One of the questions that is often not explicitly answered is that of why care needs to be delivered outside of hospital, and why we are trying to effect with this so-called “left shift” from secondary to primary and community care.  In the past, lack of clarity as to what constitutes success has caused huge problems with sustaining any efforts to make this happen.

The challenge is essentially an expectation from some that success is achieved when system savings are made.  This is based on the assumption that it is cheaper to deliver care in community settings rather than in hospitals, and therefore shifting care will result in lower levels of system expenditure.

The big problem with this in practice is that whatever care is delivered in the community is always in addition to the work carried out in hospitals.  The size of the waiting lists and (necessary) tolerances for admission based on bed availability means there is no way that carrying out work in the community will actually reduce hospital activity.  Hospital activity is more a function of hospital capacity than of demand, because the demand exceeds the available capacity.

As a result, initiatives that have been put in place get stuck in analyses of individual patients or cohorts of patients to prove lower hospital utilisation to demonstrate the value of the work.  This is ultimately futile because even demonstrating a reduction in expenditure at a patient cohort level does not produce an overall saving as there is no commensurate reduction in acute activity.  If the measure of success is short term system savings then shifting care out of hospital will inevitably fail.

Sometimes the aim (explicit or implicit) is not financial but to reduce the strain on hospitals by shifting routine work to local providers so that they can focus on the acute and complex cases.  Unfortunately, taking away the relatively straightforward work and leaving only the more acute and complex cases actually increases the strain on acutes.  It increases the pressure on staff as there is no balance between routine and complex work, and at the same time can create financial difficulties as often income generating procedures are replaced by loss-making ones.

So in the NHS world of increasing financial and workload pressure it is easy to understand why shifting care out of hospital has never actually happened.  But that is not to say it should not.

There are real benefits that this left shift of activity can realise.  Outcomes for patients can be improved by delivering care outside of hospitals, through offering greater continuity of care in community settings, through enhanced or proactive chronic disease management.  Care delivered in local communities is more accessible, convenient and personalised, which all contribute to improved outcomes for an important cohort of patients who otherwise will place increasing demands on the NHS in the future as their conditions worsen.

Ultimately, delivering care outside of hospital now can prevent the health needs of patients becoming greater in future, creating a more sustainable NHS.

But to have a chance of success, we need to be clear that this is the aim of shifting care from hospitals to the community.  It won’t save money within the financial year.  It won’t reduce short term pressure in hospitals.  It will require additional community capacity and it is a medium to long term investment in improving outcomes.  The explicit (and implicit) measures of success need to reflect this, so that expectations are managed accordingly.  If they are not, we will stay in the same cycle of failure that we have been in for at least the last 20 years.

This is one of those questions that you feel like you really ought to know the answer to, but I am finding it very difficult to pin down exactly what an integrated neighbourhood team is.

All of the presentations I have seen about integrated neighbourhood teams outline their aims rather than what they are.  I find this unhelpful because while it might describe the problem they are trying to solve it does not actually help me understand what they are.  What I am trying to understand is who is in the team? Who leads the team? Who does the team report to?  Who sets the work programme for the team? Where does the funding for the team come from? What is its relationship to the PCN?  These are the questions I struggle to get answers to.

Even the aims of these teams seem to vary somewhat, with (for example) some places claiming they will improve access to primary and community care for local citizens and others stating they will keep people well and out of hospital.  If each area is coming up with its own definition of what they will achieve it already seems highly unlikely that what they are will be consistent across the country.

Maybe the place to start is the Fuller Report where they were first introduced, as the “heart of the new vision for integrating primary care” (p6).  Despite their proposed importance, the report does not explicitly define what an integrated neighbourhood team is.  The closest it gets is stating that in neighbourhoods of 30-50,000 “teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities.”

I am not sure that clears it up for me.  I remain uncertain whether an integrated care team is a concept that is designed for local interpretation (and so will result in a whole range of different manifestations) or whether it is something more tangible that at some point in the future we will all be able to look at and immediately recognise as being an integrated neighbourhood team.  If it is the former surely that should be explicit, and surely each ICS would then be clearer on its own definition.

Here is what I am most uncertain about.  Are integrated neighbourhood teams supposed to take on the whole gamut of services that each of the member teams carry out?  So by that I mean if we are bringing primary care, social care, community care (etc) together does that mean we are bringing all of the work they do together (i.e. those services in totality)?  Or does it mean we are bringing work on the edges of each of their core functions together where there is overlap between them (e.g. individuals with multiple long term conditions, requiring community services, with social care needs)?

If the answer is the latter (and I remain unconvinced that there is consistency on this across ICSs) then it means the work of these teams is in addition to existing work.  We have the core work that each team is doing, and now we have the additional ‘joined-up’ work that is the remit of this new integrated neighbourhood team.  I understand the principle that by doing this additional joined up work together the overall work in the system may fall, e.g. less exacerbations of long term conditions, but there is no immediate reduction in the core function of the participating members of these new teams.

This would mean that the work in integrated neighbourhood teams is in addition to the day job for team members.  But what I haven’t seen is any significant funding streams for these new teams, so what am I missing?  Are PCNs the existing significant funding stream?  Is this what “evolving” PCNs into integrated neighbourhood teams means?

Integrated neighbourhood teams still feel conceptual rather than tangible to me.  Whilst at a national level I understand the desire to stimulate rather than stifle local innovation and therefore why you might start with something conceptual, what I don’t understand is the reticence to define what they actually are at a local level.  It feels like what integrated neighbourhood teams are and how they work will be a big deal for general practice in the future, and so it seems entirely reasonable that at this point we should be pushing for much clearer local definitions.

