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.