Are Integrated Care Systems doomed?

Integrated Care Systems are being hailed as the future of Primary Care. But are they doomed to be yet another forgotten reorganisation like FHSAs, PCTs and CCGs?

Politicians seem to give very fixed prescriptions about how best to improve the health of our nation. They always talk warmly about how they appreciate front line staff and support the values of the NHS. But then they say that the NHS needs to be reformed and things cannot continue as they are.

So what do they say about General Practice?

• The current system is not “fit for purpose” – what they say when they don’t like something and want to scrap it without giving an explanation
• General Practice ownership to be transferred to hospitals or private companies
• GPs to become salaried
• A move from a network of practices to a pyramid of command and control

Are they right? Is this the best way to run the NHS? Will this be good for the health of our patients?

Reorganisations R Us

But this is one of many reorganisations of General Practice. Since I started as a GP there have been a lot of central initiatives to change General Practice. Fundholding, PCGs, PCTs, CCGs, extended hours, extended access, PCNs and now ICSs. You could almost rename the NHS as Reorganisations R Us.

And the recurring theme in these changes is to lump GPs into bigger groups which are easier to control

The problem I found was that I couldn’t get excited about any of them. They seemed profoundly disconnected with what we actually do. Which is looking after patients.

Big Business ideology

I used to think this was some sort of senior management game of doing a reorganisation with much fanfare and then getting promoted before the true costs were apparent. And as soon as they had introduced one initiative they would decide it hadn’t done what they wanted and scrap it for a new one.

But now I think there is an ideology at work and that they genuinely think General Practice will be better if it is run like a big business. Perhaps they think they can cut costs with economies of scale.

Which left me wondering, since they have been trying to do this for decades, why is most General Practice still provided by partnerships? Is there something about this way of running General Practice that helps us to look after patients?

How could being locally owned give surgeries a competitive advantage?

• Long term view – Local GPs are committed to an area for years or decades. They will take a long term view about how services develop and not be impressed with short term gains which then fade. They appreciate the cost of the disruption which reorganisation brings and build their teams in a more sustainable way.

• Rapid development – Locally owned practices can try new things without needing to ask permission. This lets them make improvements and adjust to changes in their local circumstances far quicker than a bureaucratic organisation could.

• Staff Performance and Retention – Having a direct say in how you do your job makes you enjoy your job more and makes you more committed. Being locally owned can therefore improve the quality of care and reduce the costs of staff turnover.

So does this actually improve patient health?

The key question is whether local ownership helps our patients live longer and enjoy better health. This is not about whether it feels better or we prefer it. It is about whether it leads to better outcomes in the long run. This is hard to measure directly because health is affected by other things outside our control, like employment, education and housing.

However, one example where we can do a direct comparison is the COVID-19 vaccination campaign. GP and community pharmacy based services were considerably more effective (71% of doses) and cheaper (£24 vs £34 per dose) than centrally organised mass vaccination centres (1).

We can also compare APMS practices which are centrally owned against GMS practices. APMS practices receive £18 or 14% more per patient than GMS practices (2) for doing essentially the same job and there is no evidence that their patient care is better (3).

What does this mean for young GPs choosing where to get a job?

First, despite the current rhetoric from the Government, there have been many attempts to centrally control General Practice before and perhaps these have failed for a reason.

Second, there is evidence that local ownership of General Practice may be more effective at looking after patients than central control and it is likely that this will be better for our patients and ourselves.

If Integrated Care Systems engage with local practices and let them spend the money on what they need then perhaps ICSs won’t be scrapped in 5 years and become yet another footnote in the history of the NHS



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