At the table or on the menu: the choice for primary care

26 April 2018

The recently published planning guidance gives sustainability and transformation partnerships (STPs) a prominent role in planning and managing system wide efforts to improve care.  STPs are expected to evolve to become integrated care systems (ICS). The guidance also refers to STPs‘ roles as brokers of primary care networks and creators of system wide resilience.

All of this sends a clear signal to general practices that if they don’t start working together of their own accord, a solution may be imposed on them, possibly by people with no understanding of or interest in general practice.

The need to work at scale was written large in the general practice forward view (GPFV). Simon Stevens’ enthusiasm for the primary care home approach and the subsequent adoption and frequent repetition of the magic population number (30,000 to 50,000) should leave it in no doubt where this is going.

It may not feel like it, but primary care has a strong hand, partly because it holds the first point of contact card. What happens in primary care, and particularly in general practice, has a very big effect on what happens in the rest of the system. There is also a window of opportunity created by the move to new care models.

Plans for integrated care systems seem a very long way off. The multispecialty community provider contract under which some of the first ACO-style systems were to be given life has suffered setbacks. The contractual options for participation designed to attract GPs (virtual, partial and full) have created confusion and inevitably, as GPs tend towards the least binding option, give the contract a watered down appearance.

Meanwhile legal challenges to existing plans by campaign groups worried about the intentions behind ACOs add to the impression that one of the Five Year Forward View’s basic assumptions – of a formal scaling up and coming together of commissioning and provision – is stalling.

Many in general practice have been alarmed by rhetoric about moving care out of hospitals at a time when general practice is under enormous strain. There may even be satisfaction in some corners about the bumpy ride given to ACOs, NHS England’s nervous fiddling with terminology and the legal skirmishes that are delaying progress.

But anyone hoping that life will soon return to normal, that STPs will be quietly disbanded and ICSs shelved is likely to be disappointed.

The same financial and demand pressures that were present in 2014, when the Five Year Forward View was published, are even more acute today. For general practice, the arguments for working together, regardless of the needs of the rest of the system are also as strong as ever.

Practices hoping to employ a workforce with the range of skills needed to expand their business beyond core contracts, and looking to be taken seriously by commissioners need to reach critical mass. They need to modernise their IT, premises and their business processes.

So with or without the pressure to meet the demands of Simon Stevens‘ grand design, practices need to work at scale for their own sake.  They also need to recognise that the current lull in development of ICSs is an opportunity to get themselves in a stronger position. It is very clear that the GP element of the MCP contract and the more general failure to engage GPs in STP plans have slowed the FYFV bandwagon. What GPs choose to do next is the question.

Some will use the next 12 months to get their act together locally. Many will opt for mergers and other vehicles for formal collaboration. Others will take the ultimately more challenging route of less formal working arrangements. The latter group will typically need the support of well- run federations.

Any and all of the above will give local practices a more effective voice in local plans, whether for the purpose of negotiating their own contracts or for setting the direction of the ICS.

Primary care should not undersell itself – but for those not already working with others, it is now time to create links with other practices. Reaching the mandated optimal population size of 30,000 to 50,000 is a start but not an end in itself. Working out how to sustain a larger organisation of whatever kind is the far bigger challenge. At the same time as they are dealing with the internals, practices will also need to keep an eye on the outside world. This is the time to claim a place at the planning table with the STP.

The do-nothing option is of course still available. Survival is not compulsory.

Tips for general practices

  1. If you are not already working in a group that covers 30,000 to 50,000 minimum take steps to do so now
  2. If you are in some form of federation or alliance, ask yourself if the group is fit for purpose
  3. If you don’t take part in the integration agenda, you risk being run by it
  4. What can you do together that will benefit the group – can you share workforce, rationalise back office functions or find new ways to bring in income?
  5. Bring others with you – communicate what the group can do, how it will benefit every practice, particularly bearing in mind the resilience and sustainability of individual practices. Leave the door open for practices even if they are initially reluctant to get involved
  6. Engage with other groups of practices working together – and where it is sensible to share functions or deliver services across a larger footprint, start these discussions
  7. Share the vision for primary care in your local area – is it in line with the STP? If not, sit down with the STP and agree a vision you can all support
  8. Identify who is leading the STP in your area, and find out who is representing general practice at the planning discussions. Engage with the STP and get primary care seen as a key partner with a clear direction and vision that is owned across the groups of practices

The resilience funding in the GPFV is only partly about shoring up struggling practices. It’s also about finding ways to work together that benefit practices and their patients. It can help to have a neutral third party involved in leading these discussions, helping you map out the options and alternatives, the risks and opportunities, and the hurdles you need to overcome. PCC has helped many groups of practices to work together. For further information contact enquiries@pcc-cic.org.uk

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