Across the country ICBs must make new commissioning decisions to support moving care into the community and focus on neighbourhood working to prevent disease, and manage population health. This is not a new idea and significant challenges remain. Kathy Oxtoby reports
In July 2022, ICBs took over from CCGs, moving from GP led organisations to organisations with a much broader remit. The fear then was that the primary care voice would be lost. And concerns around hospitals’ absorption of the funding persist.
This January, the Government announced its new strategy for reducing the elective care backlog. But with this secondary care focus, it is unclear what room, or funds will be left for population health management, prevention and primary care, and for getting ahead of disease.
Primary care collaboratives are seen as one way forward. And Lord Ara Darzi, in his report on the state of the NHS in England, advocates neighbourhood healthcare. But what is actually happening on the ground?
Beccy Baird, senior fellow in health policy at The King’s Fund, says: ‘Capacity within ICBs to focus commissioning on primary care is limited.’
In 2023, ICBs were told to make a 30% cut to their running costs, most of which is staff, by the next financial year (2025-2026).
‘It’s a huge cut. And because the government has prioritised A&E waits and elective recovery, ICB’s attention is focused on acute services rather than primary care,’ says Ms Baird.
Overall, she says primary care commissioning is generally much weaker than other parts of commissioning. ‘ICBs prioritise the things they are held to account for, most of which is acute services and waiting times,’ she says.
Primary care itself ‘is under immense pressure at the moment’, says Ms Baird. ‘Activity is outstripping available demand. And financial pressures and strains on general practice are enormous.’
Ruth Rankine, director of primary care at the NHS Confederation, says commissioning to support moving care into the community, prevention, neighbourhood working, and population health, for example, ‘is something ICBs really want to do’.
‘But with the national focus on the financial bottom line, and waiting lists, where targets are heavily focused, ICBs are finding it hard to make that shift to the priorities they know will actually make a bigger difference in the long run – whether that’s prevention or care closer to home.
‘ICBs feel whilst they are under the spotlight for money and waiting lists, it’s hard to shift that focus, particularly in financial terms, because a lot of the funding is going into secondary care, and there are also system wide deficits. It is hard to shift money and resources when you’ve got that all very much tied up in secondary care,’ says Ms Rankine.
‘But from the conversations we’ve had with ICB chairs and chief executives, they recognise they need to focus on care outside of the hospital, because if we want to achieve better care for patients at home or in the community then we’ve got to resource that.’
She says the short term focus on money and waiting lists is ‘driving a particular type of behaviour, which is obviously not the direction of the NHS Long Term Plan’.
‘The challenge is how we both recover and reform at the same time – how we manage to keep things going today whilst we change things and build for tomorrow.’
Previously with major transformation programmes there has been money to continue with “business as usual”, while at the same time transforming services, she says.
‘The commitment is there. It’s just that ICBs feel they’re being driven to respond to where the targets and money are.’
Variation across the country
In primary care, new commissioning decisions have been or will be made to support moving care into the community, health prevention, neighbourhood working and population health. But these decisions are not uniform or widespread. The picture that is emerging is that there is variation across the country.
‘There are examples of good practice – in some areas ICBs are stronger than others in primary care commissioning,’ says Ms Baird.
The level of knowledge and experience ‘varies significantly’ across general practice, pharmacy, optometry and dentistry, but particularly with pharmacy, ophthalmic and dentistry, ‘which has come later to the ICSs, so they know less about them’, she says.
New approaches to commissioning outside the hospital are ‘happening in pockets’, says Ms Rankine.
‘Some ICBs are protecting investment for out of hospital care.
‘There are pockets of really good work going on around redesigning pathways so that more care is delivered outside of the hospital setting, and a lot of that is being driven by ICBs.’
Community diagnostics centres are ‘an obvious example of shifting more diagnostics into the community, putting them in places that people can easily travel to without having to go to a hospital site’, she says.
