The impact of the formal establishment of Integrated Care Systems and the abolition of CCGs may not have been felt straight away, but there is no escaping the huge consequences this has for general practice.  The question is whether general practice can shift from influencing as a commissioner to influencing as a provider quickly enough to prevent any real damage being done during the transition period.

For the last 30 years, ever since the introduction of the internal market, the influence of general practice has grown through the commissioning route.  It started slowly at first, with the initial forays of GP fundholding, but then steadily grew until Clinical Commissioning Groups were established built around a membership of GP practices.

While the influence of general practice grew through the commissioning route, its influence as a provider steadily receded.  A strong provider voice for general practice has not been needed because GP leaders were already at the system table via the CCG.  Indeed, GP provider representation was actively discouraged because of concerns around conflict to interest.  At best we had GP federations and GP provider organisations purporting to be the voice of general practice provision, but in reality they represented additional provision undertaken by these organisations above and beyond core general practice.

This has been of little concern to the profession because the main representation of general practice takes place nationally via the negotiation of the national contract.  It is this contract that has been pivotal to the sustainability of the service, much more important than any additional local income.

But now this is a problem for two reasons.  First, the representation of general practice at a national level is finding it difficult to secure an effective deal for the profession.  This is encapsulated by the self-defeating policy to promote the withdrawal of practices from the PCN DES, despite all the agreed additional resource for general practice over the last 5 years coming via this route.  This creates a huge risk for general practice, because it relies on a premise that this funding will be reinvested into the core contract instead, when a much more likely outcome is simply that practices will lose control of the PCN resources.

Second, all the signs are that much more practice income will come via the local route rather than via the national contract in future.  This was signalled strongly in the Fuller Report, and backed up by a letter from all 42 ICS Chief Executives.  If this is the case, how organised is local general practice to negotiate as a provider with its local system.  Are LMCs up to the job?  Is the infrastructure of LMCs sufficient for the size of what may be required? While some clearly are, there is a huge variation amongst LMCs across the country.  The system is going to want more ‘integration’ by general practice in return for more resources, so how are PCNs going to play into these discussions?  Will PCNs and LMCs be joined up, or will they be played off against each other?

For the first time in over 30 years local general practice needs to establish its voice and influence as a provider in the local system.  The support that has historically been in place from commissioners will quickly recede in the new system.  Much of the responsibility that has sat with national leaders and the national contract will become the responsibility of local leaders.  It will be up to general practice in each local area to support itself.  LMCs, PCNs, federations and practices will need to work together to ensure local general practice is unified.