There is so much going on in general practice right now, and the workload pressure is so great, that it is easy to take a head down approach to everything that is going on outside the practice.  But the landscape around practices is shifting.  What do these changes mean for individual practices?

The big change is the introduction of Integrated Care Systems (ICSs).  This change is one that most practices are largely ignoring, but one that has significant implications for practices.

One of the reasons there is little interest shown by practices is because it is a change that is rarely clearly explained.  At its most simple the way the NHS is being organised will no longer be through a separation between purchasers (or commissioners) and providers.  Instead providers will directly work together to agree how care should be delivered, what the pathways should look like, and how the money should be spent.

In practical terms, CCGs will cease to exist from March next year, and they will be replaced by new NHS ICS bodies.  These role of these organisations is essentially to enable the joint working between providers that lies at the heart of the new system.  As a result all provider organisations are represented on the Boards of the new NHS ICS bodies.

ICSs will function on two levels.  There will be the whole-ICS level, where broader strategy decisions will be taken, but then also at local levels within the ICS area.  This local level is what is being referred to as the ‘place-based’ arrangements.  This will generally be the local area or borough that general practice has been part of for many years.

In most ICSs much of the decision making, including resource allocation, will be devolved to these local areas.  This will include funding for any local enhanced services/local incentive schemes for general practice.

At the heart of integrating care within a local area lies Primary Care Networks.  These were created not in splendid isolation from the rest of the system, but with the emerging ICS explicitly in mind.  The role of PCNs within the new system is to create seamless care for physical and mental health across primary and community care, to enable care to be delivered as close to home as possible, to create seamless pathways across primary and secondary care, to strengthen the focus on prevention and anticipatory care, and to support people to care for themselves.  The PCN is the core building block of the new integrated care system.

All of the work that PCNs have been asked to do so far (primarily via the PCN DES) has been with this in mind.  It underpins the specifications that have been developed within the PCN DES, and the indicators within the Investment and Impact Fund (IIF).

The asks and requirements so far on PCNs are only the beginning.  They will inevitably grow, and increasingly these will come from the local place-based Board of the new ICS (i.e. the one that sits at a local level), as opposed to nationally via the PCN DES.

When PCNs were announced as part of a 5 year contract for general practice in 2019 the funding split was as follows: £1bn extra to come via the core contract, £1.8bn to come into general practice via PCNs.  The more recent uplift in ARRS funds to cover 100% of salaries from 70% means the split in reality is more like £1bn to £2bn.  Most new general practice funding is already coming via PCNs.

But PCNs are only just getting started.  The ICSs do not become statutory bodies until April next year, when we will already be 3 years into the 5 year GP contract, with only 2 years remaining.  What will happen then?  Most (if not all) of the local enhanced service contracts from the ICS place-based board will come at a PCN not practice level.  The differential in funding growth after 2024 if anything is likely to be greater than from this 5 year agreement (i.e. the vast majority of resources coming into general practices will be via PCNs rather than via the core contract), because the foundation the whole new system is being built on is PCNs.

All of this means there are two really important things practices need to be doing now.  The first is to start treating the funding and resources the practice receives via the PCN as part of its core resource, and not as an optional extra separate from the ‘real’ business of the practice.  Investment into general practice is coming via PCNs, and so practices that try and sustain themselves into the medium term on core contract income alone are going to find life extremely difficult.  This may in turn have consequences for how practices choose to interact with their own PCN (a topic I will return to in a future blog).

The second is that practices must ensure that their PCN is directly engaged in the Board and leadership arrangements of the local-place based Board of the ICS.  I know the level of meeting requests in relation to the system and ICSs is bewildering at present, and can feel like a waste of time, but the one ICS meeting that PCNs must prioritise is this local place-based Board.  Each PCN has a seat on this Board to represent local general practice, and because this Board will have such a strong influence on how care is organised locally, and how resources are apportioned, it is critical PCNs take up this seat and do not leave it empty.