What do Integrated Care Systems Mean for General Practice?

Following the publication of the White Paper in February, new guidance has just been published by NHS England outlining the “Design Framework” for the new integrated care systems that are to replace CCGs and bring providers and commissioners together.  What can we learn from the new guidance about what the new integrated care systems will look like, and what does it all mean for general practice?

At the top of an integrated care system(ICS) there will be two bodies: an ICS Partnership and an ICS NHS Body.  The ICS Partnership is essentially the body to bring health and social care (under the remit of the local authorities) together, and has responsibility to develop an “integrated care strategy”.  There is no explicit mention of the need for GPs or PCNs on these bodies.

The second body is the ICS NHS Body.  This will be a statutory NHS organisation which will receive and distribute NHS funding, and will take on all CCG functions and duties, including the commissioning of primary care.  It is explicitly required to “support the expansion of primary care and integrated teams in the community” (p16).

Because the changes are intended to end the commissioner/provider split in the NHS, the ICS NHS Board is described as being a “unitary” Board: it will have a Chair and at leas two other non-executive directors; an executive team of at least a CEO, Finance Director, Medical director and Nurse Director; and will also have at least 3 “partner members” – one from the NHS Trusts/Foundation Trusts, one from the local authorities, and one from general practice.  The partner members, “will be full members of the unitary board, bringing knowledge and a perspective from these sectors, but not acting as delegates of these sectors”(p20).

What does that mean?  Well, it means there will be a GP on the NHS ICS Board, but it is up to the NHS ICS Board to appoint them, and they don’t have to represent the profession.  This in turn means it is highly unlikely there will be any form of election process.  It is up the NHS ICS Board to come up with and agree how it wants to appoint the partner members.

Beyond the ICS NHS Body, there are two other important pieces of the new system architecture.  One is called “place-based partnerships”, and the other “provider collaboratives”.

In my view place-based partnerships are the most important part of the new integrated care systems for general practice.  Each local system has been asked to define its place based partnership arrangements.  A place should have “configuration and catchment areas reflecting meaningful communities and geographies that local people recognise” (p24), but it is up to local areas to define exactly what that means.

Not only that, but it is also up to local systems to agree the membership and form of governance that place-based partnerships should adopt.  “As a minimum these partnerships should involve primary care leadership, local authorities, including Directors of Public health, providers of acute, community and mental health services, and representatives of people who access care and support” (p24).

Here is where it gets interesting.  The NHS ICS Body remains accountable for any resource deployed at place level, but there are different options outlined as to how this accountability could be discharged through place based arrangements.  These range from it being a consultative forum, that informs decisions made by the ICS NHS Body (ie has no power), to it being a committee of the NHS ICS Body with delegated authority to take decisions about the use of ICS NHS Body Resources.  It can even be delegated authority by both the local authority and the ICS NHS Body as a joint committee to make local decisions and allocate resources.

This is key.  Primary care’s influence and ability to shape the delivery and provision of services is realistically going to happen at a place level not at the wider ICS level, and that ability will be determined by how the ICS designs these place based partnerships in the next few months.

There is an interesting note in the guidance on the role of Primary Care Networks (PCNs) in the place based partnerships, “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.” (p27).  Regular readers of this blog will be no stranger to my view that primary care and PCN influence in the new system is predicated on their ability to work effectively together and present a unified voice.  The good news is that the guidance explicitly states, “This work is in addition to their core functions and will need to be resourced by the place-based partnerships”(p27).

The second important new piece of the architecture is provider collaboratives.  From April 2022 NHS trusts are expected to be part of one or more provider collaboratives.  There is a strong expectation in the new system that providers will work together (as opposed to in competition with each other).  They could be paid (by the NHS ICS Body) separately, or via a lead provider arrangement.  There will be far less competition and tendering in future, as it is to be a “tool to use where appropriate, rather than the default expectation” (p30).

The transition to the new system will happen quickly.  The NHS ICS Body Chair and CEO are expected to be in place by the end of September, along with the draft ICS operating model for 22/23.  NHS staff below board level (ie CCG staff) have been given an employment commitment to continuity of terms and conditions, but this does not apply to those in senior/board level roles.