One of the questions I am most regularly asked is why I am so supportive of the independent contractor model of general practice.  Wouldn’t life be easier and simpler for GP partners if they were free to operate as clinicians, without the almost full time distraction of trying to run a small business?

For many the grass does look particularly green on the other side of the fence, where GPs as part of NHS organisations could work reasonable hours, take annual and sick leave like any other employee, and be free from all the stresses of income, cash, staff, property, and unreasonable partners.  Life looks like it would be so much simpler.

Why, then, do we prize the independent contractor model so highly?  Well, as with any situation where we are looking to move away from problems instead of towards something we want, life on the other side will always contain its own set of (albeit different) problems.

Peter Muchie summed it up really well when he described his own experience of making this transition,

“And then I surrendered my independent contractor status to become a salaried employee with an NHS out-of-hours service. To me this now equates to a surrender of power and the right to self-determination. I can no longer organise my work to best meet competing demands. I can no longer negotiate with equal partners, but must accept the impositions of a cost-cutting management which seems to work toward the lowest common denominator. I can no longer decide what to accept and reject…

I no longer have total freedom to develop my skills according to personal interest or to best meet the demands I perceive. I must instead undertake ordained ‘mandatory’ training on such delights as information governance, and diversity in the workplace. This is boring, irrelevant, and time-consuming, the main purpose appearing to be to protect the monolith for which I work, not to improve the care I give.

When I identify a real opportunity for workplace improvement I have no real power to address it. I pass it up a non-responsive bureaucratic chain to a distant and removed manager, focused on budgets and generalities. My concern is either ignored or cursorily acknowledged and placed at the bottom of a list of priorities with cost cutting, and not service improvement, at the top.” Peter Muchie, BJGP Should General Practice Give Up the Independent Contractor Status 2015.

It is easy to think that we would just turn up for work, see the patients we were asked to and then leave at the appointed hour.  But what we miss is how soul destroying this lack of autonomy will feel, how frustrating the constant interference of a middle manager with a corporate agenda and no insight into the needs of our population will be, and how being at the receiving end of decisions made at an organisational level many layers away will make us want to scream.

The independent contractor model offers freedom for practices to choose how they operate, to flexibly adapt to meet the needs of the patients they serve, and to respond quickly to any new situation that arises and requires action.  This has been a key strength of general practice, one that is not well understood, but one that would be lost if the model was replaced.  It not only enables practices to adapt and thrive in even the most testing circumstances, but also provides partners that Maslowian need for self-determination that a salaried model would take away forever.

General practice is currently being swept along on a tide of change, all based on the premise that what we need is ‘integrated primary care’.  But what is integrated primary care, and is it really what we need?

Despite the status of the Fuller Report not being clear when it was first published over a year ago, it is now being treated as the policy document for general practice.  If you ask anyone working in the system what the plan is for general practice they will say it is to implement the recommendations of the Fuller Report.  But when you read the Fuller Report it is a wordy document that is light on analysis and heavy on pushing ideas, with little clarity on how these new ideas will make things any better.

At the heart of all this lies the idea of integration.  We have moved away from the internal market and now have integrated care systems.  The four stated aims of this new system are to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development.  Having reiterated these aims Fuller states,

“The ICS CEOs believe that achieving these aims will only be possible if we support and develop a thriving integrated primary care system” p4.

And that is the only rationale that is given.  Primary care needs to be integrated because ICS CEOs believe that is what is needed, and this apparently should be enough because no other justification is given throughout the whole document.  All the NHS CEOs even put their signatures to the report, an act Fuller describes as, “an extraordinary and welcome display of common purpose across health and care” p3.

But could it be that the enthusiasm of the NHS CEOs for this report comes not from a passionate belief in unlocking the power of local communities, but rather because it would increase the span of their direct control to include primary care?  NHS CEOs do not like primary care because the independent contractor status prevents them being able to tell it what to do, so it is not surprising they are all in favour of any move to give them more control over it.  This hardly feels like a sound justification for making such major changes.

A key problem is that nowhere is ‘integrated primary care’ defined.  Without definitions we are in trouble because what I think it means, what you think it means, what Claire Fuller thinks it means, what the 42 NHS CEOs who signed the document think it means, and what the government think it means are all likely to be very different.

Does it mean primary care working effectively in partnership with local health, social care and voluntary sector colleagues in local neighbourhoods?  Does it mean general practice becoming a formal part of the NHS?  Does it mean GP practices becoming part of existing NHS organisations?  We know that this whole range of views already exists.

I am actually a fan of integration, where it means all health and social care providers working more closely together.  It makes sense.  But the notion of “integrated primary care” is actually very dangerous, because it is so nebulous.  It is behind the calls for the nationalisation of general practice, and the end of the independent contractor model.  It is an enabler for centralist CEOs who want to expand their empires.  It is also creating a system blindness to the challenges being faced at an individual practice level.

So what do we do?  In local conversations push for clarity as to what is trying to be achieved and how will we know that we have got there, before getting into the details of actions.  “Implementing Fuller” should not be an end in itself.  If we are implementing an integrated neighbourhood team then what success measures are we using?  What outcomes will it achieve?  Simply ticking the box that we have one does not constitute success.

Challenge the idea of integrated primary care when it is used without clarity of meaning, and push for a local definition that everyone can sign up to.  General practice can support integration, but it mustn’t come at the cost of the service itself.

A common challenge that many areas are having is working out who should be on the local leadership group for general practice.  A specific question is whether this should include the (often newly appointed) system clinical leads, especially where they are GPs.  So, should they be included?

