What do integrated care systems mean for general practice?
Integrated care systems bring together NHS organisations, local authority services and other partners with the aim of better meeting the health and care needs of populations across an area. The main idea behind them is to integrate care across settings bringing together hospital services, primary care, mental health services and social care. There are now 42 ICSs covering England, each with a population of around 1m to 3m people. ICSs are key to NHS England's long-term plan that was published in 2019. NHS England has pushed for ICSs to be made statutory organisations, putting forwards a series of recommendations to the government to make this happen. The result was a DHSC white paper earlier this year, which set out plans for the Health and Care Bill that was tabled in parliment on 6 July. If the bill is passed, ICSs will replace CCGs next April. Many commentators have viewed the plans as a way to undo changes that were introduced in 2012 as part of former health secretary Andrew Lansley's health reforms, which saw CCGs established. Much of what is in the bill is the direct result of a consultation by NHS England on its proposals. The changes will reverse rules around 'the market' in healthcare and competitive tendering of all contracts, instead focusing the NHS on greater collaboration. NHS England has said the plans will also make it 'more straightforward' for local areas to continue with existing providers where they don't believe there is any value in seeking an alternative, rather than all contracts having to be re-tendered when they expire. ICSs would be required to make any decisions about providers in a transparent way. However, the government has also put forward other features in the bill that go beyond facilitating integration. The bill gives the health and social care secretary greater control over NHS England and other NHS agencies and arms' length bodies, along with more powers to intervene in decisions about local service reconfigurations. Many representative organisations, including the BMA and the NHS Confederation, are unhappy about this. The BMA has argued that it is 'vital that the day-to-day running of the NHS is free from excessive political control'. The Health and Care Bill sets out legislation to form integrated care boards, which will effectively be responsible for the day to day running of the ICS. All of CCGs' current responsibilities will be transferred to integrated care boards. The bill also includes a statutory duty for the NHS and local authorities to collaborate with each other as part of an 'integrated care partnership' to deliver a plan to address health inequalities, public health and social care need across the system. The white paper which preceded the bill said that the legislation would 'aim to avoid a one-size-fits-all approach but enable flexibility for local areas to determine the best system arrangements for them'. Key to ICSs is the idea that commissioners and NHS providers will collaborate across smaller areas, known as 'places'. The white paper suggested that 'place-based joint working' and 'place-level commissioning' will usually align with local authority boundaries. The Health and Care Bill specifies that all ICSs must have a constituion, setting out how it will work, how it's board will be appointed and how potential conflict of interests will be managed. Each integrated care board will be required to have 10 mandatory members, one of whom must be from general practice, according to NHS England guidance published last month. A minimum of four executive members employed by the body will be required including a chief executive, a finance director, a director of nursing and a medical director. The ICS will also need to have three independent non-executives composed of a chair, who will be appointed by NHS England, and at least two others who will normally not hold positions or offices in other health and care organisations within the ICS footprint. A further three partner members are required who should be voted onto the board by the organisations they represent - the one member from general practice, one from an NHS trust or foundation trust and another from a local authority. The BMA has said that the one GP member is the 'bare minimum' that should be on ICS boards - and has argued that formal roles should be given to LMCs. It has stressed that the positives of CCGs, such as strong clinical representation and leadership, must not be lost in the move to ICSs. All ICSs will be expected to define their place-based partnership arrangements. Each 'place' should have agreed governance processes and the partnerships should involve 'primary care provider leadership, local authorities, including directors of public health, providers of acute, community and mental health services and representatives of people who access care and support,' NHS England guidance says. Local governance arrangements could include a forum or committee, or a lead provider managing resources and delivery. The ICS constituion should set out how these arrangements will be held accountable. Arguably PCNs are the key to making much of the changes envisaged by NHS England happen. NHS England itself has said that PCNs will be essential in helping to improving health outcomes by joining up services and using their understanding of local communities to help 'places' and ICSs to identify ways to tackle inequality. The design framework says that 'joint working between PCNs and secondary care will be crucial to ensure effective patient care in and out of hospital.' NHS England expects PCNs to work together to 'drive improvement', however it says that ICSs will need to consider the support that clinical directors, as well as primary care as a whole, will need if it is to be able to do this. The BMA has questioned whether now is the right time for the government to be embarking on sweeping changes to the structure of the NHS given that the pandemic is ongoing and the health service is facing a huge backlog of care. The government, on the other hand, believes that the changes are 'a critical part of the recovery process from the pandemic', according to its white paper. The BMA has also said that, while it welcomes the bill's plan to remove enforced competition, the changes do not go far enough. It would like to see the NHS guaranteed as the default option for all NHS contracts, which should only go out to tender if that is not possible. Meanwhile, the RCGP has warned that general practice must be the 'foundation of any successful ICS' and that GPs need a strong voice within the systems as they take over responsibility for commissioning from CCGs. A key concern relates to funding and whether budgets across a system could be pooled at some point in the future. The NHS Confederation has warned that general practice needs a guarantee of ring-fenced funding beyond 2024, when the current five-year GP contract ends, because of concerns that cash could be stripped from primary care. A report from the confederation said that proposals to move commissioning to ICS level were leading to apprehension regarding future funding for primary care. Having just one primary care representative on integrated care boards also risked the acute voice and financial demands dominating the agenda, the report added, warnning that funding could be taken away from primary care. The BMA has also cautioned that there needs to be transparency over spending decisions. There are also real concerns that there is still no proper plan  or sign of one  for social care, or for how the NHS is going to address chronic workforce shortages across the service. Health Education England this week reported a record breaking year for the GP trainee intake for the fourth year in a row, but the overall GP workforce remains in decline - with 10% fewer fully-qualified, full-time equivalent GPs now compared with five years ago.