integrated care is premised on organisations working together. General practice needs to be easy to do business with if it is going to work effectively with other organisations. But presently it is not, because, as any local provider will tell you, it is hard to know who to go to when you want to work with general practice.
If general practice does not find a way of solving this problem itself, the risk is that the system response will be to remove the independence of general practice via nationalisation or subsuming it within other provider organisations.
What places like Herefordshire and Lambeth are doing to change this is establishing a united local GP leadership group. It is no easy task, so here are 10 top tips for how to establish and make one effective in your area.
1. Operate at the scale of the local ICS ‘Place’
General practice operates with a different sense of local geography to the rest of the NHS. CCGs did not map to their predecessor PCT boundaries, PCNs don’t map to council wards, etc etc. But whatever the local GP politics it is vital that all the GP organisations within whatever has been determined as the “place” area come together to form one group. The worst thing you can do is create two groups, who then argue against and undermine each other in system conversations.
2. Include all of your GP leadership talent
Whatever you think of CCGs, general practice is losing the only advocate it had at a system level. Now general practice is on its own. When you are pulling together the local GP leadership team ideally it needs to include PCN CDs, LMC leaders, Federation leaders, and CCG clinical directors. Whatever the history, you are all now on the same team and need to be pulling in the same direction.
3. Appoint a Chair Everyone Trusts
The chair of this local GP leadership group needs to be appointed not based on position, but based on the extent to which everyone trusts them. It may be a PCN CD, a federation director, or an LMC chair. It may even be a manager. In Herefordshire the Director of Strategy at the local federation (a manager) is who they have chosen to be their chair, because of the trust and respect the group have for her.
4. Argue in private, agree in public
The reality is that such a leadership group is not going to agree on everything. What is important is that outside of the room when talking to the local acute trust (for example) the group presents a united front. One helpful way of doing this is to create some shared principles that the whole group can agree on (e.g. the importance of the independent contractor model, the value of continuity of care etc), that can be used as a guide to enable decision making by the group.
5. Identify Some Priorities
One of the risks of creating such a group is that it just becomes a forum that others can use to “engage with” general practice. You have to control the agenda. The best way to do this is to identify some local priorities. These are not necessarily the priorities for general practice (e.g. more GPs), but rather the main influence general practice wants to have in the system. So, for example, it may be how it wants the new virtual wards that are coming to operate, or how the primary/secondary care interface might work given the requirement to reduce both outpatient appointments and the elective care backlog. With priorities in place, it is much easier for the group to control its own agenda.
6. Trust your representatives
With a local GP leadership group the aim is to identify specific representatives who will operate on behalf of general practice. The key here is to ensure the rest of the group trusts these representatives. Most groups find it helpful to work on the representation process, to agree what can and cannot be agreed, communication mechanisms, and any other parts of the process. Do remember representation is not just about attending meetings; it is also about individual relationships (e.g. with the acute trust Chief Executive) and this equally applies to whoever holds these relationships.
7. Don’t try and replace the roles of existing organisations
The aim of the GP leadership group is not to become the de facto board of every PCN and member organisation. Each member organisation retains its own role and responsibilities. The job of the joint group is to work together to exert collective influence in the new system. However, if an issue comes to the group that is actually the role of one of its member organisations then it needs to be redirected appropriately, e.g. a contractual issue should be redirected back to the LMC.
8. Create some management capacity
This group cannot operate effectively in the spare time of one or two of the senior leaders. It needs dedicated senior leadership time to do things such as support the development of local priorities, coordinate effective representation across the system, and build communication systems with the system and across general practice. One option worth considering is bringing the CCG primary care team in to help with this. In the world of ICSs the commissioner provider divide is removed, and instead their job becomes enabling general practice to be an effective system partner – what better way to do this than supporting general practice in its endeavours to be united?
9. Partner with the local council
It is not in the interests of acute trusts, community trusts, mental health providers, even the ICS leadership to devolve much power from the ICS to place based boards. It is much easier for them if all the important decisions are made centrally – they do not want to be discussing the same thing in multiple place-based meetings, and they don’t want the loss of control that will bring.
Local councils, however, are huge advocates of locally-based decision making. They are general practice’s biggest allies when it comes to making this happen. Partner with your local council colleagues in your area to work together to argue for as much devolved decision making as possible, so that your local GP leadership group is able to directly influence more of the ICS decisions.
Finally, the effectiveness of the local GP Leadership Team will depend largely on the extent to which it is trusted across general practice. For this it needs to communicate effectively, and be fully transparent about the decisions it makes, how opportunities are distributed, and agreements it comes to. The only way to build this trust is to communicate way more than you think you need to!
Ben Gowland is director and principal consultant at Ockham Healthcare, a think tank and consultancy. He was an NHS chief executive for eight years and has also been a director of Croydon Health Services NHS Trust. He established Nene Commissioning, first as a PBC organisation and then as one of the largest CCGs.