The outgoing cohort of leaders has major misgivings about the new system. Our survey found that about two-thirds thought it would not be positive or improve primary care. Half thought it would not improve patient care. See box.
Even more damning, just under three-quarters of those surveyed (74%) did not have confidence in the way the Government was running the NHS.
Just 9% thought the move to ICSs would improve primary care and 14% thought it would improve patient care.
PCNs
For CCG clinical leaders thinking about the future of primary care, all roads lead to PCNs. The funding going into the Network DES via the IIF and the additional roles reimbursement scheme (ARRS) makes it clear that the Department for Health and Social Care and NHS England is putting its weight behind PCNs as the change-makers for locally driven, population-based primary care.
Dr Chowhan says it’s PCNs that will change things for primary care, not the ICBs, if they are supported to reach their potential. ‘If PCNs develop and mature in the way they could, a lot will change for primary care. [But they might] fall by the wayside and become a wallpaper title.
‘We are starting to embrace PCNs. Locally, three years in, we’ve got to a steady state. We’re starting to see the ARRS movement take effect. I think we are transitioning to a point where primary care will change.’
Dr Lakhani echoes that ‘the centre of gravity will be with PCNs for primary care’.
‘We had too many GPs who were either commissioners or providers, and there were conflicts of interest. Now, everybody is sitting round a table and saying: “Our population need is diabetes, obesity, mental health, how do we sort that out?” I think PCNs will be doing that. Instead of having the purchaser-provider split, we now say “It’s all our job to do it”.’
Dr Findlay agrees that PCNs are the future. ‘We’re seeing more services being created at a PCN level. They have to lead their practices into this new world and include other professions and services in their PCNs,’ he says, and adds that multidisciplinary working will be a key feature of the new NHS system.
But PCNs have challenges. Practices are by no means all on the same page in each of the 1,200 or so PCNs. They have issues with sharing data and IT, the sheer workload of meeting the DES and recruiting ARRS positions. And those new recruits need training and support.
Our CCG evaluation survey found that while most (42%) thought PCNs would take on work previously done by CCGs, 35% did not think they would. See box 11.
Dr Fernandes points out that while PCNs have been well funded for new staff they have nowhere to put them and managing them has created more work.
‘You’re spending more time supervising these roles, which is adding to pressure. GP partners are getting fed up of people knocking on the door all the time, as they can’t do their own work.’
Dr Fernandes says that the pharmacists, first-contact physios and home-visit paramedics add value. ‘We’ve got so many attached staff who are off sick so often it’s unbelievable’.
He added that the set-up of PCNs means there isn’t a defined structure in PCNs to manage ARRS staff because they’re all employed by practices.
Dr Lakhani says he thinks the big thing people will need from PCNs is a local solution for patients who need same-day care. Certainly this is highlighted in the Fuller Stocktake.
While CCG leaders are pleased there are new leaders coming up via PCNs they have concerns about these leaders’ relative inexperience and what will be expected of them.
Dr Chowhan says: ‘A lot of CDs will have to sign in and out of meetings in the middle of busy clinics so I don’t think they have the protected time or opportunity to develop as the next tranche of clinical leaders.’
As PCN development has not been uniform, Dr Kong feels some PCN CDs may lack the gravitas and experience to negotiate with and challenge the more established partners in the ICS as some stakeholders do not view PCNs as equal partners on the platform.
ICSs
A clear three-tier structure is emerging for the ICSs – the ICB, places and neighbourhoods (the latter two refer to council areas or boroughs and PCNs). But there are nuances. Each ICS area has different terms and groupings, which are still emerging. Some have an intermediate level between the ICS and the place. Added to that is the development of ways to represent GPs – a network of networks, an alliance, a collaboration or a board are some of the terms being mentioned. But whatever the structure, a crucial element is the finances and getting that to the front lines so local changes can be made.
Dr Lakhani says the financial framework for system working – with aligned goals of quality, stopping repeat tests and treatments and agreeing where people are best treated – ’will be good’ and should support the hoped-for changes.
Dr Chowhan hopes that the money from the ICB will be delegated to PCN level.
‘We should try to delegate as much as we can. Unless we go down beyond place to the level of PCNs, people don’t feel empowered or impassioned. And if they’re not passionate about what they’re doing, nothing will change. I hope money and decision-making delegate as far down as they can go.’
