What is the Role of LMCs in Integrated Care Systems?

As we move into the new system of Integrated Care a question is emerging around the role of LMCs, and how it will be impacted by the change.

In a traditional purchaser provider model it makes lots of sense to have someone whose job it is to negotiate contracts on behalf of the provider.  Hospital trusts have contracting teams, and general practice has the GPC nationally and LMCs locally.  LMCs have a statutory duty to represent GPs at a local level, and are mandated to represent and negotiate on behalf of their local GP practices.

Whilst recognised by statute and having statutory functions, LMCs are not themselves statutory bodies.  They are independent, and it is this independence that means most GPs and practices trust their LMC to stand up for and support them.  Current legislation includes a requirement for NHS Bodies to consult with the LMC on issues that relate to general practice in their locality.

However, the new guidance on Integrated Care Systems states,

It should be recognised that there is no single voice for primary care in the health and care system, and so ICSs should explore different and flexible ways for seeking primary care professional involvement in decision-making.” p27

It then goes on to say,

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

LMCs are not explicitly mentioned in the guidance.  The implication of the paragraphs above is that it will be PCNs representing primary care (i.e. not LMCs), and it will be up to each local area to decide how LMCs should be involved.

The challenge is that fundamental to integrated care is the need for collaboration and joint working between partners.  This requires give and take on all sides, something LMCs will find difficult because their mandate is only for general practice, and it would be hard for them to justify making concessions around the role of general practice for the greater good to their member practices.  The reality is most LMCs would not, and it is for that reason that those establishing place based arrangements in most areas will be reluctant to include LMC representation.

But if the LMC are not included it potentially serves to make life difficult for those who are representing general practice within the integrated care arrangements.  It is going to be hugely undermining if the representative agrees something for general practice, only for it to be rejected by the LMC (and then most likely member practices) at a later stage.  It won’t just be undermining for the individual leader, it will actually serve to undermine the voice and influence of general practice within the system, as it will reinforce the lack of confidence that some parts of integrated care systems have in general practice.

Any system that is formed as a collaboration of different organisations will necessarily be political.  Integrated Care Systems will be no different.  If general practice is going to be effective within the new systems it will need to find ways of bringing LMCs and PCNs (plus federations and any other general practice leaders) together itself, so that it can operate collectively and effectively.  The system is not going to do it for general practice, and unless general practice can create its own internal coherence it is at risk of having little or no influence on the new system as it develops.

What is the Right Size for a PCN?

Two years in and we are already starting to see questions emerge as to whether the PCNs that we have are appropriately sized.  But what is the right size for a PCN?

The rapid development of Integrated Care Systems (ICSs) is the main reason for the questioning.  New system leaders understand there is an important role for PCNs, particularly within place-based arrangements, and so inevitably are starting to question whether the arrangement in their particular area is the right one.

The main question these leaders are posing is whether we have too many PCNs.  If the place based population size is around 300,000 and there are (for example) 7 or 8 PCNs, the challenge is whether there are really 7 or 8 Clinical Directors (CDs) ready to be local leaders of the place-based arrangements, and whether the 7 or 8 can really operate effectively together as a unit.  Does it create too many points of contact to make place-based working really effective, due to the number of local relationships it necessitates with the local acute, community, mental health, social care and voluntary sector providers?

The other question it poses is whether the smaller PCNs can create the infrastructure needed to be able to deliver all that is expected of them.  Can they find the HR, payroll, finance, communications, IT, estates, strategy (etc etc) expertise needed to be effective?  And where will PCNs end up – is the expectation really that there will be 7 or 8 limited companies all operating alongside each other?

The questions around PCN size from a practice level are more frequently the other way round.  Practices who are part of larger PCNs are beginning to question whether this is really the right option for them, or whether they should actually be part of a smaller group of practices.

The problem practices experience is that when the population size starts to get up towards 70,000, and the number of practices gets much beyond 3 or 4, then there is always a challenge with engagement at practice level.  There always seem to be one or two “passenger practices” who at best contribute very little, and at worst block and slow down initiatives and any changes the PCN wants to introduce.

What this in turn leads to is the smaller group of more proactive practices starting to question whether they would be better off on their own, particularly as the value of the PCN contract, the value of the Investment and Impact Fund, and the number of staff that can be employed via the Additional Role Reimbursement Scheme is becoming more and more significant each year.

Larger PCNs have also not been helped by the continual “one per PCN” ruling that comes out for any PCN with a population under 100,000, such as mental health practitioners this year, which favours those areas that have opted for a larger number of PCNs with a lower population size.  It is not that surprising, then, that practices looking to maximise the value of the PCN DES are wondering whether what they actually need is a smaller PCN.  I did suggest at the start of the year that this might be the case.

Where does this all leave us?  What is the right size for a PCN?  The important thing to remember is that there will always be a trade-off between engagement and delivery/effectiveness.  Smaller PCNs can build more engagement, larger PCNs can create a better infrastructure to enable delivery.  It is difficult to deliver without engagement, and it is difficult to create the necessary infrastructure without scale.  There is no right answer, no perfect size for a PCN.

What is most important is that practices work in PCNs that work best for them.  If you are small and it is working, don’t bow down to any ICS pressure that comes down the line to get bigger.  If you are large and it is working, keep going as you are.  Changing PCN size and structure is of itself distracting  and challenging, so any planned change would not just have to be sensible, it would have to outweigh all the disbenefits that would come with making such a change.  Most of the time it will be better to understand the weaknesses of your current situation and work to mitigate them, as well to exploit the strengths that you have, rather than change the configuration of the PCN.

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.

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