A key challenge for general practice operating within an Integrated Care System is how it establishes a single voice, and how it exerts influence given the strength and size of system partners such as acute trusts and local councils.  But already up and down the country we are starting to see local areas work through exactly how they will do this.

Establishing a unified voice is difficult for general practice. The independent contractor model, and 7000+ units of general practice, puts it at a distinct disadvantage compared to local providers.  Often there will be one acute trust, one council, one community and mental health provider and then anything between 5 and 10 PCNs and 40-50 individuals practices in any local ‘place-based’ area.  Across the ICS as a whole it is even worse, as there can be literally hundreds of practices, dozens of PCNs, but one (often merged) acute provider and one or maybe two community and mental health providers.

In this set up it is not hard to see how the unified voice of these single providers, with their hierarchical structures and large management teams, is going to be more powerful than that of general practice, given its relatively disparate nature and lack of any form of comparable management support.

But what we are now seeing in different parts of the country are attempts to bring the different parts of local general practice together to create some form of a unified voice.  There is superb example of this in Herefordshire, which we featured recently in an episode of the podcast.  There they have established what they term a ‘General Practice Leadership Team’, which comprises the federation leads, the PCN Clinical Directors, the LMC, and even the CCG Director of Primary Care.

This leadership team works through things together and agrees a single voice on issues, as well as providing a forum for general practice to meet with system partners where it is needed.

Other areas are equally bringing together the federation directors and the PCN CDs and the LMC into an overarching local leadership group for general practice.  Sometimes this is done within a federation infrastructure, and sometimes it is created separately to the local federation but with federation input.  Of course sometimes there is no federation, but I am yet to find an area without one who has actually started on this journey (do get in touch if you have!).

What early lessons can we learn from those areas who are taking the early steps along this journey?

The first is that there is no right way of doing it.  All of these systems rely on trust.  So the important thing is whether all those round the table are bought into the need to create a single voice for general practice, and whether the people leading the group are trusted.  Interestingly in Herefordshire the group is chaired by a manager, the Director of Strategy at the federation, but that works because she has the trust of those round the table, has good system relationships in place, and can take a neutral stance, i.e. is not seen as favouring their own practice/PCN over others.  More commonly there is a trusted GP at the helm.  What is clear is that it is trust in the person leading that is important, rather than their role or background.

The second is that system influence is a function of relationships, not just attendance at meetings.  What that means is that those leading need to be given the time to build relationships with the other system leaders.  While there is a benefit in distributed leadership (i.e. different individuals taking on different aspects of the system leadership requirements), there is also the need for a focal point and someone who is enabled to invest the time to build relationships with the individual local leaders of the other organisations.

The third is to be effective this type of system requires clarity on the roles of all concerned.  It is not an abdication of autonomy of the general practice organisations around the table to the group.  It is a place where decisions can be made about what requires a group decision, and what remains the responsibility of the PCN or federation or LMC (etc).  It requires clarity about if someone is purporting to speak in the name of the whole of local general practice exactly what process is in place for them to be able to do that, i.e. how is that individual engaging or briefed beforehand, what can they agree/not agree, and how do they feedback and implement any actions picked up.  And it requires clarity as to where delivery responsibility lies, as the group only provides a coordinating function (it is very rarely an entity in its own right).

The fourth is that such a system or infrastructure will take time to develop and become effective.  Trust (the key ingredient) has to build along the way.  And given how close we are to these new systems going live it is probably a journey that every area needs to be thinking through now as to how this is going to work locally.

This could be left in the ‘too difficult’ box (because of the size of the challenge!) but that then leaves general practice hugely exposed in the new system, with little hope of exerting effective influence on local decision making and resource allocation.  If there is no movement in this direction locally I would suggest the best starting place would be a conversation between the PCN CDs and the LMC to agree how to get started.