To answer this question we need to go back to our understanding of what an Integrated Care System (ICS) is.  As I am sure you know, an ICS is the new NHS infrastructure that aims to bring together providers from all areas including (but not limited to) primary care, secondary care, community care, mental health, social care and the voluntary sector, so that they can collectively agree how care is organised and how resources are deployed.

This is different from the previous system of Clinical Commissioning Groups (CCGs).  In this (old) system the CCG as a commissioning organisation, with a membership of all the local GP practices, was tasked with deciding how care should be organised and how resources deployed on behalf of the local population.

In the new system there is no commissioning organisation, and no special place for general practice.  General practice is simply one of the number of providers that have to work together to agree on how care should be organised and resources deployed.

The problem that general practice now faces is that the single membership organisation that could speak on its behalf into these system discussions (the CCG) no longer exists.  General practice is multiple individual organisations, along with a set of at scale organisations including PCNs, LMCs, and (in some places) federations, and so is left at something of a disadvantage when it comes to system discussions.  While the other organisations in an area are generally single entities with a clear leadership structure, such as the local hospital, general practice (and therefore its voice) is much more dispersed.

As a result general practice in many areas is creating a local general practice leadership group.  The role of this group is to provide a united general practice voice into these system discussions.

At the same time the ICS is working to find ways of bringing the different provider organisations together and organise pathways of care across these organisations.  To this end the system is appointing pathway leads (for areas such as planned care, urgent care, long term conditions etc etc) along with clinical leads for these areas.

These clinical lead roles could be taken on by any type of clinician from any type of provider organisation.  But of course the clinicians with the most recent experience of this type of work are GPs, particularly those who worked in CCGs.  So in many places we find that there are quite a number of GPs who have been appointed into these new system clinical lead roles.

While historically these same individuals may have been able to operate as system clinical leads on behalf of the commissioning organisation owned by GP practices (and so have a link into some form of leadership role for general practice), but now this is no longer the case.  The system clinical leads have to operate on behalf of the system as a whole, and not on behalf of one single provider part of the system (such as general practice).

There is a clear difference, then, between the GPs on the local general practice leadership group, working to ensure the voice of general practice is heard in the system, and the system clinical leads (even if they are GPs) who are working on behalf of all providers within the system.  When it comes to working in the best interests of general practice the system clinical leads are necessarily conflicted and should not be core members of the group.

There is of course a value to general practice of having GPs as system clinical leads.  It can be valuable for these leads to attend the GP Leadership group meetings to ensure the group understand the work that is being carried out, how partnership work is progressing and the context in which they are operating.

But this is different from them being core members determining the actions general practice should take as it seeks to partner effectively with the rest of the system.  This should be limited to those who operate on behalf of their practices, i.e. the PCN, LMC and federation leaders.

One of the key questions facing all practices is how much effort they should expend in collaborative working through their PCN, and how much they should strive to retain their independence and own way of doing things.  But the choice between the two is not as binary as it at first appears.

This Harvard Business Review article maintains that all work relationships fall into one of five categories:

1. Collaboration (allies) – Merging self-interests with the interests of others
2. Cooperation (friends) – Maintaining self-interests while also advancing joint interests
3. Maximum possible independence (neighbours) – acting to neutralise the impact of others on self-interests
4. Competition (rivals) – working to deter another in order to protect or advance self-interests
5. Conflict (enemies) – trying to defeat or deny another’s interest

There are some important distinctions between these relationships.  Collaboration involves parties investing in the relationships to help each other.  The benefits of these relationships are the greatest for GP practices, because it means the maximum value can be derived from shared assets, such as ARRS staff and back office teams.  It means practices can potentially realise benefits beyond those that come simply from accessing PCN resources.  The drawback is that these relationships are hard to disengage from should interests change.

Cooperation is a step down from collaboration, where practices choose to work together on specific issues where interests (e.g. availability of PCN funding) align, but simply not to compete where they don’t.  This limits any potential benefits of joint working to those that come from (in our case) PCNs but nothing more.  Should PCNs end then there will still be things that need to be unravelled, but nothing too problematic.

Neighbours is where what practices are actually trying to do is maintain the maximum possible independence.  Practices deliberately reduce their reliance on others as much as they can.  This is where practices want control of their own ARRS staff, and don’t want them grouped into functioning PCN teams.  It limits the benefits that can be derived from PCN resources, but maintains practice independence.

It seems to me that in the vast majority of places now the challenges facing general practice have reached the point where practices no longer feel in competition or even in conflict with each other.  Maybe we sometimes still see it when APMS providers arrive on the patch, but other than that practices generally recognise that practices are in this together, and there is little value in making things even harder by fighting with each other.

The problem many PCNs face is that different practices within the PCN are at different places on this spectrum.  While some may be up for full collaboration, others are striving to maintain their independence.  It is very difficult for a PCN to be effective when what some of the practices are doing is rebuffing any attempts at cooperation, let alone collaboration.

What is needed is to try and get all the practices to agree on the same approach.

The critical point to understand here is that the independence question for GP practices is inextricably linked to the question of sustainability.  If a practice is not sustainable, ultimately it will lose its independence, at the point at which it is either forced to close or is taken over by another provider.  The best chance a practice has of being sustainable into the medium term is by collaborating with other practices, and making the most of the scarce resources that are available to practices.

While it feels counter-intuitive for practices, not to mention risky, the best way to maintain their independence is through collaboration.  For those leading PCNs and joint working initiatives across practices the starting point has to be building a shared understanding this is true, along with the trust needed to mitigate the risk.  How will the practice survive for the next 5 years? How will it navigate the challenges we know are coming down the line, on top of the rising demand and falling GP workforce?  How will it be able to maintain its independence within this context?  What role can the PCN and collaboration play in answering these questions?

