Much of the reaction so far to the Fuller Report has been that it’s pretty anodyne and that the implications for general practice are relatively limited. My sense, however, is different; the report could end up being one of the most significant ever for general practice and how it operates.
This is because of the impact it will have on the independence of practices and their ability to operate as stand-alone businesses as they have done for so many years. The aim of this report is to create a vision for integrating primary care. Whilst this may not sound that surprising given the context of Integrated Care Systems (ICSs), the corollary of more integration is less independence.
This is hugely significant because independence has been a hallmark of general practice since the NHS began. Instead, the onus will be on practices to work not only with the other practices in the PCN, but also the other organisations in the local neighbourhood area.
This will happen as a consequence of some of the changes outlined in the report, which I will now explore.
- Change in how funding comes to general practice
At present the majority of funding that practices receive comes via the national contract. However, the big push in this report is for much more control to come via the local Integrated Care System. This is what this particular section of the report means: “National contractual arrangements, including for PCNs, have provided essential foundations including for chronic disease management and prevention. But they can only take you so far… ICSs putting in place the right support locally will be enabled by maximising what control ICSs have over the direction of discretionary investment”(p28/29).
We already know that any additional funding for general practice will come through PCNs, and now it would seem that this funding, along with that of any local enhanced services, will be coming via this local route. This will be a big change for general practice, and will bring new challenges concerning how practices meet the requirements and expectations placed upon them. The local NHS will move from being local contract managers to playing a much more pivotal role in determining the future for practices.
- Shift to a single system-wide approach to managing urgent care
The aim of this change is to join up the services available in a neighbourhood (PCN) area and combine them to create single urgent care teams. The aim is to “connect up the wider urgent care system, supporting them to take currently separate and siloed services – for example, general practice in-hours and extended hours, urgent treatment centres, out-of-hours, urgent community response services, home visiting, community pharmacy, 111 call handling, 111 clinical assessment – and organise them as a single integrated urgent care pathway in the community” (p11/12).
This won’t work with the existing model of practices triaging their own workload. There will need to be some shared system of triaging and directing demand. What this means is that practices will soon have far less control over how they manage their own practice demand.
I’m not saying this is a bad thing. What I am highlighting is that the consequence of introducing this change will inevitably be a reduction in the autonomy of practices.
- Evolution of PCNs to Integrated Neighbourhood Teams
The report states that it expects PCNs in the most deprived neighbourhoods to become Integrated Neighbourhood Teams by this time next year, and within a year after that for everyone else. This means PCNs will shift from being primarily a joint initiative across the member practices to being much larger entities. They will have aligned resources from community, mental health, acute and social care teams. The leadership and management and support infrastructure of these teams will be expanded accordingly.
It looks very likely that some of this support may come from existing NHS organisations. This shift will be made by “making available ‘back-office’ and transformation functions for PCNs, including HR, quality improvement, organisational development, data and analytics and finance – for example, by leveraging this support from larger providers”.
Exciting as the new teams sound, what they mean is that control of PCNs may drift away from practices, as more organisations become active participants in their next iteration. At the same time, additional funding for general practice is still likely to come via these teams (continuing the trend we have seen with PCNs), and so accessing this funding may prove more difficult in future.
What does all this mean for practice managers?
For practice managers, this means their focus will have to become much more externally focussed. It will mean working with partners to ensure that sensible local decisions are made about how things will operate in the neighbourhood, as well as having a new accountability in the system for delivering their practice’s part in the new way of working.
It seems only a matter of time before the practice managers in an existing PCN area will have a collective accountability in the neighbourhood leadership and management team. It may well be that at least some of this team come from one of the existing provider organisations, such as the local acute or community trust. As more resources shift from national to local then this new accountability will most likely grow year on year.
As with any change, there is of course huge opportunity. General practice cannot carry on along the course it has been going, and there’s a chance to use these changes to create a sustainable future for the service. However, practices and practice managers will need to ensure they play an active role in making sure they shape how the changes progress locally. The more effectively practices, and practice managers, work together, then the greater the chance of influencing these changes positively and turning them into something that can work for their patients, their practices and themselves.
June 10, 2022 at 8:42 am
After 73 years of `independence` how can General Practice expect a system born to cope with 52million population now deal with 62million? In 1948 the waiting lists for hospital treatment were 500,000 , there were 53,000 empty hospital beds due to staff shortages and the Ministry of Health was frightened that GPs would be swamped by people with ‘seemingly trivial ailments, with the risk of developing a disease-conscious frame of mind’ (what unusually accurate insight from Civil Servants!!).
There is much wrong with the NHS as repeated `investigations` have highlighted. GPs complain about Secondary Care, Hospitals criticise GPs for not being effective in coping with patients suffering minor health issues, Doctors criticise managers – but MB.ChB or MRCGP are NOT management qualifications, while Managers complain that doctors don`t realise that efficiency matters – but don`t have the clinical knowledge that doctors possess to treat patients. As if that was not enough, now we have lawyers and the judiciary involved in stripping the Service of funding through inflated compensation claims and leaving clinicians scared to make clinical judgements in what is at best the imprecise science of medicine.
On top of all of this is a population over-emphasising their `rights` at the expense of their `responsibilities` to treat the NHS as a cash and time-limited public service and there is a perfect storm coming unless the whole thing is redesigned from the ground up. Collaborative working is only just a start. Stop complaining about your independence and think more about what works best first for the patient, second for the service as a whole and third for your profits – because if you don`t someone in due course will likely nationalise you and put you on a salary and dictate what you do, where and when.