As Integrated Care Boards (ICBs) officially took over statutory duties from the clinical commissioning groups that have been in place in the NHS since 2012, there was barely any public acknowledgement.
Few on the frontline in the NHS would have noticed the change but behind the scenes there remains much to work out, not least how primary care will organise itself to create the ‘single voice’ that is seemingly needed if it is not to get lost at the system level.
The ultimate Integrated Care System (ICS) goal of improving population health should in theory rely heavily on primary care but with only one mandated GP or primary care role per ICB, PCNs have raised fears that the GP role will be weak compared with what’s gone before.
Dr Caroline Taylor, a GP and chair of the National Association of Primary Care has one of two GP spots on the West Yorkshire ICB board as the representative for Calderdale. There has definitely been a concern that at a time when report after report warns of the importance of primary care development, that voice becomes lost, she says.
But what is important is not whether you have one, two or three GPs on the ICB, it’s about the structures that feed into those board meetings, she believes.
‘The key bit is getting those relationships developed. We’ve got a system for how we will make sure that that voice comes properly into the ICB and that West Yorkshire knows how to get answers that reflect the full GP voice,’ she says.
They were already fairly far down this road, with practices in Calderdale being members of the federation, five PCNs working well together and the LMC creating ‘genuine cross fertilisation of ideas’, she says. The problem with current expectation from primary care ‘is that presumes an awful lot of development has already happened in lots of places than it really has’, she adds.
Dr Ragu Rajan, clinical director at Greater Wealden PCN and NHS Sussex ICB GP partner member, says in reality most of the GP voice will be at place through the formation of leadership groups. ‘How the system works depends on how much they use the principle of subsidiarity. If a lot of it gets delegated down to place eventually there’s probably going to be little difference.’
Mostly the transition to ICSs has been smooth because of the work that has been done at place carrying on the legacy from CCGs but what is not yet clear is how the ‘system’ will pan out, he says.
‘It just depends on how important system ends up being whether it just ends up being the person that holds the budget and resource allocation part, which is not that important as long as the resources are allocated at place properly.’
In South East London, Dr Jonty Heaversedge, a GP and joint chief medical officer for the ICB agrees that advocating and amplifying the contribution of primary care won’t be done through one role on the board.
One benefit from the pandemic locally has been the joining up of primary care with PCN leaders, primary care commissioning leads, and federations in regular meetings. This ‘blended leadership model’ was not developed with the ICS in mind but has proved useful.
The question now, he continues, is how to translate into a slightly more formal organisational structure without losing the influence. But it also needs to recognise that local care partnerships within each of the six boroughs in the ICS will actually making the ‘majority of the decisions if not all of the decisions’ around general practice and primary care, he adds.
His colleague GP Dr Sam Hepplewhite led a design group to look at how primary care should be represented in this new ICS era. What became clear was they did not want to cut across what was happening at the place level. While delivery may look different, it will be about shared standards, she explains, with a primary care link the whole way round the system.
‘We’ve got a role, I think, to develop our primary care leadership to be able to work at the, the ICB/ICP level and at that local care partnership level where they will be driving most of the decisions around primary care and that wider community development.’ This thinking led last year to the South East London ICS bringing in a primary care leadership development programme.
The recent Fuller Report, backed by all 42 ICSs described the evolution of PCNs into integrated neighbourhood teams to form a stronger platform for service delivery and improvement.
One of the biggest challenges for ICSs will be realising this reality of PCNs as a more integrated, comprehensive and holistic, multidisciplinary team, says Dr Heaversedge. ‘One of the things that is highlighted [in the Fuller Report] is that it’s very unlikely to come about through the kinds of contractual mechanisms we’ve been trying to use to support change up until now.
‘If we are going to really try and realise what I think we all aspire to, in terms of primary care networks that do support local neighbourhoods and populations it will be driven through significant leadership and that will require development and that’s why we’ve emphasised that from the outset,’ he adds.
Dr Tom Holdsworth, chair of Sheffield PCN clinical directors Primary Care Sheffield subcommittee says it’s noteworthy that every ICS chief executive has signed up to the Fuller report. ‘They have signed up to this, they obviously see general practice as being important. For me, there was quite a lot in it that felt quite positive.’
‘It would be disingenuous of me to say what the ICS wants but some of the discussions that I’ve had with some people from the ICS have been enthusiastic and keen to engage with primary care. There’s been some recognition that we need to get the governance structures in place and we need to have things organised, but not necessarily a set plan of it needs to be like this,’ he adds.
Dr Taylor says the Fuller Report very much matches the NAPC’s belief around neighbourhood working which is empowered by the ICB structure. ‘If it’s done properly, then I think that puts primary care firmly in the in the mix of influence and helping to support direction of travel for their individual places.’
‘It was a good vision for the way things could and should be developing but it doesn’t go into the how. The implementation is a very different thing to describing something. It’s very much about trusting people to be able to do the right thing because actually all of these people on the ICBs and all the people have been involved in partnerships, or in PCNs or whatever, we’re all doing our jobs because we fundamentally want to improve outcomes to people. It’s going to be very interesting to see whether or how it’s facilitated,’ she adds.
Dr Jonathan Griffiths, a GP who has been working in an advisory capacity to Cheshire and Merseyside ICS, the third largest ICS in the country, explains they have two primary care partner places on the ICB who will also chair the primary care providers leadership forum, which includes PCN clinical directors from each place as well as LMC and federation representatives.
This should provide ‘a line of sight into the forum from all GPs’ he says. He also believes that it should be reassuring to GPs to realise that a huge amount will happen at place. ‘People are worried and it’s understandable to think I’m going to be lost in this, but place will be your first port of call. We need to now work out what sits in place what sits at ICB, what sits at PCN and just map it all through,’ he says.
‘Part of the problem with the ICBs coming so quickly is that we’re kind of building the aeroplane in the sky. I don’t think practices will have seen any huge change on July 1, but over time things will develop and become clear.’