Building a shared understanding that collaborative working is the key to maintaining individual practice independence, rather than a fast-track to losing it, is the starting point for successful PCN working.

In many areas the Integrated Care System has set up a Primary Care Leadership group.  These groups are purportedly to discuss and decide all things primary care, and include membership from PCNs and federations, along in many places with leaders from pharmacy, optometry and dentistry.  The problem with these groups is that they simply do not work.

Often these groups are chaired by senior GPs from with the ICS, and on paper have many of the people that you think would need to be there in order for it to act as a leadership group.  But that is not how they function, and in no way can they be described as providing leadership to primary care.

This will not be a surprising analysis for those who have attended such groups.  If the roots and tentacles of these meetings go up into the system, rather than down into front line primary care, it is not a surprise that those on the front line feel zero investment in any decisions that these groups make.

Where does the ownership of these meetings sit?  If it is sitting within the system it is not sitting within frontline primary care.  These groups end up as simply a meeting that certain PCN CDs and GP leaders attend once a month, with no actual leadership functionality.

The underpinning issue for general practice is that both its leaders and the system are struggling with its transition from commissioner to provider.

As a commissioner general practice had a clear leadership voice at the system table, where its role was to speak on behalf of the practice populations it serves.  It has done this in various guises for over 30 years, ever since the purchaser provider split was introduced, along with the notion of a primary care led NHS.

But the new model of care is different.  In an Integrated Care System each provider is responsible for working together to improve outcomes for the local populations.  Outcomes are no longer the sole preserve of primary care.  All providers need to work out how they can contribute in partnership with others to improving these outcomes.

For general practice this means it is now a partner as a provider, not as a commissioner.  As a provider its leaders cannot operate under the statutory authority that commissioning groups (in any of their guises) provided for them.  Instead its leaders have to connect directly with front line practices, work with them, engage with them, and act on their behalf in order to be able to carry out their role as a leader of general practice who can work in partnership with other providers.

System primary care leadership groups miss out this critical step, because they are still operating in the old paradigm of GP leaders having some sort of system-imbued power over their practices, when the reality is they do not.  Any primary care leadership group that is built top down rather than bottom up will not be effective in the new system, because it is built on sand.

Instead, a general practice leadership group requires the authority, support and mandate of its member practices.  It needs to be a group that connects directly with its front line teams.  It must have a focus on what general practice needs to survive and thrive in the new system, how its role in the system can practically be developed, and how its resilience an be strengthened.  It needs to be recognised by practices and have its roots and tentacles firmly within the practices. Only then can it operate as a leadership group that will add value to the system.

Integrated Care Systems (ICSs) require general practice to work together as a collective, if it wants to hold any kind of direct influence.  In recent weeks I have written about the need to form a single local leadership group for general practice, set priorities, put a single point of access in place, create a representation process, and establish a mandate from practices.  But to be effective all of these require something else.

Local general practice cannot realistically operate as a system partner if it takes the form of a meeting that happens once a week or once a fortnight.  There needs to be some form of dedicated executive capacity that can (amongst other things):

• Set the agenda for leadership group meetings and ensure actions are carried out
• Act as the single point of access
• Drive the process required to set local priorities
• Coordinate the representation of general practice at key meetings
• Ensure effective communication with both practices and the system takes place

If the collective use of the shared general practice leadership team is to be optimised, then a dedicated smaller team is needed to make sure this happens and enact all of the things above.  Just as the Board of any organisation cannot function effectively without an executive, the same is true of general practice.

The key questions this presents are where will this capacity come from and will it carry the trust and support of general practice more widely.  These are not easy questions, and the answers will inevitably vary according to local circumstances.

There are two types of additional capacity required.  There is additional clinical leadership capacity, and dedicated management capacity.  I have seen the clinical leadership capacity take a number of forms, but most commonly it is a small group consisting of the LMC Chair, federation lead and a lead PCN CD.  What these have had in common is that these individuals have been able to use funding/time from their existing roles to avoid the need for the establishment of the executive creating an additional cost for general practice.  The last thing general practice needs right now is an additional overhead.  Instead those leaders choose to make this executive work a key part of their existing role.

Dedicated management capacity is harder to come by.  If an area is in the fortunate position of having a federation that sees its role as evolving to support local general practice, then the federation management support may be able to step in and provide this.  However, I suspect this limits the number such areas to less than a handful!

Some places use the system primary care lead (i.e. the person who used to be the CCG primary care lead), but this requires that individual to have a good relationship with, and be trusted by, wider general practice.  In some areas the PCNs have sought funding from the system to have a shared senior manager, who is then able to act into this role.  Bear in mind it is in the system’s interest for primary care to self-organise and so in the absence of any obvious local contenders it is worth seeking financial support from the system to find someone.

The other problem with establishing an executive function is that it concentrates power into the hands of a much smaller group of people.  It is very difficult to bring a multitude of general practice organisations together (practices, PCNs, federations, LMC etc), and I have written previously about the challenge of any leadership group establishing a mandate to make decisions.  This becomes even more difficult for a small executive group which contains less direct representation from all parties.

The key here is making sure that the delegated powers of the executive from the leadership group are clearly defined, and are reviewed and developed over time.  The authority of the executive, and its ability to act, comes via the leadership group.  It needs to ensure there are sufficient feedback mechanisms, and clarity on the decisions it can and cannot take on behalf of the leadership group.

