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.