As we move into the new world of Integrated Care Systems (ICSs) and come to the end of the purchaser provider split, what should happen to the primary care teams that currently sit in CCGs?  Will we make the same mistakes as 8 years ago when CCGs were formed, or will a more forward thinking approach be taken?

For those who were not around back in 2013 when CCGs were first formed it was Primary Care Trusts (PCTs) that were being abolished.  The primary care commissioning function sat within PCTs, and was moved to NHS England, because of the dreaded ‘conflict of interest’ concerns that surrounded the idea of GP-run CCGs commissioning from themselves.

What followed was an inability of the regional NHS England teams to meaningfully engage with practices, because the distance was too great alongside a huge loss of skills and expertise.  In the end, it was decided that the conflict of interest wasn’t that great after all and the commissioning of primary care was ‘delegated’ back to CCGs.

What we learnt from that sorry episode was even though general practice is essentially commissioned through a national contract, practices do need local contractual support, local problems need to be discussed and tackled locally (often in partnership with local LMCs), and that a one size fits all contractual management programme does not work.

In recent times the role the CCG primary care teams plays has also been evolving.  In a system redesign programme, e.g. of long term conditions or urgent care, general practice is an essential component.  As such, the role of the primary care commissioning teams has become as much about shaping the input of primary care into these redesigns, through local enhanced services or incentive schemes, as it has around local contract management.

Within an integrated care system there is an essential need for primary care to be a core component of local redesign, particularly in a place-based arrangement.  But how will this work in practice?  Is the expectation that PCN Clinical Directors will agree changes and then ensure implementation across their practices?  Will the PCN Clinical Directors write the terms of any new local contract, agree it with the LMC, and manage its implementation with their practices?

This does not sound very realistic.  Aside from the issue of GPs writing their own contract, and the huge unwillingness there will be by PCN CDs to take on the role of contract enforcers, the continued lack of support for investment in any form of PCN management means there is simply not the capacity to do this.

Should CCG primary care commissioning teams, then, become part of local place-based arrangements?  Could they play a role there as enablers of change?

This does seem logical.  At its heart, integrated care is about providers working together to agree changes to improve outcomes, experience and value for money.  Within this model general practice needs to be suggesting and driving its own changes, not primary care commissioners.  But there is potentially an important role for the existing CCG primary care teams to work in partnership with general practice as an agent and enabler of change.  Because without this in place, how will it work?

The problem with this is one of accountability.  Who would the primary care commissioning team be accountable to?  The PCNs? The local place-based ICS Board?  The local federation?  There is no right answer, and this clearly needs some working through, but it doesn’t feel insurmountable.

The move to integrated care systems is happening quickly.  Let’s hope the same mistakes of 8 years ago are not repeated, that we don’t waste the skills and expertise we have in local primary care commissioning teams, and that primary care is supported to lead local change not be passive recipients of it.