The most important part of all of this for general practice is how the place-based arrangements will work locally.  It is vital that GPs and PCN CDs get involved in these discussions, and do not leave it just to those who are currently involved in the CCG, as they are the ones who will have to make the new system work.  At this stage there is a lot of local flexibility, and there is an opportunity to ensure systems are put in place that support locally-led bottom-up change, but it is an opportunity that won’t last long.

Do the Additional Roles Belong to the Practices or the PCN?

One of my favourite questions for guests in the current series we are running in the General Practice podcast on the additional roles in general practice is where do they belong?  Do those in the roles feel like they belong to a specific practice, or to the PCN as a whole?

Many PCNs have already experienced turnover in the additional roles, despite the scheme only having just completed two years (and for the first year only pharmacists and social prescribing link workers could be recruited).  One of the most common reasons cited by those leaving is that they did not feel like they belonged anywhere.

It is a difficult conundrum.  The PCN is a collection of practices, and is not really an entity of itself.  It does not exist in a specific place, and is defined as much by a series of meetings and actions as by any physical reality.  So when an individual is appointed to work for the PCN it is not surprising that they can lack this sense of belonging to something.

This issue is then exacerbated because these roles in many places are very new.  Most practices are not used to working directly with social prescribing link workers or health and wellbeing coaches or physician associates (etc).  Making something new work involves change, and change inevitably leads to resistance.  So those taking up post in one of these new roles is working for the less-than-tangible PCN, and at the same time encountering push back from the individual practices within the PCN.

Those taking on these roles need somewhere safe they can retreat to, somewhere they can feel supported, somewhere they can regroup and work out a plan to win over those who have not yet understood the value they can add.  They need to feel like they belong somewhere.

What is really interesting about the responses that I have had to the question from those in roles that are clearly working extremely well is that they are not consistent about where they feel they belong.  Some respond quite emphatically that they feel like they belong to their host practice.  They feel part of the practice team, welcome in the practice, supported by the practice, but at the same time enjoy working with patients from across all the practices in the PCN.

Conversely others feel part of a PCN team.  This is particularly true where there are a number of roles working together, for example social prescribing link workers, care coordinators and health and wellbeing coaches.  They feel like they belong to the PCN team, and that this is where they get the support they need.  The team often has a number of key individuals (clinical supervisors, line managers etc) from across the practices, who enable this team to feel an integral and valued part of the PCN.

Where it doesn’t work, and where more commonly we see turnover in the additional roles, is when those in the role does not feel like they belong to either a practice or a PCN team.  Problems occur when roles are isolated, and left to try and work with each PCN practice without really being a part of any of those practices and without any peer support to speak of.

As long as the new roles feel like they belong to either one of the practices or the PCN then which is not really important.  What is important is they feel like they belong somewhere.

How to Make the Additional Roles a Success

We have a strange irony in general practice right now whereby the biggest investment into the service, the Additional Role Reimbursement Scheme (ARRS), is in many places adding to the challenges practices are facing rather than helping.

What is happening is that the burden of recruitment, line management, and clinical supervision, along with the time needed in each practice to make these roles effective, is outweighing the value the new roles are bringing.  This is then exacerbated by rapid turnover in these roles, and the need to constantly start over and over again.

I have written previously on the need for PCNs to plan for the new roles, and also on the challenges associated with introducing them.  But how can PCNs and practices turn this huge investment (£746M this year) to their advantage?

In recent weeks I have been talking to areas that have found ways of making the new roles a success.  What is becoming abundantly clear is these areas have understood that the introduction of the new roles is a change process and have treated it as such, rather than simply recruiting to the roles and expecting the benefits to automatically follow.

What does this mean in practice?

The leading thinker on change at present is Professor John Kotter.  In this Harvard Business Review Article, in addition to outlining the 8 steps of a robust change process, he states 8 reasons why change processes fail.

Read the article for yourself, but my take on the first three of these reasons, as applied to the introduction of the new roles, is as follows:

Error 1: Not Linking the Roles to the Need for Change

Practices are at breaking point right now.  The workload pressures on top of trying to operate in the environment of the ongoing pandemic are making life extremely challenging for many.  What many PCNs are doing is introducing the new roles without being explicit as to how they directly link to this challenge.  Without this link in place practices feel they are making the situation worse not better.

