The big policy question of the moment is how general practice can be “integrated” with the rest of the NHS.  But I wonder if this is the wrong way round, and whether the question should really be how the rest of the NHS can be integrated with general practice.

The first problem is of course that it is not universally clear what integration actually means.  While most of us would sign up to integration meaning joining up the delivery of services across organisational boundaries, the term retains a looseness beyond that.

For some it means joining up delivery by removing organisational boundaries, and we see that increasingly across the acute sector with a whole raft of joint Chair and CEO appointments followed by formal merger.  For others it means  operating at a larger scale across organisations, which leads to thinking like mandatory urgent care centres across a whole ICB area.  And for yet others it means putting services in place to cater for those that fall between the gaps between organisations, although sometimes with an assumption that this can somehow be done with no additional investment and so at the expense of the existing core organisational services.

Underlying all of the policy thinking to integrate general practice is the assumption that the independent contractor model operates against it.  This has played out since the inception of Integrated Care Systems in 2022, which was the exact point in time at which any investment into the core contract ceased.  Since then the only new funding for practices has come via PCNs, accompanied with active disinvestment into the core contract with below inflation imposed settlements.

This ‘NHS good, independent general practice bad’ thinking seems to me to be fundamentally flawed.  The NHS is beset by waiting lists and overspends, none of which exist in general practice.  Plenty of organisations exist within the NHS that fail to collaborate or ‘integrate’ with each other.  And you can’t merge them all.

In fact, if what policy makers are really seeking is a ‘Neighbourhood health service’, then the scale at which nearly all NHS organisations operate at actively works against this.  Any practice or PCN that has started to build relationships with their local district nursing team will tell you how one day critical team members get moved to another area because of staffing shortages or issues elsewhere.  Local managers tell you it is outside of their control, and the work either has to start again or (more commonly) collapses.

The scale that NHS organisations work at, and the environment they operate in, means the need for efficiency outweighs the need for effectiveness.  They will always choose to move resources around at the expense of continuity of care and relationships in any local neighbourhood, as the alternative is to incur additional costs for the organisation as a whole.

The only way this can be stopped is if the organisational units delivering joined up care at a neighbourhood level are neighbourhood-sized.  The organisation itself has to have the health of the neighbourhood as its sole focus.  This can’t be done through a series of expensive NHS organisations.  Instead it needs general practice-style organisations, dare I say it independent contractors, who can then use the speed and innovation that are core components of general practice to join up care delivery and achieve the outcomes that an NHS organisational model never could.

Two years in and the integration agenda of ICBs has delivered very little.  While the overriding concept is laudable, many of the underpinning assumptions are flawed, in particular that the independent contractor model of general practice is preventing integration and that NHS organisational models enable it.  But reversing the thinking to consider how NHS services can be integrated with the existing model general practice would be much more likely to deliver real outcomes.