There are some individual elements within the Fuller Report that are worth exploring in detail to try and understand what they mean, and what the implications are.  The first of these is integrated neighbourhood teams.

Integrated neighbourhood teams are described as being “at the heart of the new vision for integrating primary care” (p6).  The clear action at the end of the report is to “enable all PCNs to evolve into integrated neighbourhood teams” (p34).  In terms of timescale, “systems should aim to have them up and running in neighbourhoods in the … most deprived areas by April 2023… and move to universal coverage throughout 2023 and by April 2024 at the latest” (p7).

So integrated neighbourhood teams are to be an ‘evolution’ (replacement?) of PCNs, and a rapid one at that as this is expected to happen this year, or within a maximum of two years.

What exactly is an integrated neighbourhood team?  The problem with the report is that it tries not to be too prescriptive to allow local areas to create their own versions that will work locally, but of course this means there is a lack of definition when it comes to the detail of what is intended.  It does say they will be where, “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” (p6).  The clear intention is to bring all providers in a PCN footprint together.

The obvious question, then, is how will this happen.  We know when PCNs were first introduced the clear expectation was set out that these teams should all become part of the PCN Board, but in most places that just has not happened.  This is because it is hard finding ways of enabling the practices in a PCN area to work together effectively, and PCN leaders have done a great job of making this happen.  But this relies on those practices believing they are retaining an element of control, albeit collective control, or else many would just not be prepared to give up the individual practice autonomy the joint working requires.

This report by ICS leaders displays an element of frustration with the pace of progress of PCNs (or else why produce the report?) and wants to fast forward within one or two years to a model of all organisations working seamlessly together around PCN populations.

According to the report, the reason for this perceived lack of progress is, “a lack of infrastructure and support (which) has held them back from achieving more ambitious change” (p6).  The challenge of enabling joint working across practices within a PCN is ignored.  And so the prescribed remedy is “a systematic cross-sector realignment to form multi-organisational and sector teams working in neighbourhoods. For example:

• full alignment of clinical and operational workforce from community health providers to neighbourhood ‘footprints’, working alongside dedicated, named specialist teams from acute and mental health trusts, particularly their community mental health teams
• making available ‘back-office’ and transformation functions for PCNs, including HR, quality improvement, organisational development, data and analytics and finance – for example, by leveraging this support from larger providers” (p6-7)

Does this mean, effectively, a takeover of PCNs by the system, i.e. that the practices in the PCN become one partner of this new system, that has its own infrastructure, leadership and (potentially) place within an existing organisation?  Maybe.  Local interpretation means that if a local ICS wants to interpret it like this it probably can.

The key is where the leadership of these grander integrated neighbourhood teams will come from.  Who will be in charge and have accountability for them?  It does seem unlikely that system organisations will all put resources into these teams and at the same time totally cede control of them to the PCN practices.  This is what the report says about this:

“The role of PCN clinical directors in the future will be essential to the leadership of integrated neighbourhood teams… More focus needs to be given to the development and support of clinical directors beyond the current basic arrangements provided through the national contract, including the local provision of sufficient protected time to be able to meet the leadership challenge in integrated neighbourhood teams.  Some systems will want to go beyond this and use even more innovative ways to support clinical directors to expand and develop their integrated neighbourhood teams, for example:

• some neighbourhood teams may offer an opportunity to develop different areas of focus and specialisation, with senior GPs serving as the ‘consultant in general practice’ – working across prevention, chronic and urgent care as part of wider teams
• securing the specialist input from secondary care required in neighbourhood teams, as part of job planning for consultants
• supporting community partners to operationally embed relevant teams as an integral part of existing PCN teams, recognising that the integration of community and mental health services with primary care is crucial to delivering more integrated care for patients in the community, as set out in the NHS Long Term Plan” (p22)

What should we make of this?  It seems to be saying PCN Clinical Directors will be the first port of call when it comes to who will be leading these new integrated neighbourhood teams.  But how many PCN CDs are going to be able to commit the three (or more) days a week this expanded role is going to require?  Does this then mean the bullets above are alternative leadership options?  It is not a huge step to see these being led by individuals from community trusts, mental health providers, or even secondary care.

As a minimum the implication is that the management infrastructure (if not the clinical leadership) will come from an existing provider (cf the action on p34 “baseline the existing organisational capacity and capability for primary care, across system, place and neighbourhood levels, to ensure systems can undertake their core operational and transformational functions” – I don’t suppose for one minute the answer will be to put more funding into a standalone PCN infrastructure).

The report pushes hard for additional resources for these teams to be allocated at an ICS level (as opposed to the current model of nationally via the PCN DES).  If this is the route of future additional funding for general practice (if this year’s contract negotiations told us anything it is that any new money for general practice has to come via PCNs or their successors), and the leadership and management of these teams increasingly sits outside of general practice, the profession could quickly lose control of its own resources.

Integrated neighbourhood teams are coming, and they are coming quickly.  Behind the attractive picture of clinical teams all working in harmony across the PCN, there are big issues of leadership, ownership and control that need to be played out in each area.  General practice will need to pay close attention to how this happens because of the significant consequences it will have for its own future.