Error 2: Not Creating a Cross-Practice Team to Lead the Changes

The way many PCNs work is that the leadership of the introduction of the new roles is left to the PCN Clinical Director (CD).  They have a PCN meeting to gain sign up as to which roles from the list to recruit, but overseeing the recruitment process and introduction of the roles is left to the CD, who then in turn has to assign line management and clinical supervision roles out across the network.

The problem is that it is simply not possible for someone to successfully introduce a new role into a practice if they are not part of that practice.  A team is needed with a range of individuals, taken from across each of the practices, that is multi-professional (including practice managers, reception managers, nurses etc as well as GPs), to work together to lead the changes to make the new roles a success.

Error 3: Not being Clear what Difference the New Roles will Make

Kotter calls this lacking a vision.  The places where the new roles are working well have a plan in place as to how the new roles are going to make a difference.  They have created multi-professional visit teams to take the burden of visits off practices, or created multi-professional non-clinical teams that can manage the social and non-clinical work that comes into practices, or built prevention teams with a clear plan to tackle pre-diabetes (etc etc).  This is in stark contrast to PCNs who have simply identified the roles they most like the sound of and recruited to them because the money is available, but have not taken the time to create a clear plan as to how these new roles will make a difference.

These are not the only mistakes being made.  All of the errors Kotter outlines can easily be applied to the introduction of the new roles.  The key message, however, is to think of the introduction of the new roles not as a task to be completed, but as a change process that if done well can add huge value, but if done badly will probably make things worse.

The Investment and Impact Fund Year 2

Whilst we are already a couple of months into the new financial year, with so much going on it has been hard for everyone to fully get their heads round the changes to the Impact and Investment Fund (IIF) for 2021/22.  This week I summarise those changes and what it means for PCNs and practices.

I wrote last year about the Impact and Investment Fund when it was first introduced.  You will recall for the first six months of last year the funding was protected as a covid fund for PCNs.  The IIF was then launched in October, in the format of a ‘QOF for PCNs’.

PCNs are yet to receive money earned from the IIF for the last six months of 2020/21.  As I understand it once the figures have been collated nationally, and they have established exactly what an “average” PCN comprises of, PCNs will be sent a draft declaration which they will need to confirm as accurate, or appeal to their commissioner if the figures are wrong.  The amount of time it is taking to pull these figures together suggests there may be trouble ahead in getting final agreement on these figures!

Year 2 of the IIF is nonetheless underway.  The scheme works the same way as last year, with minimal changes.  The prescribing indicators have been dropped (I suspect at least in part to do with the challenges of integrating the prescribing database with the information from GP systems).  This year there are three flu vaccination indicators, the social prescribing and annual LD health check indicators remain (with adjusted thresholds), and there is a new one off indicator of “mapping appointment categories to new national categories” which needs to be completed by the 30th June.

There is £200 available per point (adjusted for list size and prevalence), with 225 points available in total.  The indicators and amounts available for an “average” PCN are below (also see the PCN DES specification Annex D, p103):

 

Indicator No. of points Upper Limit Lower Limit £ available
% patients aged 65+ who received a seasonal influenza vaccination 01/09-31/03 40 86% 80% £8,000
% patients aged 18-64 and in a clinical at-risk group who received a seasonal influenza vaccination 01/09-31/03 88 90% 57% £17,600
% children aged 2 – 3 who received a seasonal influenza vaccination 01/09-31/03 14 82% 45% £2,800
Percentage of patients on the Learning Disability register aged 14+, who received an annual Learning Disability Health Check and have a completed Health Action Plan 36 80% 49% £7,200
% patients referred to social prescribing 20 1.2% 0.8% £4,000
Confirmation that, by 30 June 2021, all practices in the PCN have mapped all active appointment slot types to the new set of national appointment categories, and are complying with the August 2020 guidance on recording of appointments 27 Binary target – all practices to achieve for PCN to receive in year payment £5,400

 

The amount available is roughly double what was available for the last six months of last year (£40,500, compared to £21,500 for an average PCN last year).  A key point to note here is that only one third of the £150M set aside for the IIF in the contract for this year has currently been allocated. The plan is to allocate the rest of it to new indicators to be introduced from 1st October (Covid permitting) with double the value of the existing indicators.  My understanding is these indicators are most likely to be linked to delivery of the new PCN specifications also due to be introduced at that time.

