Why general practice needs to act now

This week will mark the end of the current system of Clinical Commissioning Groups and the commencement of the new system of Integrated Care Systems (ICSs).  It also represents the opening of a window of opportunity for general practice to take action that might not last for very long.

Many consider this current round of system changes to be just another turn in the wheel of NHS structures, the latest in a line of changes that have been happening every few years for at least the last 20 years.  But my sense is that this is a much more fundamental change, and one that could mark the beginning of an (even more) difficult period for general practice.

The end of CCGs marks the end of the purchaser provider split and the internal market that has been the organising principle of the NHS since 1990.  Alongside that principle has always been the idea of a primary care led NHS, and this also is coming to an end.  Instead, ICSs are based on the principle of providers working together, but of course not all providers are equal and the dominance of trusts and in particular acute trusts creates huge risks for general practice around priorities, contracts and funding.

How can general practice future-proof itself within the new system?  What action can it take?

The good news is that it seems that there is unlikely to be a nationally prescribed ‘solution’ for general practice.

When the system talks about needing a solution for general practice it means how can it work with general practice playing its role as a partner provider in developing system-wide responses to the challenges local health systems face.  With the GP leadership role of CCGs gone, there is no obvious route for working with general practice.  When there are upwards of 50 practices, 10 PCNs, and maybe 2 or 3 federations and LMCs in any area it can be virtually impossible to find any kind of consensus across general practice, let alone a shared commitment to collective action.

Despite Sajid Javid floating the idea of GP nationalisation earlier in the year, and the incorporation of general practice into an existing NHS organisation as the best solution, the Fuller Report very much points towards the development of local solutions for general practice within each system context.

The challenge for general practice, then, is to demonstrate that is can organise itself in any given area, that it can be united, and that it can create a consistent and influential voice.  If it can do this effectively, it can future proof its own autonomy as there is no need for the system to go down the route of asking another organisation to take over control.

But there is no time to waste.  It wont be long before ICSs find their feet and start to try to impose solutions upon general practice.  While currently this might seem well outside their control, if funding for general practice shifts from national to ICS level then they will most likely have the levers to be able to make this kind of change happen.

There are plenty of areas up and down the country already working hard to try and create a local cohesion across GP practices and organisations.  It is really important that everywhere starts to consider how to develop this in their area.  If practices do not start this work now, it may end up being too late and someone else may be brought in to do it to them.

The Future of General Practice funding

Hot on the heels of the Fuller Report, there is now talk of a reform of general practice funding allocations, all of which is pointing to some big changes coming for how the money flows to general practice.  What exactly do we know, and what is likely to happen?

Let’s start with the Fuller Report.  This says a number of interesting things when it comes to funding.  It reiterates the point made by NHS England recently when it says, “We welcome the clarity from NHS England that staff in post will continue to be treated as part of the core PCN cost base beyond 2023/24 when any future updates to the GMS contract are considered” (p19).

This is welcome, as many had been concerned that general practice would be expected to pick up the staffing bill for the ARRS staff post 2024.  It is noteworthy, perhaps, that the description is of these staff being part of the  “PCN cost base”, given the push for PCN funding to come via ICS’s in future that I will come on to.

The report also indicates that no change is planned to general practice funding until after the current five year contract has run its course – the recommendations on p35 around funding are that they should take place “beyond 2023/24”.  Nikki Kanani’s recent comments were also all about planning for the next contract after the current 5 year one.

However, the big push in the Fuller Report is for primary care funding, including general practice funding, to shift from being nationally to locally driven.  The report states, “National contractual arrangements, including for PCNs, have provided essential foundations including for chronic disease management and prevention. But they can only take you so far. As already highlighted in the report, getting to integrated primary care is all about local relationships, leadership, support and system-led investment in transformation. ICSs putting in place the right support locally will be enabled by maximising what control ICSs have over the direction of discretionary investment. This should be looked at by NHS England as part of the implementation of recommendations.” (p28).

Now in case that was missed by anyone the report was accompanied by a letter from the 42 Chief Executives of the new ICSs which reinforced this very point, repeating it almost verbatim, “National contractual arrangements, including for PCNs, have and will continue to provide essential foundations. But they can only take you so far. Getting to integrated primary care is all about local relationships, leadership, support, and system-led investment in transformation.”

There will undoubtedly be a variation across the ICS CEOs in how they view primary care and the role it can play.  But what they can agree on (unsurprisingly) is that they would like the funding for general practice to come via them rather than via a national contract.  It is hard not to believe that this shift of funds was at least to some extent behind the universal support ICS CEOs displayed for the report.

