As the NHS shifts away from the purchaser provider split and into the new world of integrated care, can general practice actively drive the agenda? Or is the ability for general practice to be proactive locally made impossible by the national contract?

At its heart integrated care is built upon the notion of the different providers of health and social care working together to improve outcomes for patients.  Instead of competing with each other, the providers seek to actively collaborate in order to make the best use of the resources available.

If we take even the place-based arrangements, the ones within an ICS where general practice is guaranteed a seat at the table via PCNs, then there will be representatives from acute, community, mental health, social care, the voluntary sector alongside general practice.

The first and most obvious question is whether general practice can provide a unified voice within this arena.  I discussed this in more detail recently, and the need for PCNs to find ways of establishing a single voice.  But this is not the only challenge.

The potentially greater challenge is whether general practice can be proactive in the discussions, or even lead them.  Can general practice come to the ICS table and drive the agenda?  Can the strategic direction be set by general practice, so that meeting the needs of the population that general practice often understands best is prioritised?  Or will the discussions be driven by the large providers such as the acute trusts, demanding to know how primary care is going to support a reduction in attendances at A&E, or help tackle the backlog of outpatient attendances?

The problem is that in recent times general practice has become mostly reactive.  The way that general practice operates is by being offered things e.g. changes to the national contract, national Enhanced Services like the PCN DES, or local enhanced services, and then responding to these offers.  It reacts to the proposals that are put in front of it.

Alongside this reactivity there is very commonly a learned local helplessness.  Most practices feel too small to be listened to, that their voice is not heard, and that no one understands the pressure they are under or what life is really like in general practice.  They do not feel able to influence the system, only able to react to the demands or requests that are made of them.

To some extent this is due to the national GP contract.  Any one of the 7,000+ individual GP practices is too distant from the negotiation of that contract to really feel able to influence it.  As it forms the largest part of general practice income the national contract provides security, but the price of this is a sense of local powerlessness.

None of this helps general practice if it wants to be influential and proactive within local ICSs.  For local general practice to be influential it needs to not only have a collective voice, but be able to proactively flex its offering into the local system.  “Collective voice” has to mean more than an ability to react collectively, it has to mean operate effectively together to come up with and drive changes across itself as well as the rest of the system.

How realistic is this?  There will undoubtedly be those who are at the head of the curve who are proactively thinking this through and working out a way to do it.  But for the majority at present this seems out of reach, and without strong local leadership it seems unlikely general practice will be able to play a role proactively shaping the direction of local ICSs.