There are ‘lots of primary care providers’ working with secondary care to look at what role they can play in terms of delivering services. Some providers have been subcontracted by acute trusts to deliver, say, dermatology, ophthalmology or orthopaedic day surgery in primary care settings, says Ms Rankine.
Some ICSs are ‘on the right track with all the right tools, while some are still trying to get off the ground’, says Dr Caroline Taylor, a GP, chair of the National Association of Primary Care (NAPC), and mental health clinical lead for Calderdale Cares, part of West Yorkshire ICS.
‘Some ICSs are ‘much further along with their development and working together with other parts of the system, and not just health.
‘Other places are quite old fashioned and still running in a fairly hierarchical and non-clinical way.
‘There are ICSs, Places, PCNs, and practices that have been getting on with a broad approach to improving the health and wellbeing of their population. Others are stuck in the development phase of the ICS and may have even gone backwards,’ she says.
Integrated neighbourhood team working
Dr Taylor says there has been a ‘lot of newly established and growing of existing neighbourhood working’, at ICS, PCN and practice level.
NAPC is supporting some ICBs with their work with integrated neighbourhood teams – work that is ‘genuinely integrated’, she says. This means everyone is ‘collectively working together to make decisions that have people at the centre. And you have a group of people who work together and trust each other’.
‘The point of neighbourhood working is that the size of the neighbourhood is such that you will know all the other professionals working in that system.’ And whatever a patient needs, whether it’s an occupational therapist or employment support, ‘it should be a phone call or a conversation away, not a big referral process or a waiting list ’, says Dr Taylor. ‘This means patients only telling their story once, improves productivity and facilitates team building’
Accessing services
With new approaches to commissioning services in primary care it is important to ensure that any patient can find them easy to navigate, and understand any processes required to access them and use them.
‘What I’ve found as a GP is that when we make a change to an appointment system, for example, some people quickly work out how to use the new system, and some just can’t catch up, and we’re disenfranchising them if we’re not careful,’ says Dr Taylor.
Service design principles need to put people with challenges that make them potentially vulnerable to health inequalities ‘front and centre’, she says. ‘And we need to have the evidence that we’ve made a genuine difference to their lives – that the outcome has improved for that individual.’
Supporting primary care commissioning
Vital to ICSs flourishing is everyone being in agreement, and ‘everyone believing in the “new world”’, says Dr Taylor.
Measuring outcomes, and valuing and prioritising staff motivation and wellbeing are key to helping ICSs make a difference, she says. Other elements include prioritising use of data so ICBs are ‘genuinely’ doing population health management, along with an effective IT strategy.
The NHS Confederation sees ‘really great examples of ICB teams working alongside general practice and at-scale primary care providers, supporting them to develop through, for example, building provider collaboratives’, says Ms Rankine.
Some ICBs have GP provider support units, which offer training, education, leadership development, peer review and support for workforce management, and bring people together to share their work, she says. These units offer support for primary care providers, predominantly PCNs and general practices.
But ICB support will very much depend on the size of the ICB teams around primary care, she says.
Where primary care commissioning works well ‘it’s a partnership’, says Ms Rankine. While there is a contractual relationship, ‘it’s very much about working alongside practices, PCNs and federations on what the solutions might be. And let’s not forget the opportunities for wider primary care providers such as optometry and audiology, dentistry and community pharmacy to contribute massively to delivering care closer to home and reducing demand on secondary care’.
Challenges and obstacles
In terms of what is ‘getting in the way’ with primary care commissioning, there is ‘the size of ICB teams around primary care’, says Ms Rankine. ‘We’ve examples of large teams and smaller teams, and most teams are not just thinking about general practice but are also responsible for commissioning pharmacy, optometry and dentistry.’
There is wide variation in ICB capacity around primary care commissioning, and ‘where they have large teams it works well, where they have smaller teams that is a challenge because of the scope of what they cover’, she says.