So by the end of the year the IIF is likely to be worth over £120k to the average PCN.  This is due to increase further to £250k by 2023/24.  During this year the IIF will overtake the core funding of £1.50 per head in terms of value to the PCN, and will continue to grow thereafter.

The flu indicators, representing 142 of the 225 points on offer, do not start until September, so at present there is relatively little for PCNs to do, other than to ensure they have effective monitoring and reporting systems in place, to try and get ahead of the social prescribing referral target, and to ensure all practices carry out the appointment mapping exercise.

But this will most likely be the calm before the storm.  The importance of the IIF may be minimal at present, but the values attached to it mean this is likely to change significantly in the second half of the year.  At that point the new indicators alongside the existing flu ones will mean the work really begins.

Training and Development Support for New GP Partners

A few years ago I wrote an outline of a training programme for new GP Partners.  In recent months I have received regular requests from GPs interested in accessing the programme.  Whilst we never set it up at the time, I am working with some great partners to now make this happen.

Below is an updated and adapted version of the original blog:

“Taking on responsibility for a business, for its staff, for its performance, and for its liabilities, is a big commitment. While in the past GPs took it on because that was the established career route for them, that no longer appears to be the case. Increasingly GPs are opting out of being a partner, and taking on salaried, locum or portfolio careers. Even GPs who had previously become partners are now choosing these alternatives.

It is into this environment that we are developing a training programme for GP partners. It is for those GPs who are considering becoming a partner, want to understand better what is involved, and want to develop the skills to be a good partner should they choose to make that step. It is also for those GPs who have already made the decision to become a partner, and want training and development to ensure they can be successful in the role.

The programme will comprise of the following areas.  We will work with participants to tailor it to their individual needs through the course of the programme

Section 1: Internal – understanding the business

Success Measures: What constitutes success for the practice? Is the practice there to serve patients or to make money? What does independent contractor status really mean?

Partnership: What is a partnership; why partnership agreements are important; what makes a good partnership agreement; building a strong partnership team; “last man standing” and strategies for dealing with it.

People: How to lead people, how to manage people (and understanding the difference!); dealing with difficult people (including other partners!); staff appraisals; staff surveys; team meetings; the importance of coffee.

Finances: Partner financial responsibilities; dealing with accountants; understanding cash flow; how to manage the finances.

Processes: Appointment systems: the good, the bad and the ugly; DNAs; workflow redirection; active signposting. How to implement change within the practice.

Property: Understanding premises; types of ownership of property; leases and rent reimbursement; working with NHS Property Services.

Practice Manager: What to expect from your practice manager; how to get the best out of them; understanding the difference between the role of the practice manager and the role of a GP partner; how to know if you need to change your practice manager and how to do it.

 

Section 2: External – understanding the environment

NHS: Understanding where GP practices fit within the NHS; the different structures and types of organisation within the NHS and how they impact on GP practices.

Commissioners: Friend or foe? Understanding the GP contract and how it works; understanding the different commissioners; how to build effective relationships with commissioners.

Regulators: The role of the CQC; surviving inspections

Primary Care Networks: What is a Primary Care Network (PCN); how to build relationships with other GP practices in the PCN; overcoming history and other barriers to joint working.

Integrated Care: What is integrated care?  What is an Integrated Care System?  What does it mean for my practice?  Is building relationships with other organisations, such as community pharmacy, community trust, local voluntary organisations, local council, local hospital important? Who to prioritise; how to do it.

 

Section 3: Future – understanding the risks

Changing NHS: The changing NHS, including the new (2019) GP contract; integrated care systems; and the role of PCNs moving forward.

Strategic Change: Understanding strategic options for your practice for the future; how to develop them; how to implement them.

Practice mergers: When to consider it, when not to, and how to do it successfully.”

 

If you are interested in being part of our pilot cohort which has a maximum of 15 place available, please get in touch (ben@ockham.healthcare). The course will start in September, and will be delivered online.  We will work with this cohort to tailor the programme to the specific needs of those on the programme.  I am hugely excited about taking this forward, and I will share more details as we finalise the programme over the coming weeks.

Page 2 of 52
123452