What is the plan for general practice within an Integrated Care System (ICS)?  It seems that for most the pressure of everyday life is far too much for GPs to be even thinking about this question, let along working out what the answer is.  But if general practice is to have a voice in the new system that is developing some form of plan is necessary.

For local general practice to have as big a voice as possible, and in the absence of any more tailored local solution, I would suggest the following as simple 3-point plan.

1. Push for as much as possible to be devolved to place-based arrangements

ICSs are to work on two levels.  There is the overall ICS level, and a  number of local ‘place-based’ levels.  Each ICS has to decide how the local place based arrangements will work.  Specifically it has to decide whether to use the local arrangements as advisory within the wider ICS decision making, or whether to devolve decision-making authority to the local level.

The reality is that the influence of general practice will be much greater at a local level than at an ICS level.  An ICS Board only has to have one GP.  That GP will be appointed and in no way has to be representative of general practice.  However, at a local level the PCN Clinical Directors (CDs) are to represent general practice on the local place-based board.

It is difficult for general practice to establish consistent and shared views across practices.  The bigger the area, the harder the challenge of creating a shared view across practices is.  It makes sense to try and push decision making down to a local level, to give general practice the best chance of creating a consistent voice.

On the plus side the local councils will also be pushing for decision making to be devolved to a local level.  While there may be challenges ahead with the council within the place-based board now is a good time to ally with them to influence the ICS to establish a devolved decision making model.

2. Create an Integrated Voice for General Practice at a Local Level

The challenge for general practice is to bring together all the constituent parts of general practice together to create a single, unified and therefore powerful voice.  This includes the individual practices, the PCNs, the local federation and the LMC.  For general practice to have influence with other system partners it needs to speak with one voice.  If it spends its time contradicting itself (e.g. the LMC speaking against the PCNs) then its voice can simply be ignored by system partners.

The areas that have had most success have done this at a borough or local level.  I wrote recently about what we can learn from the experiences these places have had.  Some ICSs are trying to push practices into creating a shared voice (or general practice ‘collaborative’) at ICS level.  It is hard enough making this work at a local level, and my strong view is that if you attempt to do this at too wide a level the internal arguments will be too difficult to overcome and the net result will be an extremely weak voice for general practice.  Far better to create local arrangements, and then ask the leaders of these local arrangements to come together and influence at an ICS level.

3. Make Use of the Opportunity to Influence at Local Level

This strategy only works if once the ICS has agreed to devolve decision making to a local level that general practice actually takes the opportunity to influence decision making locally.  It means PCNs and practices working together to identify their priorities and to push these in the local meetings.  It means building relationships with local leaders and taking an active role in the working of the local place-based partnership meetings.

This is more challenging than it sounds.  PCN CDs are overwhelmed as it is with meetings and demands on their time.  The delivery responsibilities for PCNs have just been ramped up.  It is easy to ignore the local ICS partnership board as one more meeting that you don’t have time for.  But losing control of this now and giving it up to local authority and community providers who will be eager to take it would be a mistake that general practice could rue for a long time.

Not only does local general practice need to come together and create a single voice.  It needs to establish how it will discharge this voice and influence the local meetings.  This involves identifying one or two senior leaders who it will choose to build relationships with the other local leaders to represent general practice in discussions and at these meetings.

This three point strategy will only work if all elements are carried out.  If decision making is devolved but local general practice cannot agree with itself, its voice will still be weak or limited.  If it doesn’t attend the meetings or find a way of ensuring its views are adequately represented the same will apply.  However, if done well the rewards could be significant, as it is an opportunity for general practice to work with other providers and shape the provision of healthcare in their area.