Ben Gowland muses on the potential roles for GPs in the integration agenda and finds himself away with the fairies.

I recently asked a GP whether she felt that GPs should play a leading role in integration across the system. She peered at me through her half-rimmed spectacles, and said, “I don’t even have time to go to the loo let alone get involved in Integration. It sounds great in theory but there is more chance of little green fairies doing a magic dance at the bottom of my garden than there is of me taking on any more work.”

So that was me told. The RCGP have produced a new report entitled, ‘The Future of GP Collaborative Working’. You can find it here. The report, as far as I can tell, has two key messages. One is that GPs, as the expert medical generalists, have a key role to play in the integration of services around patients with increasingly complex needs. The second message is that this central role of GPs is often not recognised and that any additional funding generally either falls short of what is needed, or is not maintained over the longer term.

So we are left with something of a conundrum. This is the ‘little green fairy’ problem; GPs now exist under such extremely severe time constraints that the prospect of them taking on more and more system responsibility seems, to many, simply preposterous. There are not enough GPs and no prospect of there being enough any time soon. But, at the same time, the system requires GPs to play a greater role in bringing services together around the needs of patients.

The RCGP Report contains a number of really interesting examples of how GPs have taken a leading role in integration. They are worth a closer look. They fall into three groups. There is one whereby a new service has been created that employs GPs directly into a new service, for example the @home scheme in London and the Memory Assessment Service in Brighton. There is a second whereby a small number of GPs are upskilled in a specific specialty and then work in partnership with a specialist centre to improve the General Practice offering, e.g. the child health hubs/clinics in London and in Lerwick in the Shetland Isles. The third is one whereby the GP practice team is expanded, for example the addition of a prescribing pharmacist as a partner, or employing a mental health therapist.

The analysis required is of the impact of these developments upon General Practice overall. Integration does not replace the need for core General Practice. Rather, it aims to fill the hole that often exists between core General Practice and secondary care, and indeed other services. But filling that hole at the expense of the core General Practice service would clearly be a mistake (a point, I fear, that is missed by some new-models-of-care enthusiasts).

This isn’t wholly scientific, but here is the little green fairy analysis of these three groups of examples:

Group One could either attract new GPs into the profession by creating a new range of options for newly qualified GPs to choose from, or it could pull from an already too small pool and make it smaller. Little green fairy verdict: I’m dancing.

Group Two can enable a small number of GPs to develop an interest, receive proper support, and enable that to be monetised by the practices of those GPs to recruit replacement capacity. At best the impact on GP practices is likely to be neutral. Little green fairy verdict: now you see me, now you don’t.

Group Three involves reshaping core General Practice by incorporating new roles and responsibilities as a driver for integration. This enables core General Practice to develop alongside integration initiatives. Little green fairy verdict: I’m toast.

We need integration; not as a replacement for General Practice but as well as General Practice. GPs have a key role to play. The only way this is going to be realistic at any sort of scale is if the integration work helps, rather than adds to, the delivery of core General Practice by GPs. If it doesn’t, then we would be better off looking at the end of our gardens for the elusive magic dance of the little green fairy.