The extent of this shift is made clear in the annex at the very end of the report.  They want firstly the Additional Role Reimbursement Scheme to be delivered via ICSs not via a national contract (“Specifically consider, with DHSC and HEE, how the (ARRS) scheme should operate after March 2024, including the role of ICSs in working with national colleagues and PCNs in delivering it” p35), and secondly any additional funding for general practice to come under the control of local systems (“Move to greater financial flexibility for systems on primary care… Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35).

The report also sets the context for Nikki Kanani’s comments at the recent NHS Confederation Expo about reviewing the national funding allocation formula as part of the contract negotiations for the next contract from April 2024.  The report says, “It is also generally accepted that the distribution of primary care funding to neighbourhoods is not always well aligned to system allocations and underlying population health needs – and we need a concerted local effort to try and fix this.” (p28).

All of this, then, is pointing to a shift of resources out of the national contract after this 5 year deal expires, with far more to be allocated via ICSs.  The distribution of this additional resource (it seems) will be made by ICSs dependent on population health needs, regardless of the specific local needs of primary care providers.

All of this means there are a number of risks ahead for general practice.  First, ICSs are governed by a requirement to break even across the system, and cannot ringfence funds in the way areas could in the previous system when commissioners held individual contracts with providers, so funding via an ICS cannot be guaranteed in the same way as funding via a national contract.

Second, the allocation of locally distributed funds is likely to be based on population health need, meaning the distribution across practices will vary significantly.  Third, the ability of general practice to influence the direction of funds within a local ICS is far less than its collective ability negotiating a national contract together.  Fourth, there does seem to be some form of play for some of the existing PCN resources to shift out of the national contract and into local control.  And finally once resources are within ICS control they don’t have to come direct to general practice but could come via a partnership mechanism, i.e. via a third party provider of “support” such as an acute or community trust, which would likely further impact on the independence and autonomy of general practice.

My view for what it is worth is that general practice should think extremely carefully about agreeing to any significant shifts of funding from the national contract into local systems, but the GPC appears to be positioning itself badly in this regard with its position on the PCN DES, and so whether the service ends up with any choice in the matter remains to be seen.

The Fuller Report: Single Urgent Care Teams

There is much that is worthy of further discussion in the Fuller report.  Last week I considered integrated neighbourhood teams, and this week I take a deeper look into the idea the report introduces of single urgent care teams.

There is a context for this notion, which is the Our Plan for Improving Access for Patients and Supporting General Practice paper published last October.  That particular paper incurred the wrath of general practice, and the Fuller Report does seem to be trying to tread a difficult line between a national desire for the GP access ‘issue’ to be resolved, whilst avoiding letting it dominate the whole report.

Hence, while the paper introduces the idea of single urgent care teams in the middle of the document, it is telling that the number one action emerging from the report is to, “develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for practices.  This should be for all patients clinically assessed as requiring urgent care, where continuity from the same team is not a priority” p34.

It is also hard not to believe that implicit behind this idea is the erroneous belief seemingly shared by much of the system that lack of access to urgent care in the community (i.e. GP access) is the primary cause of the problems experienced in A&E and the wider urgent care system.  The report actually says that this change, “can also help to reduce demand on other urgent care services across the NHS iv”, although the reference it uses is of a video of how a practice has this system in place without any reference to the knock on consequences for the rest of the system.

This will inevitably lead to this particular action taking a high priority in the majority of Integrated Care Systems.  But what is the action?  The report states that it is for, “primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them” (p11).  “Same-day access for urgent care would involve care from the most clinically appropriate local service and professional and the most appropriate modality, whether a remote consultation or face to face” (p34).

It involves taking, “general practice in-hours and extended hours, urgent treatment centres, out-of-hours, urgent community response services, home visiting, community pharmacy, 111 call handling, 111 clinical assessment – and organise them as a single integrated urgent care pathway in the community” (p11/12).

But despite my best efforts, I am still not 100% sure what this means.  Maybe the idea of the paper is to build scope for local interpretation rather than dictate a one size fits all model, and this is why it feels difficult to nail down the exact intent of what is written.  Is it saying that all the on the day demand needs to be managed by a single team, and so that will include the team currently managing this within each practice?  Or is it saying that each practice will be a virtual part of a wider community team, operating with a single triage and capacity management system?  Or is it saying something else?

Either way, the implication is that each practice will no longer be managing its on the day demand separately from other practices.  If the model is going to “guarantee same day access”, what if a practice cannot offer same day GP slots to its patients?  Are those patients going to be seen by a GP at another practice?  The implications of a single team across a neighbourhood for managing all of this demand are enormous, and the only examples given in the report operate at a single practice level.

