The value of primary care

GPs and primary care are crucial in delivering integrated care services. With the legislation currently falling short on defining their role, now is the time to build trust and engagement.

During the pandemic, we have seen the impact that primary care and general practices can have on service delivery. The most recent example is the vaccination programme. Although this was originally planned to be delivered through mass sites, to date GPs have delivered almost two thirds of all vaccinations.

Previously, clinical commissioning groups (CCGs) put GPs in a crucial role in specifying local services, through the lens of commissioning. While there are places for GPs in primary care networks (PCN), neighbourhoods and on ICS boards, there is a real sense they are not involved in such a pivotal position as before. That role now seems to have been taken up much more by NHS providers. Given how important GPs and primary care will continue to be in the delivery of services, it is important to make up this deficit.

With a significant ambition for transferring care to the community, primary care and GP participation is key. Part of the solution is to make primary care more flexible and agile through digital transformation, which will unlock areas that have proved difficult and streamline training, development and quality assurance.

It has sometimes proved difficult to ensure that GP voices are heard at the right level. Different GPs and PCNs face different challenges and therefore have different priorities. Building the relationship between all primary care actors and GPs will be vital in establishing common ground. There has been a move to creating more collaborative partnerships between PCNs which, much like any relationship building, takes a lot of time and effort.

Challenges

There will be challenges along the way. Currently, the draft legislation does not state what the role of primary care and GPs will be. This has quite rightly caused concern, although it is expected that roles will be made clearer in the next iteration of the legislation.

As things stand, the proposed ICS governance structures seem to reduce the voice of GPs. This needs to change to ensure they don’t feel marginalised. But it won’t be possible to simply increase the number of PCNs on an ICS board. More representation at such a high level will only dilute the conversation and could slow down decision-making. Plus, it might not sway the conversation from acute to primary care.

Instead, it's essential that GPs are able to speak for and represent the views of their colleagues and that when on ICS boards they enforce some realism about timing and the resources needed for changes within ICS plans.

There is still some debate over how to include the voice of general practice on the board. One voice could be highly effective if it's connected to a wider group of GPs and primary care leads, and if the culture of the wider boards is such that the GP voice is accepted as an essential conduit for effective implementation. The issue is getting GPs and primary care to be represented by one voice or a small number of voices.

There are examples of primary care involvement developing well, indicating that current structures are not insurmountable barriers. In south west London, for example, there has been a place-based alliance with GPs at the heart of it, which has led to great strides in integration.

Perhaps most important for this alliance has been the principle of equity between its six partners. This has forced the group to come to a consensus and operate under one voice as much as possible. Moving to this form of partnership working is vital for success.

What we can do right now

Over the last nine years, GPs have been performing increasingly difficult duties and will have lots of experiences and thoughts to share. Getting these out of them and taking them forward will be extremely valuable for the future development of primary care and its integration.

As CCGs and other current structures close down to make way for new ones and GPs are moved out of their current roles, they should be invited to exit interviews. This will not only help to establish what they thought the impact and shortcomings were but will also make them feel as though they are being listened to.

One approach that should be adopted more widely is the appointment of GPs as assistant medical directors to specifically engage with GP practices. A medical director’s team has evolved over the years to have four or five assistant medical directors. While some have been based around sites or functions, prioritising one to liaise with other GPs can help create better relationships.

To aid the development of PCNs and building on the previous point, it might be beneficial to set up a unit to manage conversations between ICSs, providers and general practices.

Place will be important to the delivery of services and could be a construct in which primary care and GPs have a lot more involvement in the delivery of services. At a place-based working level, the arrangements could be to develop co-leadership of local priority setting and resource allocation, co-leading pathway redesign and engaging peers from each of the professional workgroups participating in transformation.

Subsidiarity at place is a valuable notion and something that primary care and GPs will be central to achieving.

At a whole-system level it is crucial that GPs have some influence over strategic priorities, realistic timelines and essential resources. Croydon has a place-based alliance, with GPs at its heart, achieving good levels of cooperation and collaboration, which has helped them make great strides in integration.

It will take time

It’s important to bear in mind that all of this will take time to successfully implement. Bringing a unified GP voice to the board will mean a lot of legwork in developing relationships between PCNs and GPs – and there is also so much else to do. It is important to get the balance right and ensure GPs do not feel as though the new structures and development of care collaboratives feels like some sort of takeover.

It will take time to build the trust needed for people to accept the risk of changing the way they’ve always done things and there’s no way of speeding up that process.

Illuminations

• Each ICS should establish a primary care leadership group with terms of reference that enable the group to shape all areas of ICS work then feed in through the GP member of the board.
• Early development of the ICS boards should focus on building understanding of primary and community services among all members and building a commitment to respect and respond to the advice of the primary care governance group that sits behind the single representative.
• There should be realism about the pace of change that can be achieved, and the resources needed to support transformation and the trade-offs needed between BAU and implementing change.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk.

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