With the priority in terms of financial baselines and secondary care, ‘money is obviously a challenge’, says Ms Rankine. ‘It is often a challenge for ICBs to keep their arms around primary care funding and make sure that funding is dedicated to primary care.’
Bureaucracy impeding progress
Too much bureaucracy and not enough trust, IT that is inadequate across the system, and primary care data not being utilised are some of the factors impeding progress in systems, says Dr Taylor.
She says many GPs feel ‘very detached’ from their ICS, and ‘some ICSs don’t involve GPs, even at board level’.
Even where GPs feel well connected with their ICS, there is ‘a much lower degree of clinical leadership, particularly from primary care, than there was with CCGs’.
‘Some ICSs are more positive in their approach to GPs, whereas others are acute focussed, and GPs are very much an afterthought,’ she says.
GPs understand their populations and how best to support them, ‘so general practice needs to be at the centre of all of this change’, says Dr Taylor.
Of the ‘eternal dilemma on how we move money from acute to primary care’, Dr Taylor says the £20 fee to be paid to GPs for each advice and guidance contact they make to a hospital specialist announced in the government’s elective reform plan this January, ‘is a starting point’. ‘It’s putting money into primary care.’
But what is needed is a ‘confident move of resources into primary care’, which will require changes in policy and direction from the government, ‘and hopefully we’ll get that with the NHS 10-Year Plan’, she says.
Shift focus to primary and community services
The health and care system in England ‘must shift its focus away from hospital care to primary and community services if it is to be effective and sustainable’, according to a report by The King’s Fund, co-authored by Ms Baird.
The report ‘looks at 30 years of policy which suggests moving care closer to home is the right thing to do – and yet we have spectacularly failed to do so’, says Ms Baird.
The report calls for ‘a wholesale shift in the focus towards primary and community health and care across the domains of leadership, culture and implementation’. ‘This will free up every sector to provide the care that it is best equipped to deliver,’ the report says.
‘The only way to improve primary care commissioning is to focus on improving care in communities closer to where people live. That has to be the focus of ICBs and that has to come from government and NHS England,’ she says.
An as yet unanswered question is whether the government will set a national target or measure around the level of activity it wants to see delivered outside hospital. ‘That then gives some people something to aim for,’ says Ms Rankine.
‘“What gets measured matters”. Some people have a view that if there isn’t a target or a measure, there isn’t an incentive to do it, and no one is going to hold you to account for not doing it.’
Without a clear commitment to the level of activity the government wants to see outside the hospital setting, and the level of investment it wants to see put into primary and community care, ‘it’s hard to get that real national drive’ that supports ICBs to make it happen, she says.
‘We need to see the things that ICBs could be measured on to demonstrate progress towards care closer to home, for example the percentage of activity delivered outside hospital settings or the percentage level of investment we want to see in primary and community,’ she says.
It is also important for ICB and ICS leaders to ‘work alongside primary care providers and engage them in solutions, because they can do and see things differently, particularly in the context of care closer to home’, says Ms Rankine.
When redesigning pathways ‘it’s making sure you’ve got multisector input into that work. So it’s not about secondary care redesigning pathways that will have a significant impact on primary and community care. It’s about all of the relevant disciplines being engaged in that conversation, because everybody’s seeing things from a different perspective, and secondary care doesn’t completely know the capability primary and community care have to deliver.
‘And it’s also about helping people understand the wealth of expertise that’s sitting in primary care, and just how much it can do.’
To ICB leaders, Dr Taylor says: ‘GPs are experts in what their practice population needs and how best to deliver it to them, so involve them in discussions and decision making.
‘Primary care is perceived by patients as being the first point of call, and their default place to come for health and care, and it needs to be the same for those who are commissioning it as well – it needs to be the keystone around which everything revolves.
‘If that GP voice is not listened to, ‘we won’t have effective change. And we won’t deliver what the health and care systems and, most importantly, patients need’.