Dr Kong thinks the worst-case scenario of infighting between the places and boroughs for the ICS resources will be over issues of deprivation. Having worked in different London boroughs she knows that even those that are perceived as affluent have significant challenges.
Much of the work of CCGs is contracted and will therefore transfer to the ICB, but Dr Gupta points out that when new people come in they revert to the contract so anything that is ‘a loose agreement’ will fall apart as there is no continuity of staff.
‘My worry is, that even with a contract, if you lose the organisational memory and the relationships, the contracts will not be sustained because people forget the rationale. And the relationships that help you to troubleshoot are lost. We are going to see a reduction in the number of GPs on the commissioning side. There will be clinical leads still. But the ability to build and maintain those relationships between the commissioner and, let’s say, a secondary care consultant, is going to be diminished.’
Dr Gupta is concerned that the provider-commissioner split, the ICB commissioning the providers, will still be heavily weighted towards reactive acute care in terms of how money is spent.
‘Our outcomes will go nowhere or get worse. That’s the worst-case scenario for me, that nothing changes other than the personnel. We’ve still got a commissioner-provider split. This idea that we’ll have an ICS focused on population health, which is the holy grail, will not come to pass.’
For Dr Watt, the biggest concern is the tension between national and local priorities. ‘There may be national initiatives that have nothing to do with what we’ve identified for our population. We will have to divert our staff and teams to whatever the national initiative is, which may or may not be a local problem for our system,’ she says.
However, CCG leaders do feel that the changes brought about by the Health and Care Act 2022 will benefit the acute sector. More than two-thirds of our survey respondents felt the new system would benefit hospital trusts (68%) – and 42% felt ICSs would not support primary care. See box 12, above left.
Dr Lakhani acknowledges the concerns about renewed dominance of the acute sector, but says it’s not something he’s seeing in his area. ‘There is a real concern that the ICS will be dominated by issues with acute providers. I’m not seeing this, because one of the requirements of ICSs is collaborative leadership. To use a football analogy, you think about “what’s best for the country, rather than the club”.’
Reality check
As mentioned, three-quarters of those surveyed do not have confidence in the way the NHS is being run by the Government. CCG leaders interviewed were also critical about the reality versus the rhetoric.
Dr Kong says: ‘Needs and wants are different things. It is in our Hippocratic oath not to ignore clinical needs. So we must have honest, mature conversations with everyone involved. With the current workforce crisis and limited funding and resources, we have to contain the “wants” realistically, to deliver the clinical needs and outcomes, working with our residents, our patients and carers. Otherwise, GPs face bad press as they do now.’
Dr Watt agrees. ‘We are still dealing with Covid and are likely to be for the next two years. It is a really difficult patient message, because they’re being asked to pay more money in their taxes. They have been told: “It’s over, it’ll be better”. That’s what the politicians want people to hear, but given the workforce we have, the demand, the capacity and the challenges, it’s not that realistic.
‘CCGs and ICBs are being asked to save money. In real terms this means budget cuts, despite the public feeling as though they’re paying more, and the cost of living going up. In many respects, because of the unmasked demand, I don’t think it can feel better,’ she says.
The pandemic gave people time to reflect and identify previously undiagnosed conditions such as autism or ADHD, which means the demand has increased. Also, there is the increased complexity of patients presenting later, especially those with cancer.
NHS England figures from January 2022 show a record 6.1 million people waiting to start treatment, with more than 300,000 having waited for a year and nearly 24,000 people having waited for more than two years. While patients wait for hospital care it is the GPs and primary care services that hold the risk and take the calls from patients following up about their condition, in turn adding to the demand.
Workforce
And of course, we need people to meet this demand. Anyone who works with or in the NHS is united on this issue – there is a lack of available workforce to meet the current demands, let alone the demands in the future. Time and again, lobby groups, clinicians, the House of Lords and the health select committee urged the Government to set out a workforce development plan in the new Health and Care Bill. The Lords passed an amendment, backed by around 100 organisations, that would have ensured the Government published independent reports on workforce numbers every two years. The reports would have been accompanied by an ‘independently verified assessment’ of current workforce numbers and ‘the projected workforce supply for the following five, 10 and 20 years’. But this was rejected by the Government and the bill was passed without it.
