The move to Integrated Care Systems (ICSs) puts general practice in a vulnerable position. While its influence has been reduced with the abolition of CCGs, the influence of large providers like acute trusts has increased. General practice is suddenly much more vulnerable, particularly given the background whispers about the end of the independent contractor model and of ‘vertical integration’. What can general practice do about this?
One area determined to engage with the system as a peer is Herefordshire. In the county there is a GP Federation (Taurus Healthcare), five PCNs, and 20 practices covering a population of just over 200,000. When the pandemic first struck a GP leadership team was made up of the PCN CDs, the federation executive, the LMC secretary and the CCG director of primary care.
Nearly three years later this leadership team is still going, and over time its remit has expanded. Now its role is to support practices and PCNs and provide coordinated leadership across general practice. It brings the voice of general practice into the system, as well as providing a point of access into general practice for the wider system. It oversees delivery of clinical services, and works to develop local solutions to local problems.
It is not a group that only meets once a month or once a quarter. Instead it acts as the pulse of general practice, meeting for two hours every week, with dedicated time every other week for system partners. Following the meeting a weekly video update is provided for practices and all GP partners.
The benefits of this cohesion are beginning to bear fruit. The leadership group is recognised as the ‘go to’ place in the system for local general practice. As a direct result of the group there has been increased recognition and funding for general practice infrastructure. They have invested in analytics, which has included the creation of impressive dashboards of general practice activity that feed directly into system discussions.
They have increased capacity by developing an additional workforce through a locally owned remote GP service which provides 14 practices with daily duty doctor support. The ethos is to support service delivery across all practices in a way that builds resilience, but still puts the practices first and prioritises and enables continuity of care.
Now the system has even asked the chair of the leadership group to lead the development of integrated teams across community services. Because general practice is recognised as an effective and competent system partner it is now playing a leadership role in shaping the future.
But general practice in Herefordshire is not resting on its laurels. Instead, it is working out how it can take things to the next level. They have recently agreed in principle to create a single infrastructure for general practice. The leadership group will become the executive of the integrated organisation. The federation infrastructure will merge to become just part of ‘Herefordshire General Practice’ alongside the PCNs and the LMC, giving general practice the opportunity to maximise its expertise and capacity to behave as an effective peer in the ICS.
This is not about making things overly complicated or introducing unnecessary bureaucracy. The principles the local leaders have used have been ones of keeping things simple, of building on what works and not making change for change’s sake, of building togetherness, of retaining the can-do and action focussed mentality of practices, of giving primacy to practice and PCN autonomy, and of creating headspace for sharing and support.
What Herefordshire is doing is making general practice strong in the new system. They are future-proofing local, independent general practice by organising themselves as a collective. They are providing a focal point for practice and PCN support. They are continuing to build the influence of general practice in system discussions.
But is the Herefordshire model possible to replicate in other areas? Dr Mike Hearne, Managing Director of the federation, thinks absolutely this is the case. His advice is, ‘Keep it simple, build trust and take time to develop relationships so that the leadership group feels like it is a team’.
General practice does not get an automatic voice within ICSs. But what Herefordshire have shown is that by focussing on relationships within general practice that voice can both be established and be effective in the new system.
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.