The model is also seemingly based on patients who ask for a face to face GP appointment being redirected to either a virtual appointment or an appointment with an alternative practitioner (and now add in alternative provider), something that practices have been articulating with little support for a number of years.  Meanwhile both NHS England and the government have been insisting in the national media that anyone who wants a face to face GP appointment can have one (regardless of need).  However, no action on a national communications about-face appears within the paper.

The vagueness around this idea is both an opportunity and a risk for general practice.  It is an opportunity because if this is really to be a system where solutions are generated locally as opposed to imposed nationally general practice can create its own interpretation of what it means, turn it into something useful, and then use the authority of the report to access system funding to support its implementation.  It is a risk because others may start to impose their interpretation of what it means on practices in an area, citing the report as their authority for action.

It highlights once again the need for general practice to organise itself locally so that it can positively influence how things develop.  A united local general practice can work together to make the most of the opportunity, but where no such unity exists the risk will almost certainly prevail.

The Fuller Report: Integrated Neighbourhood Teams

There are some individual elements within the Fuller Report that are worth exploring in detail to try and understand what they mean, and what the implications are.  The first of these is integrated neighbourhood teams.

Integrated neighbourhood teams are described as being “at the heart of the new vision for integrating primary care” (p6).  The clear action at the end of the report is to “enable all PCNs to evolve into integrated neighbourhood teams” (p34).  In terms of timescale, “systems should aim to have them up and running in neighbourhoods in the … most deprived areas by April 2023… and move to universal coverage throughout 2023 and by April 2024 at the latest” (p7).

So integrated neighbourhood teams are to be an ‘evolution’ (replacement?) of PCNs, and a rapid one at that as this is expected to happen this year, or within a maximum of two years.

What exactly is an integrated neighbourhood team?  The problem with the report is that it tries not to be too prescriptive to allow local areas to create their own versions that will work locally, but of course this means there is a lack of definition when it comes to the detail of what is intended.  It does say they will be where, “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” (p6).  The clear intention is to bring all providers in a PCN footprint together.

The obvious question, then, is how will this happen.  We know when PCNs were first introduced the clear expectation was set out that these teams should all become part of the PCN Board, but in most places that just has not happened.  This is because it is hard finding ways of enabling the practices in a PCN area to work together effectively, and PCN leaders have done a great job of making this happen.  But this relies on those practices believing they are retaining an element of control, albeit collective control, or else many would just not be prepared to give up the individual practice autonomy the joint working requires.

This report by ICS leaders displays an element of frustration with the pace of progress of PCNs (or else why produce the report?) and wants to fast forward within one or two years to a model of all organisations working seamlessly together around PCN populations.

According to the report, the reason for this perceived lack of progress is, “a lack of infrastructure and support (which) has held them back from achieving more ambitious change” (p6).  The challenge of enabling joint working across practices within a PCN is ignored.  And so the prescribed remedy is “a systematic cross-sector realignment to form multi-organisational and sector teams working in neighbourhoods. For example:

  • full alignment of clinical and operational workforce from community health providers to neighbourhood ‘footprints’, working alongside dedicated, named specialist teams from acute and mental health trusts, particularly their community mental health teams
  • making available ‘back-office’ and transformation functions for PCNs, including HR, quality improvement, organisational development, data and analytics and finance – for example, by leveraging this support from larger providers” (p6-7)

Does this mean, effectively, a takeover of PCNs by the system, i.e. that the practices in the PCN become one partner of this new system, that has its own infrastructure, leadership and (potentially) place within an existing organisation?  Maybe.  Local interpretation means that if a local ICS wants to interpret it like this it probably can.

The key is where the leadership of these grander integrated neighbourhood teams will come from.  Who will be in charge and have accountability for them?  It does seem unlikely that system organisations will all put resources into these teams and at the same time totally cede control of them to the PCN practices.  This is what the report says about this:

The role of PCN clinical directors in the future will be essential to the leadership of integrated neighbourhood teams… More focus needs to be given to the development and support of clinical directors beyond the current basic arrangements provided through the national contract, including the local provision of sufficient protected time to be able to meet the leadership challenge in integrated neighbourhood teams.  Some systems will want to go beyond this and use even more innovative ways to support clinical directors to expand and develop their integrated neighbourhood teams, for example:

