Following the publication of the White Paper in February, new guidance has just been published by NHS England outlining the “Design Framework” for the new integrated care systems that are to replace CCGs and bring providers and commissioners together.  What can we learn from the new guidance about what the new integrated care systems will look like, and what does it all mean for general practice?

At the top of an integrated care system(ICS) there will be two bodies: an ICS Partnership and an ICS NHS Body.  The ICS Partnership is essentially the body to bring health and social care (under the remit of the local authorities) together, and has responsibility to develop an “integrated care strategy”.  There is no explicit mention of the need for GPs or PCNs on these bodies.

The second body is the ICS NHS Body.  This will be a statutory NHS organisation which will receive and distribute NHS funding, and will take on all CCG functions and duties, including the commissioning of primary care.  It is explicitly required to “support the expansion of primary care and integrated teams in the community” (p16).

Because the changes are intended to end the commissioner/provider split in the NHS, the ICS NHS Board is described as being a “unitary” Board: it will have a Chair and at leas two other non-executive directors; an executive team of at least a CEO, Finance Director, Medical director and Nurse Director; and will also have at least 3 “partner members” – one from the NHS Trusts/Foundation Trusts, one from the local authorities, and one from general practice.  The partner members, “will be full members of the unitary board, bringing knowledge and a perspective from these sectors, but not acting as delegates of these sectors”(p20).

What does that mean?  Well, it means there will be a GP on the NHS ICS Board, but it is up to the NHS ICS Board to appoint them, and they don’t have to represent the profession.  This in turn means it is highly unlikely there will be any form of election process.  It is up the NHS ICS Board to come up with and agree how it wants to appoint the partner members.

Beyond the ICS NHS Body, there are two other important pieces of the new system architecture.  One is called “place-based partnerships”, and the other “provider collaboratives”.

In my view place-based partnerships are the most important part of the new integrated care systems for general practice.  Each local system has been asked to define its place based partnership arrangements.  A place should have “configuration and catchment areas reflecting meaningful communities and geographies that local people recognise” (p24), but it is up to local areas to define exactly what that means.

Not only that, but it is also up to local systems to agree the membership and form of governance that place-based partnerships should adopt.  “As a minimum these partnerships should involve primary care leadership, local authorities, including Directors of Public health, providers of acute, community and mental health services, and representatives of people who access care and support” (p24).

Here is where it gets interesting.  The NHS ICS Body remains accountable for any resource deployed at place level, but there are different options outlined as to how this accountability could be discharged through place based arrangements.  These range from it being a consultative forum, that informs decisions made by the ICS NHS Body (ie has no power), to it being a committee of the NHS ICS Body with delegated authority to take decisions about the use of ICS NHS Body Resources.  It can even be delegated authority by both the local authority and the ICS NHS Body as a joint committee to make local decisions and allocate resources.

This is key.  Primary care’s influence and ability to shape the delivery and provision of services is realistically going to happen at a place level not at the wider ICS level, and that ability will be determined by how the ICS designs these place based partnerships in the next few months.

There is an interesting note in the guidance on the role of Primary Care Networks (PCNs) in the place based partnerships, “PCNs in a place will want to consider how they could work together to drive improvement through peer support, lead on one another’s behalf on place based service transformation programmes and represent primary care in the place based partnership.” (p27).  Regular readers of this blog will be no stranger to my view that primary care and PCN influence in the new system is predicated on their ability to work effectively together and present a unified voice.  The good news is that the guidance explicitly states, “This work is in addition to their core functions and will need to be resourced by the place-based partnerships”(p27).

The second important new piece of the architecture is provider collaboratives.  From April 2022 NHS trusts are expected to be part of one or more provider collaboratives.  There is a strong expectation in the new system that providers will work together (as opposed to in competition with each other).  They could be paid (by the NHS ICS Body) separately, or via a lead provider arrangement.  There will be far less competition and tendering in future, as it is to be a “tool to use where appropriate, rather than the default expectation” (p30).

The transition to the new system will happen quickly.  The NHS ICS Body Chair and CEO are expected to be in place by the end of September, along with the draft ICS operating model for 22/23.  NHS staff below board level (ie CCG staff) have been given an employment commitment to continuity of terms and conditions, but this does not apply to those in senior/board level roles.

The most important part of all of this for general practice is how the place-based arrangements will work locally.  It is vital that GPs and PCN CDs get involved in these discussions, and do not leave it just to those who are currently involved in the CCG, as they are the ones who will have to make the new system work.  At this stage there is a lot of local flexibility, and there is an opportunity to ensure systems are put in place that support locally-led bottom-up change, but it is an opportunity that won’t last long.