Can General Practice Lead an ICS?

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.

What will happen to Primary Care Commissioning?

As we move into the new world of Integrated Care Systems (ICSs) and come to the end of the purchaser provider split, what should happen to the primary care teams that currently sit in CCGs?  Will we make the same mistakes as 8 years ago when CCGs were formed, or will a more forward thinking approach be taken?

For those who were not around back in 2013 when CCGs were first formed it was Primary Care Trusts (PCTs) that were being abolished.  The primary care commissioning function sat within PCTs, and was moved to NHS England, because of the dreaded ‘conflict of interest’ concerns that surrounded the idea of GP-run CCGs commissioning from themselves.

What followed was an inability of the regional NHS England teams to meaningfully engage with practices, because the distance was too great alongside a huge loss of skills and expertise.  In the end, it was decided that the conflict of interest wasn’t that great after all and the commissioning of primary care was ‘delegated’ back to CCGs.

What we learnt from that sorry episode was even though general practice is essentially commissioned through a national contract, practices do need local contractual support, local problems need to be discussed and tackled locally (often in partnership with local LMCs), and that a one size fits all contractual management programme does not work.

In recent times the role the CCG primary care teams plays has also been evolving.  In a system redesign programme, e.g. of long term conditions or urgent care, general practice is an essential component.  As such, the role of the primary care commissioning teams has become as much about shaping the input of primary care into these redesigns, through local enhanced services or incentive schemes, as it has around local contract management.

Within an integrated care system there is an essential need for primary care to be a core component of local redesign, particularly in a place-based arrangement.  But how will this work in practice?  Is the expectation that PCN Clinical Directors will agree changes and then ensure implementation across their practices?  Will the PCN Clinical Directors write the terms of any new local contract, agree it with the LMC, and manage its implementation with their practices?

This does not sound very realistic.  Aside from the issue of GPs writing their own contract, and the huge unwillingness there will be by PCN CDs to take on the role of contract enforcers, the continued lack of support for investment in any form of PCN management means there is simply not the capacity to do this.

Should CCG primary care commissioning teams, then, become part of local place-based arrangements?  Could they play a role there as enablers of change?

This does seem logical.  At its heart, integrated care is about providers working together to agree changes to improve outcomes, experience and value for money.  Within this model general practice needs to be suggesting and driving its own changes, not primary care commissioners.  But there is potentially an important role for the existing CCG primary care teams to work in partnership with general practice as an agent and enabler of change.  Because without this in place, how will it work?

The problem with this is one of accountability.  Who would the primary care commissioning team be accountable to?  The PCNs? The local place-based ICS Board?  The local federation?  There is no right answer, and this clearly needs some working through, but it doesn’t feel insurmountable.

The move to integrated care systems is happening quickly.  Let’s hope the same mistakes of 8 years ago are not repeated, that we don’t waste the skills and expertise we have in local primary care commissioning teams, and that primary care is supported to lead local change not be passive recipients of it.

How Will PCNs Work Together?

A new challenge has emerged for PCNs with the advent of Integrated Care Systems – that of working effectively with each other.  To date joint working between PCNs has been something of an optional extra, but the transition to the new arrangements mean firm plans need to be put in place.  How are PCNs going to make this work?

The new guidance on Integrated Care Systems states,

PCNs in a place will want to consider how they could work together to drive improvement through peer support, lead on one another’s behalf on place-based service transformation programmes and represent primary care in the place-based partnership. This work is in addition to their core function and will need to be resourced by the place-based partnership.” p28

This seems to be a gentle way of saying that not every PCN can be individually represented in the place-based partnership (the local arm of the Integrated Care System).  Instead PCNs need to find a way of being able to work together and represent each other.  Bear in mind that place based partnerships could potentially be making funding allocation decisions that will impact on the whole of primary care, so getting this right feels very important.

In some places this is not going to be a problem.  Effective joint working arrangements between PCNs are in place, often via a federation or shared umbrella organisation, and those PCNs will be able to use that system within the new arrangements.  However, in other areas no formal joint working mechanism exists, and for these the challenge could be much greater.

