Last week NHS England published a paper in which it backed legislation to abolish Clinical Commissioning Groups (CCGs) by April 2022.  The aim is to replace them by giving the newly developing Integrated Care Systems statutory status.  What will these changes mean for general practice, and in particular for PCNs?

When they were established much of the rhetoric around CCGs was about putting NHS money in the hands of GPs, who know their patient populations and their needs best.  Whilst an attractive idea, the reality right from the outset was close control of CCGs by NHS England with very little room for GPs within CCGs to actively change the flow of NHS money.  Whatever else it might signal, the end of CCGs does not feel like it will be a loss of influence for GPs, because it is not clear that CCGs really ever had any.

NHS England’s paper is significant because it not only heralds the end of CCGs, but also the end of the purchaser provider split in the NHS.  This split was created by the last Thatcher government in the early 1990s in an attempt to create an internal market within the NHS.  Hospitals became provider Trusts, money to purchase care was given to Health Authorities, and GP fundholding was the first iteration of GPs being involved as the “commissioners” of healthcare.

What this paper does is (in effect) recommend the split (which has been largely ignored since the publication of the 5 Year Forward View anyway) is finally put out of its misery.  It is fair to say it was an experiment that has not worked.  At 30 years it is probably also fair to say it was an experiment that was allowed to go on for far too long.

What does this mean for general practice and PCNs?  Integrated care systems (ICSs) are to become statutory bodies, and general practice is represented on ICSs by PCNs.  Indeed, PCNs were created to represent local populations of 30-50,000 within ICSs, and ensure care is organised across agencies around the needs of those local populations.  It means the role of PCNs will become even more important.

Where in the internal market the commissioning organisation was expected to exert control over the delivery of local care via the use of contracts with provider organisations, within the new system the provider organisations are expected to work together and make sensible decisions as to how to use their resources to improve outcomes.

I can almost feel your scepticism as you read these words as to whether the new system will make things any better.  What the internal market has done through its attempt to create internal competition within the NHS is not to improve efficiency (as intended) but instead breed huge mistrust between different provider organisations.  It is going to take time for these organisations to get used to the new environment and learn to trust each other.

The real opportunity for the new integrated care system to work is only (in the short to medium term at least) at a local level.  Where relationships are between individuals trust can develop and mature quickly.  Where relationships are between organisations, with years of bad blood to overcome, trust will take much longer to build.  Front line clinical teams talking to front line clinical teams and working out sensible ways of doing things is how integrated care can make a difference that the internal market never could.

The changes that are coming represent an opportunity for general practice and PCNs, but they will need to take action to ensure they can make the most of it.  By April 2022 PCNs will be nearly 3 years old, and by then they need to be firmly established, have built some delivery capacity and capability, and have developed strong working relationships with local partners.  The challenge for PCNs and GP leaders in the meantime is to ensure that as ICSs develop primacy is given to making and supporting change at a local level, and that decision making doesn’t drift into large regional areas divorced from local teams.