General practice is currently being swept along on a tide of change, all based on the premise that what we need is ‘integrated primary care’.  But what is integrated primary care, and is it really what we need?

Despite the status of the Fuller Report not being clear when it was first published over a year ago, it is now being treated as the policy document for general practice.  If you ask anyone working in the system what the plan is for general practice they will say it is to implement the recommendations of the Fuller Report.  But when you read the Fuller Report it is a wordy document that is light on analysis and heavy on pushing ideas, with little clarity on how these new ideas will make things any better.

At the heart of all this lies the idea of integration.  We have moved away from the internal market and now have integrated care systems.  The four stated aims of this new system are to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development.  Having reiterated these aims Fuller states,

“The ICS CEOs believe that achieving these aims will only be possible if we support and develop a thriving integrated primary care system” p4.

And that is the only rationale that is given.  Primary care needs to be integrated because ICS CEOs believe that is what is needed, and this apparently should be enough because no other justification is given throughout the whole document.  All the NHS CEOs even put their signatures to the report, an act Fuller describes as, “an extraordinary and welcome display of common purpose across health and care” p3.

But could it be that the enthusiasm of the NHS CEOs for this report comes not from a passionate belief in unlocking the power of local communities, but rather because it would increase the span of their direct control to include primary care?  NHS CEOs do not like primary care because the independent contractor status prevents them being able to tell it what to do, so it is not surprising they are all in favour of any move to give them more control over it.  This hardly feels like a sound justification for making such major changes.

A key problem is that nowhere is ‘integrated primary care’ defined.  Without definitions we are in trouble because what I think it means, what you think it means, what Claire Fuller thinks it means, what the 42 NHS CEOs who signed the document think it means, and what the government think it means are all likely to be very different.

Does it mean primary care working effectively in partnership with local health, social care and voluntary sector colleagues in local neighbourhoods?  Does it mean general practice becoming a formal part of the NHS?  Does it mean GP practices becoming part of existing NHS organisations?  We know that this whole range of views already exists.

I am actually a fan of integration, where it means all health and social care providers working more closely together.  It makes sense.  But the notion of “integrated primary care” is actually very dangerous, because it is so nebulous.  It is behind the calls for the nationalisation of general practice, and the end of the independent contractor model.  It is an enabler for centralist CEOs who want to expand their empires.  It is also creating a system blindness to the challenges being faced at an individual practice level.

So what do we do?  In local conversations push for clarity as to what is trying to be achieved and how will we know that we have got there, before getting into the details of actions.  “Implementing Fuller” should not be an end in itself.  If we are implementing an integrated neighbourhood team then what success measures are we using?  What outcomes will it achieve?  Simply ticking the box that we have one does not constitute success.

Challenge the idea of integrated primary care when it is used without clarity of meaning, and push for a local definition that everyone can sign up to.  General practice can support integration, but it mustn’t come at the cost of the service itself.