Whilst the starting point for general practice to be able to influence the new-in-place Integrated Care Systems (ICSs) is its ability to establish a unified voice, the challenge quickly follows as to whether it can also act and operate collectively.  But is this a bridge too far for independent contractors?

It is one thing for all the general practice organisations in any given area (practices, PCNs, federations, LMCs) to create a unified voice that it can provide into any system discussion.  General practice can create its own leadership team that can work to be the group representing the whole of general practice in an area.  This is an important and crucial first step towards establishing influence in the new system.

Once leadership groups are established they can very quickly become the place where the system and other organisations come to talk to general practice, a helpfully accessible route that has rarely previously existed.  They can also provide a viewpoint on the ideas, plans and strategies of others, and identify what general practice does and does not agree with.

But it is another thing for those general practice organisations on the leadership groups to be able to work together and agree how general practice as a whole will operate.  It is difficult for them to get to a place and agree that this is what PCNs and practices will do, this is what the federation will do and this is how we will oversee and ensure that what we have agreed is working.

Enhanced access is a good example of this.  The debate is often lost in internal general practice arguments as to which PCNs will do what, what the federation will do and how any ‘hybrid’ model will work.  Very few places have been able to establish and present a unified, coherent, local model with a single reporting structure that can feed into the wider system discussions around urgent care.

The Fuller report points to a model of managing urgent care that brings in-hours on the day demand for general practice, enhanced access, and out of hours care all together (Fuller Report p11/12).  This was number one in the list of actions for local systems to take (Fuller Report p34).  Can general practice agree for itself how this model should be introduced, or will it require the system to enforce a model upon it?

The problem is that practices, PCNs and federations are often focussed on their own autonomy and the needs of their own individual organisations, but this is coming at the expense of what is best for general practice as a whole.  For general practice to be able to preserve its overall autonomy, and resist system advances for it to be ‘integrated’ into some existing part of the NHS machinery, it will have to demonstrate to the new ICSs that it is able to organise itself.  The paradox is that individual general practice organisations will have to give up some autonomy in order for general practice as a whole to retain it.

Ultimately it will not be enough for general practice to create a shared leadership group if it cannot then convert that into collective action.  For influence to be real it needs to go beyond having seats at system meetings, because it is not really about how loud the voice is but whether it can actively impact what happens across the system.    Of course, general practice can have more of an impact than any other organisation on the system, but only if it finds a way to operate collectively.