  • some neighbourhood teams may offer an opportunity to develop different areas of focus and specialisation, with senior GPs serving as the ‘consultant in general practice’ – working across prevention, chronic and urgent care as part of wider teams
  • securing the specialist input from secondary care required in neighbourhood teams, as part of job planning for consultants
  • supporting community partners to operationally embed relevant teams as an integral part of existing PCN teams, recognising that the integration of community and mental health services with primary care is crucial to delivering more integrated care for patients in the community, as set out in the NHS Long Term Plan” (p22)

What should we make of this?  It seems to be saying PCN Clinical Directors will be the first port of call when it comes to who will be leading these new integrated neighbourhood teams.  But how many PCN CDs are going to be able to commit the three (or more) days a week this expanded role is going to require?  Does this then mean the bullets above are alternative leadership options?  It is not a huge step to see these being led by individuals from community trusts, mental health providers, or even secondary care.

As a minimum the implication is that the management infrastructure (if not the clinical leadership) will come from an existing provider (cf the action on p34 “baseline the existing organisational capacity and capability for primary care, across system, place and neighbourhood levels, to ensure systems can undertake their core operational and transformational functions” – I don’t suppose for one minute the answer will be to put more funding into a standalone PCN infrastructure).

The report pushes hard for additional resources for these teams to be allocated at an ICS level (as opposed to the current model of nationally via the PCN DES).  If this is the route of future additional funding for general practice (if this year’s contract negotiations told us anything it is that any new money for general practice has to come via PCNs or their successors), and the leadership and management of these teams increasingly sits outside of general practice, the profession could quickly lose control of its own resources.

Integrated neighbourhood teams are coming, and they are coming quickly.  Behind the attractive picture of clinical teams all working in harmony across the PCN, there are big issues of leadership, ownership and control that need to be played out in each area.  General practice will need to pay close attention to how this happens because of the significant consequences it will have for its own future.

Trying to Understand the Fuller Report

There are some far reaching implications of the Fuller Report for general practice.  However, getting underneath exactly what they are and understanding what the report means for practices is far from straightforward.  For me this is primarily because of the way this report has been written, published and launched.  I have picked out four points to note about this here.

The first is that it is not a report about the future of general practice.  Indeed, the report goes to great lengths to insist that it is about all the different parts of primary care, and even then that is about how primary care should be ‘integrated’ not about its future per se.

There is, however, no escaping the fact the two are inextricably linked, despite this seemingly being something the paper tries as far as it can to ignore.  To give two examples: the paper pushes hard for resources for general practice to shift away from the national contract to come under the discretion of local systems (“Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35); the paper also mandates that there should be a single system of managing urgent care in every neighbourhood (i.e. across practices).

These are huge changes for general practice, so it does seem specious to argue that this is only about primary care integration and not about the future of general practice itself.

Which brings me to the second point about the paper.  It is not an options paper, or a discussion paper, but is rather produced as a fait accompli – that this is the only possible way forward.  The paper outlines what it describes as a ‘vision’ of the future, and finishes with the actions needed to begin its implementation. For such a radical change you may have expected a period of discussion, deliberation and consultation, but because this is about ‘integration’ not general practice there is apparently no need.

The third point to note is that the paper is not an easy read.  There is no easy to navigate contents page, no numbering or anything to help an unseasoned observer make sense of what they are reading.  There is a great deal made of the three elements of the new vision, but very little on the what all that means for the existing models and ways of working.  In some ways I was left at the end of the paper feeling that much more was implicit than explicit.

The fourth point is about the launch of the paper itself.  The report is accompanied with a letter of support from all 42 of the ICS Chief Executives.  It is explicitly noted in the document that the Chairs of 9 workstreams and 4 task and finish groups all “endorse its findings” (p37).  Following the publication of the report there were then lots of seemingly pre-orchestrated messages of support for the report and a reinforcement of the idea that this is the only possible way forward.  Have a look at this message from the Chair of the RCGP, and even this one from the BMA.

Now it may be that all of these organisations were fully engaged in the production of the report, and what has emerged is a consensus model that all parties concur is the best way forward.  I just find the lack of any clearly articulated implications of the report surprising (in particular from the BMA and RCGP), even if they support the report.

All of this leaves me with the sense of a very highly politically managed process with the report trying to be pushed through, without the debate and discussion that you would normally expect for such a significant change.

It is for individuals to make their own mind up about the attractiveness of the vision laid out in the report and the extent to which they sign up to the proposed way forward.  My ask would be that more clarity is brought to the implications of this report for general practice before these decisions are made, but my fear is that rapid national agreement will quickly push any real debate to a local level and the course will already be irreversible.

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