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.