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How will ICSs steer change in general practice?


By Andy Brooks
GP and Senior Visiting Fellow at The King’s Fund
4 August 2022

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Have you noticed much of a difference now that your CCG is no more, and you are part of an Integrated Care System (ICS)? Whilst the three letter abbreviations in the NHS have changed, the problems facing a more familiar abbreviation – GPs – have not.

Change requires much more than altering a name and can be difficult in any organisation or system. The ICS is comprised of an Integrated Care Board (ICB) which has the responsibility for NHS resources and an Integrated Care Partnership (ICP) which is responsible for health and care strategy. General practice can expect to have dealings with the ICS.

As ICSs get to grips with the primary care agenda and determine what needs to be done, an often-neglected element is how this is best carried out. This prompts two important questions, firstly how will systems approach change in general practice? And secondly, what does it mean for general practice teams?

NHS England recently published the Fuller stocktake on primary care, which outlined the priorities for integrated care systems relating to primary care, setting out the challenges, and proposing potential changes. To support this work, The King’s Fund was commissioned to provide a review of the evidence about how changes can best be made in primary care which was published alongside the review. Based on the evidence we found, we have produced a practical guide that draws out four principles: the first is that changes work best when they’re driven bottom up and secondly, financial incentives and priorities can distort priorities. The third is that the ‘soft’ stuff is important and finally, people need capacity and capability to make change happen.

You now may be thinking that these are not new, or revolutionary and you would be correct. However, they are not often adhered to, even though the evidence base is strong. In fact, historically the NHS has relied on financial and contractual incentives to the extent that it is an international outlier.

There are a few reasons why old habits may not die in the NHS’s approach to change. General practices are funded and run differently to most of the NHS and there is a prevailing view that GPs won’t change unless they are paid. It is certainly true that for small business, any change to cash flow is significant and so practices might respond, but whether those responses improve quality, or lead to sustainable improvements, is not at all clear.

Systems have new leadership, new management teams and are getting to grips with the new structures, added to that there is a loss of clinical involvement compared with CCGs. The current operational pressures mean there is a temptation to fire fight and look for quick fixes rather than create systemic change, or approaches that might take time. The sum of these problems means sticking to current practices and entrenched views about how change should be done rather than follow the evidence is understandable but disappointing.

Whilst this makes difficult reading all is not lost, and the evidence is clear; change is possible if done well. Besides producing the four principles, we outline why each one matters and describe actionable ideas for GPs and systems. It is important to note here that actions are required by both general practice and systems, and neither can be done in isolation. The challenges facing general practice are not going to be solved unless all parties embrace a new way of delivering change.

Culture is at the heart of this and changing it takes time and commitment. Given new NHS structures and compounding pressures, now is an opportune moment to instigate a different approach. Solving the complex problems facing general practice needs to start with agreement about how it should be approached. Success tends to breed success and spending some time getting one change right will increase trust and make the next change easier.

As one example, following through the principles above, the evidence tells us that getting buy-in from all concerned is worth the time and effort and brings results (bottom-up change) and carefully choosing metrics can be a great way of focusing activity (incentives and priorities). However, remembering not to bombard staff with too many obligations (soft stuff) and ensuring sufficient capacity (managerial and clinical) is critical (capacity and capability).

Using the principles as a guide to help with change should in turn facilitate changing the culture of both general practice and systems. Getting the ‘how’ right means the ‘what’ is much more likely to be implemented and therefore improve care.

Andy Brooks is lead author of How to make change happen in General Practice. He is a GP in Surrey Heath and Senior Visiting Fellow at The King’s Fund.

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