The biggest challenge to general practice operating effectively within an integrated care system is gaining alignment across all of the general practice organisations (practices, PCNs, federations and GP providers and LMC).  As previously outlined, the first step is to create a local GP leadership group.  But what decisions can that group actually take?

The challenge such a group faces is that it has no formal authority.  If one PCN decides it doesn’t agree with a decision made by the group, and is going to plough its own furrow rather than toe the corporate line, what ability does the group have to enforce its decision?  Very little, because attendance and participation in the group is voluntary.

General practice’s ability to operate collectively is what will give it authority within an Integrated Care System (ICS).  If general practice signs up to a course of action through its leadership group but then a large proportion of the practices take a different course that authority will quickly slip away. Or if the federation or one of the PCNs is having side conversations this will undermine the leadership group and its value will be rapidly diminished.

What can general practice leaders do to build the authority such a group requires?

A common mistake at this point is to start by trying to create governance structures to establish this authority.  The thinking is that a hierarchy will enable the leadership to enforce its decisions, in a way that cannot be done with a voluntary group.  But the reality is that even within a governance structure PCNs or GP provider organisations will still go rogue if they are unhappy. A governance structure will just paper over pre-existing cracks, and while it may be a helpful end point once ways of working have been established it certainly is not the place to start.

However, there are two key actions that GP leadership groups can take.  The first is to ensure that decisions are made by consensus.

GPs, more than any other professional group that I have worked with, love a vote.  There is something clean about making a decision based on the democratic ideals of one person one vote.  The problem with a vote is that it creates winners and losers, and it is the losers that are prone to taking matters into their own hands and working against the group decision.

There is also a laziness around voting, because it often (not always) means that not enough time and energy has been put into creating a solution or a way forward that everyone is happy with.  Independent general practice organisations working together in one leadership group requires a commitment by all to working though issues until a solution that everyone can sign up to is found.  Whilst this is hard and time consuming, it is the only way the group can make effective collective decisions that everyone will stand by.

The second action is to create a golden thread from the leadership group through to the practices.  If core general practice has no idea that the leadership group exists or what its function is, it will struggle to have any real collective mandate.  Conversely, if each practice has a very clear sense of what the leadership group is, how it works, and why it is important, then the challenge for the leaders of groups sitting in between practices and the leadership group (individual PCNs, federations etc) of having to explain why certain decisions have been taken is significantly reduced.

This second action is also difficult.  It requires a level of over-communication that GP leaders have not historically been good at.  The general rule is that if you think you have communicated twice as much as you need to, you are probably just about hitting the minimum amount needed.  A direct connection and visibility between those leading the collective group and individual practices is required.  The group and its function must be simple to explain (one of the reasons CCGs struggled was because they could never really explain themselves in sufficiently simple and relevant terms to practices) and have buy in from the front line of general practice.

Establishing a mandate and an authority for the leadership group is probably the biggest challenge of all for general practice as it seeks to exert influence within an integrated care system.  But even though it is difficult, the good news is the ability to make it happen lies solely within the control of general practice itself.