It is less than 6 weeks until Integrated Care Systems (ICSs) go live, and yet most of us are still trying to get our heads around exactly how they are going to work.  While some are sticking with the “nothing much is gong to change” mindset, the reality is that this transition does pose significant risks for general practice.  I am not trying to be a prophet of doom, but understanding the risks is the first step to being able to mitigate them.

Here are 4 key risks the shift to the new system creates for general practice.

1. Less funding for general practice

The biggest risk is that the funding coming into general practice reduces.  There is already pressure on the new ICSs to break even.   It is no longer individual organisations that are overspending, but rather whole systems. What this means is that if the hospital is overspending, general practice funding is on the table as a means by which the system can get back into balance.

This could manifest in a whole number of ways.  If general practice funding levels are different across different parts of the ICS, the system could argue that the funding should be reduced across all areas to the level of the lowest.  If different levels of funding are used for out of hours services, arguments are likely to be made that it be reduced to the level of the lowest.  When a system is deciding upon how much discretionary expenditure to make on general practice (remember all local enhanced service funding will come under the jurisdiction of the ICS), these decisions will be made within the context of the overall financial situation of the ICS.

2. System decision making more likely to negatively impact GP practices

With such important financial decisions being taken at an ICS level, it will be important for general practice to have a strong voice at these discussions.  The problem is there is no obvious route for this to happen.  The mandated GP on the ICS Board only has a few sessions a week, and the size of the ICSs mean there is a huge risk of a disconnect between ICS decision making and individual GP practices.

If the large providers dominate the decision making, then it is much more likely the decisions will be made in their favour.  Some hospitals have already started to make an argument that because of all the fixed building costs within their estate it would be better for more work to come to them from general practice – with the associated funding!  It is thinking like this that poses one of the biggest threats to general practice.

3. Loss of support for GP practices

Many will remember when CCGs were first created and the commissioning of general practice moved to NHS England.  Systems lost all of the relationship managers that had existed in PCTs, and the whole thing was such a disaster that worries about conflicts of interest were put to one side and responsibility was returned to CCGs to restore individual contract relationships with practices.  But with the move to ICSs it could well be that we see the same mistake made again, only this time with no CCGs available to give it back to.

If ICSs mean the system decides to take a hard contracting line with GP practices, with no thought or concern for the individual pressures and challenges practices face, then it could quickly become a very hostile environment for practices.

4. Less protection for the independent contractor model of general practice

This shift to ICSs is taking place at the same time as the Secretary of State is declaring his preference for a nationalised model of general practice.  ICSs are all about providing support services at scale across the NHS, and doing things once that only need to be done once.  It doesn’t take a huge leap of imagination to see ICSs thinking that a more efficient (ie less costly) model of general practice would be if multiple practices were consolidated into existing organisations (making use of their existing back office infrastructure etc etc).

In the past we have had sufficient GP leadership in CCGs and across the system to counter such thinking.  But it is questionable as to whether this voice of reason is going to be loud enough in the new system, and the protection that has previously existed is likely to be sorely missed.