This is one of those questions that you feel like you really ought to know the answer to, but I am finding it very difficult to pin down exactly what an integrated neighbourhood team is.

All of the presentations I have seen about integrated neighbourhood teams outline their aims rather than what they are.  I find this unhelpful because while it might describe the problem they are trying to solve it does not actually help me understand what they are.  What I am trying to understand is who is in the team? Who leads the team? Who does the team report to?  Who sets the work programme for the team? Where does the funding for the team come from? What is its relationship to the PCN?  These are the questions I struggle to get answers to.

Even the aims of these teams seem to vary somewhat, with (for example) some places claiming they will improve access to primary and community care for local citizens and others stating they will keep people well and out of hospital.  If each area is coming up with its own definition of what they will achieve it already seems highly unlikely that what they are will be consistent across the country.

Maybe the place to start is the Fuller Report where they were first introduced, as the “heart of the new vision for integrating primary care” (p6).  Despite their proposed importance, the report does not explicitly define what an integrated neighbourhood team is.  The closest it gets is stating that in neighbourhoods of 30-50,000 “teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities.”

I am not sure that clears it up for me.  I remain uncertain whether an integrated care team is a concept that is designed for local interpretation (and so will result in a whole range of different manifestations) or whether it is something more tangible that at some point in the future we will all be able to look at and immediately recognise as being an integrated neighbourhood team.  If it is the former surely that should be explicit, and surely each ICS would then be clearer on its own definition.

Here is what I am most uncertain about.  Are integrated neighbourhood teams supposed to take on the whole gamut of services that each of the member teams carry out?  So by that I mean if we are bringing primary care, social care, community care (etc) together does that mean we are bringing all of the work they do together (i.e. those services in totality)?  Or does it mean we are bringing work on the edges of each of their core functions together where there is overlap between them (e.g. individuals with multiple long term conditions, requiring community services, with social care needs)?

If the answer is the latter (and I remain unconvinced that there is consistency on this across ICSs) then it means the work of these teams is in addition to existing work.  We have the core work that each team is doing, and now we have the additional ‘joined-up’ work that is the remit of this new integrated neighbourhood team.  I understand the principle that by doing this additional joined up work together the overall work in the system may fall, e.g. less exacerbations of long term conditions, but there is no immediate reduction in the core function of the participating members of these new teams.

This would mean that the work in integrated neighbourhood teams is in addition to the day job for team members.  But what I haven’t seen is any significant funding streams for these new teams, so what am I missing?  Are PCNs the existing significant funding stream?  Is this what “evolving” PCNs into integrated neighbourhood teams means?

Integrated neighbourhood teams still feel conceptual rather than tangible to me.  Whilst at a national level I understand the desire to stimulate rather than stifle local innovation and therefore why you might start with something conceptual, what I don’t understand is the reticence to define what they actually are at a local level.  It feels like what integrated neighbourhood teams are and how they work will be a big deal for general practice in the future, and so it seems entirely reasonable that at this point we should be pushing for much clearer local definitions.

One of the questions I am most regularly asked is why I am so supportive of the independent contractor model of general practice.  Wouldn’t life be easier and simpler for GP partners if they were free to operate as clinicians, without the almost full time distraction of trying to run a small business?

For many the grass does look particularly green on the other side of the fence, where GPs as part of NHS organisations could work reasonable hours, take annual and sick leave like any other employee, and be free from all the stresses of income, cash, staff, property, and unreasonable partners.  Life looks like it would be so much simpler.

Why, then, do we prize the independent contractor model so highly?  Well, as with any situation where we are looking to move away from problems instead of towards something we want, life on the other side will always contain its own set of (albeit different) problems.

Peter Muchie summed it up really well when he described his own experience of making this transition,

“And then I surrendered my independent contractor status to become a salaried employee with an NHS out-of-hours service. To me this now equates to a surrender of power and the right to self-determination. I can no longer organise my work to best meet competing demands. I can no longer negotiate with equal partners, but must accept the impositions of a cost-cutting management which seems to work toward the lowest common denominator. I can no longer decide what to accept and reject…

I no longer have total freedom to develop my skills according to personal interest or to best meet the demands I perceive. I must instead undertake ordained ‘mandatory’ training on such delights as information governance, and diversity in the workplace. This is boring, irrelevant, and time-consuming, the main purpose appearing to be to protect the monolith for which I work, not to improve the care I give.