Ultimately, putting such an executive in place will be key to how successful general practice is as it attempts to operate as a partner alongside the trusts within the integrated care system.  It is not without its challenges, but having it will ensure the proactive leadership that general practice requires is in place.

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.

Effective joint working is the key to successful general practice.  It may be joint working between the partners in a practice, joint working between the practices in a PCN, or joint working between the PCNs in an area.  Joint working is difficult, and where it is not effective individuals, practices and general practice as a whole all suffer.

The most important metric for joint working is trust.  How much do I trust my partners/the other practices/the other PCNs?  Where my trust is low I assume the intentions of others are poor, I avoid interaction where I can, and I am unwilling to be helpful because I do not believe there would be any reciprocation.  Life in a low trust environment is generally tense, unpleasant and often draining.

I spend much of my time supporting joint working within general practice.  Here are 5 steps that I have found to be extremely helpful in shifting from a low to higher trust environment:

1. Stop communicating primarily by email. One clear indicator of poor relationships is where the majority of the communication takes place by email.  The problem with email is that it is one way and open to misinterpretation.  You are not there to correct any misunderstandings when the email is being read.

2. Communicate by talking at least once a week. It is far better to have a short conversation of 20-30 minutes once a week than to have a (poorly attended) monthly meeting interspersed by heavy amounts of email communication.  Simply shifting the mode of communication from email to conversation in this way can have a huge impact.  It shows respect (people feel more valued when they are told things in person rather than by email), and allows questions and concerns to be answered and dealt with straight away, as well as preventing misunderstandings from festering.

3. Communicate in person. Whilst there has been a huge time and convenience benefit to meeting and talking online, it is very difficult to develop and improve relationships in a virtual space.  It is too easy for individuals to simply disengage from the conversation (how often are we in meetings where the majority of people have their cameras off and are on mute?), rather than have their concerns noted and dealt with.  Online it is difficult to spend enough time understanding and valuing each other as people, as without shared coffee breaks or pre-meeting chat we focus only on the business.

I worked recently with a PCN that shift from monthly virtual meetings and email as the primary communication route, to weekly half hour virtual meetings and a monthly face to face meeting with far less reliance on emails.  The impact on relationships across the PCN was transformational.  Trust that had become low was restored.  There was a shared confidence in a new sense of transparency, and a new willingness to take actions together as a group of practices.

4. Show vulnerability. The counterintuitive thing about building trust is that you build more trust by sharing your weaknesses than your strengths, and asking for help builds more trust than offering to help.  If I ask you for help I show that I respect you, that I believe you have strengths that I do not have and that I trust you enough to show you my weakness.  Conversely if I offer to help you I reinforce your belief that I think I am better than you, that I have no sense of my own weaknesses, and even that I may have a secret agenda to take you over – however well-intentioned the offer may be.
5. Admit when you are wrong. We all make mistakes.  Sometimes we are convinced that a course of action is the right one to take, but with hindsight we can see the error of our ways.  But it makes a huge difference to other people if we are prepared to put our hands up and say we are sorry when we have made a mistake.

I worked with one federation who had a difficult relationship with some of the PCNs in its area.  But this all suddenly changed when in one meeting the federation acknowledged that it had made mistakes in the past, said sorry for the impact of those mistakes, and asked what it could do to put them right.  Almost immediately the relationships were changed and moved to a much more positive place.

While it is generally true that trust can be hard to gain and is easy to lose, my experience has been that by starting with a good intent and taking the right actions in line with these 5 steps trust can be rebuilt surprisingly quickly.

The world is moving quickly and the need to take a step back and consider how everything fits together is becoming more and more frequent.  For GP federations the move into Integrated Care Systems (ICSs) is creating one of these moments.

Historically GP federations have been set up in local areas often by a relatively small number of enthusiastic GPs.  They generally began with high expectations, and then over time relationships with member practices have waxed and waned, particularly as it has been challenging for federations to fulfil the delivery requirements needed to establish themselves as a provider and at the same time carry out the amount of communication necessary for practices to feel engaged and part of the organisation.

Then along came PCNs.  Up until that point it had been easy for federations to describe themselves as the ‘at-scale’ arm of general practice, as there were only individual practices and the federation.  But with PCNs came a mandated at-scale operation of general practice in every local area.  Now there are practices, PCNs and a federation, and it has made it more difficult for federations to articulate their role in the system.

The preference has generally been to describe themselves as the at-scale provider across any given area, as their remit tends to mirror old CCG areas and hence be larger than nearly all individual PCNs.  The mainstay of many federations has been the delivery of extended access, and recently federations and PCNs have been undertaking a round of relatively strained conversations to agree what the federation will do and what PCNs will do, now that responsibility for the service has shifted to PCNs.

But it is the emergence of ICSs that is bringing things to a head.  General practice needs to be able to operate as a collective entity within an ICS “place” area.  Within such an area there is often a number of PCNs, an LMC and (if one exists) a federation.  The question is whether, in such an environment, a federation can stand alone as a GP provider organisation, separate from core general practice?

This is problematic because the system wants to do business with general practice as a whole (not a limited company that can access GPs to deliver services).  Whereas in the past federations could point to their practice membership as a proxy for working across all practices, with PCNs in place this is no longer the case as they have a much clearer practice membership.  Federations were never really set up as a way of other organisations being able to do business with general practice, so now federations have a problem.

The most obvious way forward would seem to be to strengthen the federation/PCN relationship.  If federations can be the glue that holds PCNs together they would be perfectly placed to continue to provide at-scale services, provide support for PCNs and practices, and by including the LMC could start to be able to talk with authority in the system as local general practice.

