What is Integrated Care?

“Integrated care” is the term used to describe provider organisations in the NHS working together to improve care for patients.  The ambition of the NHS, as described in the Five Year Forward View, is to move away from a system of care organised via contracts between providers and commissioners, towards one in which groups of providers are given the budget to work together to deliver outcomes for a local population.

Why is it important for GP practices?

Within an integrated care system GP practices will have stronger relationships with local community services teams, social care, the voluntary sector and even the local hospital.  It will also change the way that GP practices receive (some of) their money.  Whilst the core contract will remain nationally negotiated and paid directly to practices, other income streams such as enhanced services will ultimately come via the new provider partnership (or integrated care “system” or “partnership”).

When will this happen?

There is no national timetable for the changes, as there has been no new legislation to dictate it.  Each area is implementing changes in line with their local STP (Sustainability and Transformation Plan).  Eight areas nationally are acting as pilot systems to “fast track” the introduction of the new system.

The changes have, however, already started, primarily through a push for practices to work together in populations of 30-50,000.  This is evident in the procurement of extended access for general practice, and CCGs have been explicitly asked to “encourage” practices to work together at this scale.

What will integrated care look like locally?

There is no blueprint for what integrated care will look like.  The lack of legislation means there is freedom for each area to determine this for itself.  We are currently in the critical period where each area is deciding and agreeing how integrated care will develop locally.  Providers and commissioners are meeting together to work this out, in meetings with a range of titles but that generally include the terms STP or Accountable Care System/Partnership or Integrated Care System/Partnership.

How is my practice represented in these discussions about integrated care?

This is an important question.  I carried out a quick poll on twitter to find out.  The results are below:

Who represents your GP practice in discussions about integrated care? #generalpractice #primarycare

— Ben Gowland (@BenXGowland) February 26, 2018

It is not surprising that practices do not think they are represented by their CCG or LMC. CCGs cannot represent practices, as they are a commissioning body that exists to represent their local population not their practices. LMCs have traditionally been the representatives of general practice. The challenge for LMCs is convincing the other providers they are there as a genuine partner rather than trade union. Integrated care is about building partnerships between providers, not negotiating terms. Some LMCs have stepped up into the role (Tracey Vell in Manchester is the obvious example) but many are simply not able to.

This essentially leaves federations (where they exist) to represent their practices, unless practices are of a size (so called “super practices”) to represent themselves. Some federations have been reluctant to take this on, because their relationship with their members is not one where they feel they can speak on their behalf. Some areas have not included GP federations in the meetings about integrated care. Whatever the reason, the absence of a federation around the table means that many GP practices are not currently represented in these important discussions.

What happens if no one represents me?

There are (at least) two consequences of practices not being represented in discussions about integrated care. The first is that general practice, as the provider of by far the largest number of patient contacts, has no voice in determining what the local integrated care system will end up looking like. The second is that acute trusts, community trusts and other large provider organisations will have the greatest influence on how care is organised and how local funds are allocated between providers in the future.

Why is no one asking how I want to be represented?

The representation of general practice is difficult because of the large number of practices, and because it is not a contract negotiation but a building of relationships between providers. It falls to general practice to organise itself so that it can be represented effectively and build relationships with the rest of the system. There is no incentive for other providers to take on this responsibility for general practice. Tracey Vell talks about how she had to fight to secure a place for general practice around the top table making these decisions in Manchester.

How can I ensure I am represented?

Practices need to do two things:

Establish who (if anyone) is representing you in local integrated care discussions. If it is no one, agree with the other local practices who should be representing you, and then push for this to happen.

Create an explicit agreement with this organisation to establish what they can and cannot agree on your behalf, and what requires further discussion and debate with you directly. Don’t make their job representing you impossible, and ensure they have a strong mandate so they can have a powerful voice with the other providers around the integrated care table. Agree the feedback and communication mechanisms to be put in place between the discussions and the practices, and review them regularly.

Who represents your practice in integrated care?

In summary, it is of critical importance for the future that general practice is represented, and represented well, in the local discussions that are taking place now about integrated care and how the future system will be organised. It is up to each practice to ensure they are being represented, and for practices to work together to empower and enable those representing them to present a strong and unified voice. For federations it is vital they establish a mandate from their member practices to undertake this role on their behalf.