GPs have not been overly enamoured with CCGs.  It was not long after their inception in 2013 that the promises of GP control of the funding fell flat, and that they were subsumed within the tentacles of the all-encompassing NHS system.  Now they are so far removed from any individual practice that the membership model sold to general practice 10 years ago is barely recognisable.  But in only a few years’ time GP practices may well be reminiscing fondly about the days of CCGs.

This is primarily because the system replacing CCGs contains no obvious place for general practice.  Integrated Care Systems (ICSs) are more than just the latest incarnation of the NHS.  They represent the first shift away from the purchaser provider split that has been at the heart of the NHS since 1990.  Whatever our views on the internal market, it was always accompanied by an underpinning philosophy of creating a primary care led NHS.

ICSs mark the end of any notion of a primary care led NHS.

The internal market was first introduced in 1990 via the National Health Service and Community Care Act.  The very same act introduced GP Fundholding.  Since then we have had over 30 years of different versions of trying to create a purchaser provider split where primary care held the purse strings: Primary Care Groups; Primary Care Trusts; Practice Based Commissioning; and, in what was the last throw of the dice, CCGs.

It is not just CCGs that are going, it is the whole notion of an internal market, and the concept of a primary care led NHS.  Instead, the new system is supposed to be based on partnerships, on providers working together to agree how to distribute resources to deliver the best outcomes for patients.

In this system there is little to no incentive for anyone to find a seat for general practice at the leadership table.  The less people around the table, the easier it is to reach agreement.  Hospitals are merging and creating “hospital chains” so that they will essentially be one hospital per ICS.  There is also roughly one community trust and one mental health trust per ICS.  And even then sometimes these organisations are merged.  In all likelihood the bigger you are, the more say you will have in these “partnership” discussions.

By contrast, at 42 ICSs we are looking at c170 practices per ICS, plus c30 PCNs, and maybe a couple of LMCs and federations, so somewhere in the region of 200 general practice organisations per ICS, all with little or no track record of being able to operate collectively.  In a system where bigger is better and less is more, general practice is not in good shape.

The consequences of this will be real for general practice.  Systems are under real pressure to break even, and the “do whatever is necessary, whatever it costs” pandemic mentality has already disappeared.  In this environment, if an ICS has three different levels of funding for general practice across three areas expect it to level down not level up.  Once CCGs are gone, who will be left to argue the general practice corner?  Are we going to pin all our hopes on the GP representative on the ICS Board?

Ultimately the loss of CCGs is going to leave general practice exposed, with little or no voice in important system discussions.  Local general practice needs to be working hard right now to mitigate this risk.  The government’s answer seems to be to nationalise general practice and put it under the control of one of the local trusts.  We are waiting to see what the Fuller Review recommends.  It would be better if local general practice could take advantage of the window of opportunity that is left to organise itself as a force to be reckoned with, because at least then it will be controlling its own destiny.  In this article for PCN Pulse I outline the steps general practice can be taking now to make this happen.