But while some federations have been bolder in taking steps towards taking on the provision of support for PCNs as a new part of its core business, many have shied away from this (often because of emerging PCN/federation tensions, and because of the costs involved).  While PCNs are funded by the PCN DES, federations rely on funding from the delivery of services.  The need to breakeven/fund the federation infrastructure and even generate a return for shareholders has often created a tension in terms of what federations have been willing or able to do in terms of support for PCNs.

The irony is that federations are highly unlikely to be able to generate any kind of sustainable financial return if they maintain their separation from PCNs.  They will increasingly rely on the PCNs for the work (like extended access), and if federations are not the support provider for PCNs then whoever takes this on will end up being better placed to take on any at-scale work.

Without the protection of CCGs the ICSs are not going to tolerate small-scale provider organisations with no real remit.  If federations are not providing the scaled up support the new integrated neighbourhood teams are going to require, and don’t become the organisation that holds general practice together in an area, it is hard to see how they will survive beyond the next few years.

GPs have not been overly enamoured with CCGs.  It was not long after their inception in 2013 that the promises of GP control of the funding fell flat, and that they were subsumed within the tentacles of the all-encompassing NHS system.  Now they are so far removed from any individual practice that the membership model sold to general practice 10 years ago is barely recognisable.  But in only a few years’ time GP practices may well be reminiscing fondly about the days of CCGs.

This is primarily because the system replacing CCGs contains no obvious place for general practice.  Integrated Care Systems (ICSs) are more than just the latest incarnation of the NHS.  They represent the first shift away from the purchaser provider split that has been at the heart of the NHS since 1990.  Whatever our views on the internal market, it was always accompanied by an underpinning philosophy of creating a primary care led NHS.

ICSs mark the end of any notion of a primary care led NHS.

The internal market was first introduced in 1990 via the National Health Service and Community Care Act.  The very same act introduced GP Fundholding.  Since then we have had over 30 years of different versions of trying to create a purchaser provider split where primary care held the purse strings: Primary Care Groups; Primary Care Trusts; Practice Based Commissioning; and, in what was the last throw of the dice, CCGs.

It is not just CCGs that are going, it is the whole notion of an internal market, and the concept of a primary care led NHS.  Instead, the new system is supposed to be based on partnerships, on providers working together to agree how to distribute resources to deliver the best outcomes for patients.

In this system there is little to no incentive for anyone to find a seat for general practice at the leadership table.  The less people around the table, the easier it is to reach agreement.  Hospitals are merging and creating “hospital chains” so that they will essentially be one hospital per ICS.  There is also roughly one community trust and one mental health trust per ICS.  And even then sometimes these organisations are merged.  In all likelihood the bigger you are, the more say you will have in these “partnership” discussions.

By contrast, at 42 ICSs we are looking at c170 practices per ICS, plus c30 PCNs, and maybe a couple of LMCs and federations, so somewhere in the region of 200 general practice organisations per ICS, all with little or no track record of being able to operate collectively.  In a system where bigger is better and less is more, general practice is not in good shape.

The consequences of this will be real for general practice.  Systems are under real pressure to break even, and the “do whatever is necessary, whatever it costs” pandemic mentality has already disappeared.  In this environment, if an ICS has three different levels of funding for general practice across three areas expect it to level down not level up.  Once CCGs are gone, who will be left to argue the general practice corner?  Are we going to pin all our hopes on the GP representative on the ICS Board?

Ultimately the loss of CCGs is going to leave general practice exposed, with little or no voice in important system discussions.  Local general practice needs to be working hard right now to mitigate this risk.  The government’s answer seems to be to nationalise general practice and put it under the control of one of the local trusts.  We are waiting to see what the Fuller Review recommends.  It would be better if local general practice could take advantage of the window of opportunity that is left to organise itself as a force to be reckoned with, because at least then it will be controlling its own destiny.  In this article for PCN Pulse I outline the steps general practice can be taking now to make this happen.

The most significant additional investment into general practice at present comes via the PCN DES, and the much of that arrives in the form of the ARRS.  We are three years into the five year deal, which means there are only two years left of significant growth of this funding.  Further similar increases in future seem unlikely.  How can practices make the most of this additional resource?

The scale of the opportunity remains relatively high.  Most PCNs have not yet spent their full allowance to date, and some of last year’s expenditure was often used for the vaccination programme rather than being deployed recurrently.  This means that many PCNs have getting on for £1M available to invest in new roles over the next two years.

There are three things that practices can do to make more of the opportunity of the ARRS.  The first is to think differently about the roles that are needed.  To date the process of identifying which roles to employ has often consisted of looking at the list of available roles and choosing the ones that the practices most liked the sound of.  But continuing to do this is likely to mean practices will fail to make the most of the opportunity this funding presents.

We know that general practice workload will continue to increase. Demand from the local population will continue to go up, and the advent of ICSs is likely to accelerate the shift of activity from secondary to primary care.  At the same time, the number of GPs continues to fall, as despite the push for extra GPs the number leaving continues to exceed those entering the profession.

This means that for general practice to be resilient into the future the model has to change from one where all the activity coming into practices defaults to a GP, to one where the service is led by GPs but delivered by a much wider range of professionals.  This is the only way it will be sustainable.

What the ARRS provides is an opportunity to bring in the new roles that are needed and change the way general practice operates.  If practices spend some time working out what workforce they want in two years’ time, they can then use the opportunity of the ARRS to create a more fit for purpose workforce and employ the roles that will enable this vision to be realised.

The second is changing the approach to the PCN DES work.  At present the approach is generally that practice staff focus on practice work and PCN staff focus on PCN work, and only support practice work if they have any capacity left over.  As a result the additional roles feel like an additional burden on practices because of all the training and supervision that is required, and their time is sucked up meeting the increasingly onerous requirements of the PCN DES.