There is an underlying issue when it comes to representation, and making it work in practice.  It relies heavily on trust.  When an individual is at a meeting, do those he or she is representing trust that individual to work in the best interest of all, or are there concerns that he or she will make decisions on what is best for their practice or their PCN? If an opportunity arises, e.g. to pilot a new way of working, will everyone receive a fair opportunity to take it, or will the representative have first choice?

Even where motives are good, how strong and effective are the communication feedback loops?  Is each PCN canvassed for their views ahead of important items being discussed and a consensus reached ahead of time, and is timely feedback on decisions made provided to all?  Or do those that are being represented feel left in the dark, without any real idea of what is being discussed let alone decided?

It is concerns such as these that lead individual PCNs to wanting their own individual representative at system discussions.

Even for those who do attend the meetings, life is not much easier.  It is hard to comprehend everything that is being discussed, given the complexity around Integrated Care Systems (which even seems to have its own language!).  Worse, many are left with the nagging sense that the decisions seem to be made outside of the formal meetings, with the meetings themselves just a rubberstamping of conversations that have already taken place.

Of course that is to some extent true.  Integrated care is about relationships between organisations, which means relationships between individuals within those organisations.  It is not as straightforward as objective discussions within a meeting environment.  This begs the question as to whether what PCNs need is not one of the PCN CDs to ‘represent’ the others, but a senior manager who can operate at the same level of as the senior leaders of the other organisations, and who can be part of the decision making both inside and outside of the meetings.

Appointing such an individual would have the added benefit of being effectively neutral across all the PCNs, as well as potentially being skilled at pre and post meeting communication.

The problem for those wanting to go down this route is inevitably one of funding.  The guidance says that this work “will need to be funded by the place based partnership” so if a case can be made there is mileage in exploring receiving funding for such an individual directly from the ICS.  While for the role to be effective a senior and experienced individual capable of operating at director level is required, it probably does not have to be full time which would bring the cost down.  And with an imminent turnover of CCG Directors as CCGs are abolished at the end of March there may be secondment opportunities worth exploring.

This is not an issue that can be ignored any longer.  Whatever the local difficulties, it is important for general practice as a whole (the guidance says the PCN representative will “represent primary care in the place-based partnership”), and so it is important PCNs are working now to establish how they will make this work.

I take a more detailed look at how to create a strong voice for general practice in my free guide, “10 Steps to a Powerful voice for General Practice”, which you can access by simply signing up to our weekly newsletter here.

The Importance of Training for New GP Partners

There is a big difference between being a GP and being a GP partner.  All of the training to become a GP is designed to ensure you have the clinical skills needed to deliver great patient care.  The training is not designed, however, to provide you with the skills you need to be an effective GP partner.

A partner in a GP practice has overall responsibility for the running of the business of the practice.  The staff who work in the practice rely on the partners to run the business effectively.  If things go wrong, the buck stops with the partners.  It is a big responsibility.

At the same time, it is a huge opportunity.  Uniquely within NHS, GPs as clinicians have the opportunity as partners to run their own businesses in the way they choose to.  They can employ the staff they want, design their own way of doing things, and have their own rules about how things should work.  This freedom is highly unusual (ask any hospital consultant!), and means that GP partners are independent.  They have no line manager, and no one telling them what they have to do and how they have to do it.

Of course, life is never that simple!  Practices have contracts, and partners are responsible for ensuring the practice fulfils the contract it undertakes.  There may not be any line manager, but there are contract managers, CQC inspectors and others who will step in if the practice is not fulfilling its duties.

But the opportunity to choose how things are done, and to shape the culture of the GP practice, are what have drawn many to GP partnership.  I spoke to Dr Liz Phillips about why, after many years as a salaried GP, she chose to become a partner.  You can hear her story here, but for her it was all about the ability to make a difference.  She is loving her new life as a GP partner!