Following the devastation of the global pandemic, where NHS staff put themselves in harm’s way, some losing their lives, the Government has piled on the pressure to clear the backlog and increase access to meet patient demand. But many feel it has failed to address the shrinking numbers of health professionals available to do that work.
Our survey found more than half (57%) cited lack of workforce and lack of time (53%) to carry out the work as major barriers to the success of CCGs. See box 13 and box 14.
Dr Kong says: ‘They want PCNs to do the extended hours – 8am to 8pm Mondays to Fridays and whole-day Saturdays. Where are we going to get the workforce? It’s the same people doing the same jobs two or three times over. People working in 111 are sometimes GPs locuming. You get the nurses to do it, the nurses come from somewhere else. Nobody is saying “let’s be real”. Extending access points is not the solution.’
The negative media about GPs only compounds the issue, making recruitment all the more difficult, says Dr Watt.
‘There are fewer GP partners this year than last year and the numbers keep going down. With the media bashing, why would anyone want to go into general practice?
‘We need to be loved. As a GP we are strongly identified with our practice, and it matters to us deeply,’ she says, and adds that it feels personally insulting when there is negativity towards general practice.
Board-level representation
The ICSs are required to have one primary care representative on the board. This worries some people. Others are creating systems to feed up to that person.
The 42 ICSs published their constitutions at the start of June, detailing how they would appoint people to the board. ICBs are required to have one primary care representative on the board, but a Healthcare Leader investigation found that two, NHS Bedfordshire, Luton and Milton Keynes ICB and NHS Hertfordshire and West Essex ICB are appointing three, while 12 have stated they want two primary care reps on the board. Five have gone further and mentioned experience as a PCN CD will be a requirement or desired.
Dr Watt says that while it is essential that general practice has a presence at strategic level, it’s equally important to have ‘appropriate provider representation every level of the system’.
‘It’s not one person on the board. It’s about general practice being everywhere that providers should be, and linking general practice into communities of practice education.
‘One of my hopes is that the generalist approach GPs have been able to bring to commissioning continues in the future, because obviously when we’re in commissioning roles we’re not speaking on behalf of our practices. But we are able to give that generalist view because our patients will tell us what their journey has been like.’
Dr Fernandes questions whether there will be any GP representation on the ICB.
‘They say it’s going to be a GP, but actually might be a primary care representative. At place level we’ve got a primary care provider representative, but they will be representing GPs as providers, and also dentists and ophthalmology and pharmacy. Then we’ve got a primary care development lead, which again is about primary care in the wider sense – not only general practice but also pharmacy and the other primary care providers, community services and PCNs.’
Multidisciplinary leadership
Dr John says the biggest change the move to ICSs will bring is the push for multidisciplinary leadership.
‘We are moving to a much wider multidisciplinary leadership than we’ve ever done before. If you look at some of the evidence we’ve seen in other streams, like personalisation, there are huge assets in our communities that we probably haven’t explored enough.’
Dr John also feels that the ICSs are well placed to ‘get hold of the population health and health inequalities agenda that we’ve struggled with’.
He highlights the Covid vaccination campaign, which showed that traditional ways of advertising the vaccine didn’t work in North East London.
‘We needed to work with faith groups and communities, support people’s concerns about vaccination and target things in a different way,’ he says.
‘That’s one of the big advantages of the ICS looking at this, in a very reflective way, to address problems through the lens of voluntary sector groups, the local authority, the councillors and the wider stakeholder group.
‘It’s a much more integrated approach. But I think that’s where, in some respects, the pandemic has given me confidence that this is the approach we need to take, going forward. Building on the successes of the CCG.’
Next generation of leaders
As well as concerns about the ending of the clinical influence and commissioning-level CCGs, leaders are also concerned about developing future leaders.
Dr Lakhani says he hopes the importance of training in medical leadership will be recognised in the new system and called for ‘everybody to have a mentor’.
‘It’s crucial, because how can GPs suddenly run a billion-pound organisation? How does that happen? We need credentials. I like new blood. One of the things I’ve seen in the transition from CCGs to ICS is that new blood has come in. We’ve done a recruitment process that’s been very open. People are interested, particularly under-represented groups such as female GPs, and they’ve come forward in the hundreds saying: “We want a role, tell us how we do it”,’ he says.