A better way to think about this is in terms of the totality of the workload (across practices and the PCN) and the totality of the workforce, i.e. how do we incorporate the ARRS staff to create a total workforce able to best support both the practice and PCN requirements.  By keeping such a strong division between practice and PCN work we are preventing ourselves from making the most of the workforce we do have.

The third is not to underestimate the need to invest in a change or redesign process to go alongside the introduction of the new roles.  Incorporating the new roles effectively means changing the way we operate.  If we don’t we are simply trying to plug holes in a sinking ship, rather than building ourselves a new boat.  But this of course requires additional investment and time, both of which are in short supply.

One way round this however is a creative use of the care coordinator role.  So if, for example, we are changing the way practices in a PCN manage prescriptions using pharmacists and pharmacy technicians, then we can use a care coordinator as a change resource to support the change of the prescription process.   Once they have done this they can then be a resource to support the change to the way MSK presentations are managed across practices using an ESP (etc etc).

The ARRS is an opportunity for practices to start to build a model that will be resilient into the future.  But it won’t happen automatically, and practices need to act now to make the most of it because in two years’ time it may well be too late.

I am spending some time working with a number of areas thinking through how to create and develop a strong, unified voice for general practice, that can be effective and influential within the new integrated care landscape.  It is a challenge that is harder than it sounds.

The problem comes because “general practice” in any given area generally consists of about 50 different, independent, autonomous organisations.  There are the 40 or so individual practices, 5 to 10 PCNs, maybe a federation, and the LMC.  How do you get 50 organisations to speak and act with one voice?

There is a framework that is quite helpful to consider in this context, called the Cynefin Framework.  Essentially it breaks problems down into different categories.  For our purposes what is helpful to understand is that there is a difference between simple, complicated and complex problems.

Simple is a problem that has a relatively straightforward solution, such as how do I lower my car window.  There is a specific, straightforward answer (press the right button).

Complicated is a problem that does have at least one solution, but which can be difficult to deliver.  An example that is commonly used is sending a rocket to the moon.  It is not a simple thing to do, and may well require multiple teams and specialised expertise.  But by really effective project planning, and using the experience of those who have done it before, it is possible to create a path to making it happen.

Complex problems are ones that are impervious to a reductionist approach that strips the problem (however complicated) down to its core components to work out the solution.  The example commonly used is raising a child.  There is no handbook because each child is unique.

For a complicated problem you can use a project planning Lewinian style approach to solving it.  But for a complex problem the approach needed is an emergent one, using trial and review (like PDSA cycles for you NHS improvement fans, or probe, sense and respond which Snowden, who introduced the Cynefin framework, uses).

This distinction is useful because in healthcare we commonly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches.  We look for business cases with defined outcomes as a default mechanism for moving forward, when this approach can only work for something that is simple or complicated, not for something complex.

Back to our problem.  How do we get 50 general practices organisations to operate as 1?  It is a complex problem.  There is no handbook, because everywhere is different.

That is not to say it is impossible.  What we can do, even operating in the domain of emergence, is understand what factors we need to build in order to give ourselves the best chance of success.  Two stand out.

The first is the need to build some capacity and capability at the collective general practice level.  If general practice is trying to operate as one then whatever forum or entity is trying to bring it all together needs to develop the ability to do a number of things.  It needs to be able to communicate with its 50 organisations.  It needs to be able to coordinate activities across those organisations.  It needs to be able to interact effectively with partner organisations.  These things don’t happen because the different parts of general practice simply meet together.  They need to put in place.

The second is the need to build trust.  Trust is the key ingredient.  If the 50 organisations don’t trust the 1, all is lost.  Here we get into the area of the prisoner’s dilemma, which explains why rational actors won’t cooperate even when it is in their best interest to do so.  Just because it makes sense for general practice to create a single unified voice it doesn’t mean they will do, and in fact without trust it is much more likely that they will not.

It is particularly challenging in general practice because we are all so instinctively independent.  That is why we have 50 different organisations in the first place.  We hate our independence and ability to act autonomously being in any way compromised.  We find working in PCNs difficult enough.  We instinctively pull away from any notion that we might get into scenarios where our practice or PCN has to act for the greater good rather than simply what is best for our practice or PCN.

As we move forward with the 50 to 1 challenge, our approach then needs to be an emergent one, i.e. one where we try things, see how they work, and then adjust accordingly.  We need to keep our eyes on the outcome (why are we doing this), and work hard to build trust and create some capacity and capability along the way.  It might make plan writers uncomfortable, but it is the way forward that will give us our best chance of success.

There is so much going on in general practice right now, and the workload pressure is so great, that it is easy to take a head down approach to everything that is going on outside the practice.  But the landscape around practices is shifting.  What do these changes mean for individual practices?

The big change is the introduction of Integrated Care Systems (ICSs).  This change is one that most practices are largely ignoring, but one that has significant implications for practices.

One of the reasons there is little interest shown by practices is because it is a change that is rarely clearly explained.  At its most simple the way the NHS is being organised will no longer be through a separation between purchasers (or commissioners) and providers.  Instead providers will directly work together to agree how care should be delivered, what the pathways should look like, and how the money should be spent.

In practical terms, CCGs will cease to exist from March next year, and they will be replaced by new NHS ICS bodies.  These role of these organisations is essentially to enable the joint working between providers that lies at the heart of the new system.  As a result all provider organisations are represented on the Boards of the new NHS ICS bodies.