When I identify a real opportunity for workplace improvement I have no real power to address it. I pass it up a non-responsive bureaucratic chain to a distant and removed manager, focused on budgets and generalities. My concern is either ignored or cursorily acknowledged and placed at the bottom of a list of priorities with cost cutting, and not service improvement, at the top.” Peter Muchie, BJGP Should General Practice Give Up the Independent Contractor Status 2015.

It is easy to think that we would just turn up for work, see the patients we were asked to and then leave at the appointed hour.  But what we miss is how soul destroying this lack of autonomy will feel, how frustrating the constant interference of a middle manager with a corporate agenda and no insight into the needs of our population will be, and how being at the receiving end of decisions made at an organisational level many layers away will make us want to scream.

The independent contractor model offers freedom for practices to choose how they operate, to flexibly adapt to meet the needs of the patients they serve, and to respond quickly to any new situation that arises and requires action.  This has been a key strength of general practice, one that is not well understood, but one that would be lost if the model was replaced.  It not only enables practices to adapt and thrive in even the most testing circumstances, but also provides partners that Maslowian need for self-determination that a salaried model would take away forever.

General practice is currently being swept along on a tide of change, all based on the premise that what we need is ‘integrated primary care’.  But what is integrated primary care, and is it really what we need?

Despite the status of the Fuller Report not being clear when it was first published over a year ago, it is now being treated as the policy document for general practice.  If you ask anyone working in the system what the plan is for general practice they will say it is to implement the recommendations of the Fuller Report.  But when you read the Fuller Report it is a wordy document that is light on analysis and heavy on pushing ideas, with little clarity on how these new ideas will make things any better.

At the heart of all this lies the idea of integration.  We have moved away from the internal market and now have integrated care systems.  The four stated aims of this new system are to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development.  Having reiterated these aims Fuller states,

“The ICS CEOs believe that achieving these aims will only be possible if we support and develop a thriving integrated primary care system” p4.

And that is the only rationale that is given.  Primary care needs to be integrated because ICS CEOs believe that is what is needed, and this apparently should be enough because no other justification is given throughout the whole document.  All the NHS CEOs even put their signatures to the report, an act Fuller describes as, “an extraordinary and welcome display of common purpose across health and care” p3.

But could it be that the enthusiasm of the NHS CEOs for this report comes not from a passionate belief in unlocking the power of local communities, but rather because it would increase the span of their direct control to include primary care?  NHS CEOs do not like primary care because the independent contractor status prevents them being able to tell it what to do, so it is not surprising they are all in favour of any move to give them more control over it.  This hardly feels like a sound justification for making such major changes.

A key problem is that nowhere is ‘integrated primary care’ defined.  Without definitions we are in trouble because what I think it means, what you think it means, what Claire Fuller thinks it means, what the 42 NHS CEOs who signed the document think it means, and what the government think it means are all likely to be very different.

Does it mean primary care working effectively in partnership with local health, social care and voluntary sector colleagues in local neighbourhoods?  Does it mean general practice becoming a formal part of the NHS?  Does it mean GP practices becoming part of existing NHS organisations?  We know that this whole range of views already exists.

I am actually a fan of integration, where it means all health and social care providers working more closely together.  It makes sense.  But the notion of “integrated primary care” is actually very dangerous, because it is so nebulous.  It is behind the calls for the nationalisation of general practice, and the end of the independent contractor model.  It is an enabler for centralist CEOs who want to expand their empires.  It is also creating a system blindness to the challenges being faced at an individual practice level.

So what do we do?  In local conversations push for clarity as to what is trying to be achieved and how will we know that we have got there, before getting into the details of actions.  “Implementing Fuller” should not be an end in itself.  If we are implementing an integrated neighbourhood team then what success measures are we using?  What outcomes will it achieve?  Simply ticking the box that we have one does not constitute success.

Challenge the idea of integrated primary care when it is used without clarity of meaning, and push for a local definition that everyone can sign up to.  General practice can support integration, but it mustn’t come at the cost of the service itself.