White Papers are not known for their readability, and at 80 pages long it easy to understand why the White Paper published on the 11^th February has not made it to the top of the reading list of GPs busy dealing with the pandemic.  But how important a document is it, and what implications does it have for general practice?

The document signals three changes important for general practice:

1. The Primacy of Integration
2. Integrated Care Systems to become Statutory Bodies
3. Locally Determined Place-based Arrangements

 The Primacy of Integration

At the core of the changes proposed is a shift away from the internal market and towards joined up, or integrated, care.  The aim is to continue to bring different parts of the systems closer together, and to support “GP and healthcare specialists to work together to arrange treatment and interventions that either prevent illness or prevent their conditions deteriorating into acute illness” (4.2).

Integration does not mean merger.  “While NHS provider organisations will retain their current structures and governance, they will be expected to work in close partnership with other providers and with commissioners or budget holders to improve outcomes and value.” (6.8)

There is, however, a new duty to collaborate. “This will require health bodies, including ICSs, to ensure they pursue simultaneously the three aims of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.” (3.11).  One assumes this will equally apply to general practice.

The expectation in recent years has been for GP practices to work together and in partnership through Primary Care Networks (PCNs).  While the White paper says very little directly about PCNs, it certainly signals integration as the direction of travel moving forward.

Integrated Care Systems to Become Statutory Bodies

Integrated Care Systems (ICS’s) are not new, as most areas already have one, and the White Paper is very much about legislation catching up with what it already happening.  However, as a result of the proposed legislation the ICS’s will become statutory bodies.

Each ICS “will be made up of an ICS NHS Body and a separate ICS Health and Care Partnership, bringing together the NHS, local government and partners. The ICS NHS body will be responsible for the day to day running of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the systems’ health, public health, and social care needs.” (3.9).

Why separate the ICS NHS body and the ICS Partnership?  The White Paper explains that the creation of an ICS NHS body is needed to, “merge some of the functions currently being fulfilled by non-statutory STPs/ICSs with the functions of a CCG. We aim to bring the allocative functions of CCGs into the ICS NHS body so that they can sit alongside the strategic planning function that we would like the ICS to undertake” (5.8).

Effectively then the role of CCGs become subsumed under the ICS NHS statutory bodies, who will take on both responsibility for allocating NHS money and the commissioning of general practice. However, interestingly, “It will not have the power to direct providers, and providers’ relationships with CQC will remain unchanged.” (6.15 e)

So the days of general practice being responsible for NHS money – the claim made when CCGs were introduced – will formally be over with the introduction of the new ICS NHS bodies.  General Practice will still have a say, however, as, “Each ICS NHS body will have a unitary board, and this will be directly accountable for NHS spend and performance within the system, with its Chief Executive becoming the Accounting Officer for the NHS money allocated to the NHS ICS Body. The board will, as a minimum, include a chair, the CEO, and representatives from NHS trusts, general practice, and local authorities, and others determined locally for example community health services (CHS) trusts and Mental Health Trusts, and non-executives.” (6.15 f)

In addition to this statutory board, ICSs and NHS providers can create joint committees and delegate decisions to them. At the same time NHS providers can form their own joint committees.  These are relevant for general practice as, “Both types of joint committees could include representation from other bodies such as primary care networks, GP practices, community health providers, local authorities or the voluntary sector” (5.26).

It will be important for general practice to ensure it both has representation and get its representation right on both the local statutory boards and joint committees.

Locally Determined Place-based Arrangements

An important term used in the White Paper is that of “place”.  By place it means local areas within a larger ICS, “Most usually aligned with either CCG or local authority boundaries… Many provider organisations and groupings of organisations such as primary care networks look to their ‘place’ as their primary focus” (6.5).  Place, then, is not a PCN, but the local area within which a PCN operates.

The White Paper does not propose any legislative arrangements at a place level, although they, “will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14) – i.e. expect guidance to come.  Local Authorities will have a big say in these place-based arrangements, which include aligning ICS allocation functions (i.e. where the money goes).  Health and Wellbeing Boards are explicitly recognised as having “the experience as place-based planners” (5.11), and so will feature in the local arrangements.

Local place arrangements may well end up being the ones that impact general practice and PCNs most.  Individual areas will have more of a say as to how these end up as they are outside of the scope of the new legislation, so it is important GPs and PCNs start to influence now how these develop locally.

Overall the White Paper signals a continuation of the changes already started across the NHS.  It does means a new contract manager for general practice (the new ICS NHS body), but more importantly it requires general practice to work in partnership with other organisations, and those partnerships will be pivotal to its future success.  Little if anything is said in the White Paper about PCNs and their future role in the new system, but everything suggests PCNs will be the key enabler of these partnerships.