ICSs will function on two levels.  There will be the whole-ICS level, where broader strategy decisions will be taken, but then also at local levels within the ICS area.  This local level is what is being referred to as the ‘place-based’ arrangements.  This will generally be the local area or borough that general practice has been part of for many years.

In most ICSs much of the decision making, including resource allocation, will be devolved to these local areas.  This will include funding for any local enhanced services/local incentive schemes for general practice.

At the heart of integrating care within a local area lies Primary Care Networks.  These were created not in splendid isolation from the rest of the system, but with the emerging ICS explicitly in mind.  The role of PCNs within the new system is to create seamless care for physical and mental health across primary and community care, to enable care to be delivered as close to home as possible, to create seamless pathways across primary and secondary care, to strengthen the focus on prevention and anticipatory care, and to support people to care for themselves.  The PCN is the core building block of the new integrated care system.

All of the work that PCNs have been asked to do so far (primarily via the PCN DES) has been with this in mind.  It underpins the specifications that have been developed within the PCN DES, and the indicators within the Investment and Impact Fund (IIF).

The asks and requirements so far on PCNs are only the beginning.  They will inevitably grow, and increasingly these will come from the local place-based Board of the new ICS (i.e. the one that sits at a local level), as opposed to nationally via the PCN DES.

When PCNs were announced as part of a 5 year contract for general practice in 2019 the funding split was as follows: £1bn extra to come via the core contract, £1.8bn to come into general practice via PCNs.  The more recent uplift in ARRS funds to cover 100% of salaries from 70% means the split in reality is more like £1bn to £2bn.  Most new general practice funding is already coming via PCNs.

But PCNs are only just getting started.  The ICSs do not become statutory bodies until April next year, when we will already be 3 years into the 5 year GP contract, with only 2 years remaining.  What will happen then?  Most (if not all) of the local enhanced service contracts from the ICS place-based board will come at a PCN not practice level.  The differential in funding growth after 2024 if anything is likely to be greater than from this 5 year agreement (i.e. the vast majority of resources coming into general practices will be via PCNs rather than via the core contract), because the foundation the whole new system is being built on is PCNs.

All of this means there are two really important things practices need to be doing now.  The first is to start treating the funding and resources the practice receives via the PCN as part of its core resource, and not as an optional extra separate from the ‘real’ business of the practice.  Investment into general practice is coming via PCNs, and so practices that try and sustain themselves into the medium term on core contract income alone are going to find life extremely difficult.  This may in turn have consequences for how practices choose to interact with their own PCN (a topic I will return to in a future blog).

The second is that practices must ensure that their PCN is directly engaged in the Board and leadership arrangements of the local-place based Board of the ICS.  I know the level of meeting requests in relation to the system and ICSs is bewildering at present, and can feel like a waste of time, but the one ICS meeting that PCNs must prioritise is this local place-based Board.  Each PCN has a seat on this Board to represent local general practice, and because this Board will have such a strong influence on how care is organised locally, and how resources are apportioned, it is critical PCNs take up this seat and do not leave it empty.

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.

Over the last 8 years a wealth of skills, knowledge and experience has built up within a relatively small group of GP leaders who took on Clinical Director roles within Clinical Commissioning Groups (CCGs).  Now that CCGs are coming to an end, what will happen to these Clinical Directors?

The first thing to say is that some CCG Clinical Directors have taken matters into their own hands and have taken on roles as PCN Clinical Directors, thus cementing their place in the new system.  But there are still a considerable number continuing to undertake their CCG roles whose places are less clear moving forward.

The context this sits in is the shift of the system as a whole from a commissioner provider split to one of integrated care systems (ICSs).  Within ICSs the different providers are expected to collaborate and work together to decide how care will be delivered and how resources will be deployed.  One of those providers is general practice.

Many of the functions of CCGs are transferring directly over to the new NHS ICS bodies.  It may well be that roles have or can be identified within these bodies for the GPs in CCG Clinical Director roles.  But the key question is whether general practice as a whole wants these GPs to be deployed providing clinical advice and leadership across the system within the ‘neutral’ NHS ICS bodies, or to be more squarely deployed as part of the leadership team of general practice?

Within CCGs GP Clinical Directors have an explicit remit as GP leaders within GP membership organisations responsible for the health of the whole population.  Within an NHS ICS body, it is less clear that any clinical leadership role should be filled by a GP.  They could just as legitimately be filled by clinicians from anywhere across the provider landscape.

If general practice is to genuinely operate as an equal partner with an equal voice within ICS discussions, it will need leaders who are able to develop strategy, think strategically, and operate politically.  These are exactly the skills that CCG CDs have been developing over the last 8 years, and are not skills that commonly exist amongst the provider-based GP clinical leadership teams.

The Consultant leadership within an acute trust is primarily deployed in medical and clinical director roles within the hospital.  It is only when these roles are filled that it will start to consider supporting system roles.  General practice is in danger of having this the other way round: making sure the system roles are filled before ensuring it has the internal leadership skills and expertise it needs.

History is, inevitably, getting in the way.  GPs who have undertaken CCG Clinical Director roles are sometimes perceived as being distant from core general practice, particularly when they may have been on the commissioner side of developing services and specifications that practices may not have been happy with.

Equally funding is a barrier.  CCG Clinical Directors were well remunerated for their time, and there is no obvious source of remuneration for GP leaders outside of the PCN Clinical Directors at present.

But general practice in every area needs to think through how it is going to be effective in the new world of ICSs.  CCG CDs are a hugely valuable resource for general practice, and the service as a whole would be well advised to consider how it can ensure that this resource is deployed where general practice needs it, rather than passively allowing the system to decide where it should go.