I have worked with a number of colleagues to provide training sessions on partnership for GPs.  It is interesting to me that the reflections are often not that the model of GP partnership needs changing, but as one salaried GP put it, “I left (the session we ran) feeling GPs need to be conversant with politics, finance, and management, so that we make informed decisions about our roles and the services we run for patients.” (you can read her full reflection here).

She is right.  Practices won’t run themselves, and responsibility cannot simply be delegated to a practice manager.  Partners need to be actively engaged in the business of the practice.  And for this GPs need specific tools and skills.

I wrote recently on the content of a training programme for new or potential GP partners that myself and some colleagues are putting together.  I am delighted to say that this week we are formally launching that programme.  For more information about the programme and how to secure your place, simply click here.

There is no doubt that the role of a GP partner is challenging, but it also presents a huge opportunity to make a real difference to people’s lives (both patients and staff).  As with any role, it requires specific skills and understanding, and our aim in this programme is to give new GP partners the tools they need to be successful in the role.

All Your PCN CD Mastermind Programme Questions Answered!

Dr Rachel Morris and myself are setting up a new “Mastermind” programme exclusively for PCN Clinical Directors.  Here is everything you need to know about the programme (and more!).

What is a Mastermind Group?

A Mastermind group is a group of peers that meet to give each other support and advice.  The beauty of a Mastermind group is that it combines brainstorming, education, peer accountability and support in a group setting to sharpen your leadership and personal skills. A Mastermind group helps you and the other Mastermind group members achieve success. Members challenge each other to set strong goals, and more importantly, to accomplish them.

Mastermind group facilitators start and run groups. They help the group to dive deeply into discussions, and work with members to create success — as each member defines it. Facilitators are the secret to thriving mastermind groups, and I am really excited to be working alongside Dr Rachel Morris to facilitate our new Mastermind Group for PCN CDs.

Through a Mastermind group process, first you create a goal, then design a plan to achieve it. The group helps you with creative ideas and wise decisions-making. Then, as you begin to implement your plan, you bring both success stories and problems to the group. Success stories are applauded, and problems are solved through peer brainstorming and collective, creative thinking.

The group requires commitment, confidentiality, willingness to both give and receive advice and ideas, and support each other with total honesty, respect and compassion. Mastermind group members act as catalysts for growth, devil’s advocates and supportive colleagues. This is the essence and value of mastermind groups.

Why is it only for PCN Clinical Directors?

Being a PCN Clinical Director is one of the most challenging roles there is in general practice right now.  And there is precious little support available.  Those most able to provide support to PCN Clinical Directors are other PCN Clinical Directors, because they are the only ones experiencing the same challenges.  By providing a safe space for a small number of PCN Clinical Directors to come together and support each other we are creating a unique opportunity for those who participate to support each other and thrive in their roles as PCN CDs.

Who are the Facilitators?

The group will be facilitated by Dr Rachel Morris and myself.  We will support the group by facilitating the meetings, providing input, expertise and challenge tailored to the individual needs of each of the participant, and making sure everyone gets what they need out of the group.

Why is it called a Mastermind Programme?

The reason it is a Mastermind Programme is because as well as the mastermind group meetings, those on the programme will be part of an exclusive WhatsApp group for participants (for ongoing support and challenge between meetings!), and will have access to Dr Rachel Morris’s fantastic Resilient Team Academy – with all the resources that includes!  You can find more details about the Resilient Team Academy by clicking here.

When does it start and how often will it meet?

The group will meet every 6 weeks on a Thursday lunchtime from 1pm to 3pm.  All the dates are on the website and can be found here.

How much does it cost and how do I join?

The cost is £1995 plus VAT for a year’s membership of the Mastermind Group.  Applications are via a short application form, which you can find here.  There are a maximum of 12 places available for the group so get your form in quickly, and no later than 31st July 2021.

More Questions?

If you have any further questions, please do not hesitate to contact me.  Email me at ben@ockham.healthcare

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