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Making the system work – general medical practice representative and formal structures in Cheshire

Introduction

This short paper highlights the key developments in Cheshire to ensure there is an active and effective interface between general medical practice service (GMS) providers and the Integrated Care Board (ICB) of the Cheshire and Merseyside Integrated Care System (ICS).

William Greenwood
William Greenwood

Background

Cheshire was previously divided into four former Clinical Commissioning Group (CCG) footprints. In 2019 and following a detailed communication and engagement exercise the four CCGs merged into a single CCG for the whole of Cheshire. This did cause some local concern at the loss of the ‘member’ practice interface arrangements with the principal NHS commissioner of services.

The former CCGs would have had between 18- 25 practices each and this changed to around 80 with the single CCG. Many GPs feared a loss of ‘voice’ with the commissioner especially as Cheshire has a diverse geography with city and rural areas, and pockets of deprivation which due to the area did not always show up in statistical reviews. The same can be said for our traveller and ‘boat people’ (those living on canal boats) populations.

Local representative and commissioning links were well managed and most GPs fears were resolved due to the work the new merged CCG put into the process.

Just over 18 months ago we saw the disestablishment of CCGs and the emergence of the ICS structures. In Cheshire’s case an ICS for Cheshire and Merseyside with nine former local authority areas and significantly different former approaches to developing and financing general medical practice development.

Former CCG member fora and representative links with LMCs, GP federations and primary care network (PCN) clinical directors (CDs) were replaced by new arrangements either at a ‘Place’ (local authority level) mainly for PCN CDs or via an ICS developed Primary Care Provider Forum. The GP voice in commissioning appeared to have virtually disappeared except via Local Medical Committees place within the NHS Acts and Place arrangements with PCN CDs.

Most practices felt distanced from the ICB central primary care team and having to work through very small Place teams with no direct contact to the ICB or NHS England.

Why do anything (and developing arrangements)?

It was clear the ICB found the thought of having to work with over 350 individual practices across Cheshire and Merseyside as too much for them. This was aided by the centrally commissioned Fuller Stocktake Report which was written for an ICB audience. PCNs were to be front and centre in future planning even though they had no statutory legal structure; being a voluntary add on to the national GMS contract arrangements.

Whilst there was no suggestion this would change the direction of travel was clearly “let’s see how things develop ‘organically’ at a local level.” Mature PCNs might incorporate and become super practices or similar without the need for NHS England or ICBs to dictate it. Increasing the proportion of funding going direct to PCNs rather than via the GP national contract was obviously aimed at achieving this outcome.

In Cheshire two Place structures were established to match local authority areas. Each with its own small ICB outposted staff and a senior accountable officer (Place director) who was part of the ICB senior structures. The GP practices were aligned to each of these dependent on geography.

Above this structure sits the ICB of the ICS. The ICB being responsible for GP contracts and the PCN directed enhanced service (DES) amongst other roles. Places have delegated authority and funding from the central Cheshire and Merseyside resource.

Separate to these structures sit NHS England (Cheshire and Merseyside) a subset of NHSE North West England.

Shortly after its establishment the ICB established a Primary Care Providers Forum which included all four-family health service independent provider professions (each local representative committee having one representative and two for the LMCs), plus representatives for PCN CDs and GP federations. This was not a decision-making committee but one which fed into the ICB making recommendations and putting forward proposals. After 18 months this was not felt to be adding value and so a proposal is currently being discussed to modify the terms of reference and structure of this set up.

Separate to the above ICB led forum the following structures are in place (as they relate to GMS)

Cheshire LMC reformed its constitution so that it’s 18 constituencies reflected the 18 groupings of GP practices making up the 18 PCNs. (note each of the GP federations has a co-opted seat on the LMC as do the two PCN CDs who sit on the ICBs Primary Care Provider Forum)

The LMC, GP federations and PCN CDs agreed to form to GP provider collaboratives, or confederations, (one per local authority area) to act as a single voice for general practice locally. Mandates were obtained from all practices in each area and steering groups set up to develop the structures and support. These two confederations meet monthly to discuss a range of issues and outputs are agreed and fed up to Place, the ICB and Local Authorities as required. Discussions are also fed into other fora as required (such as via the LMC to the Cheshire and Merseyside Association of LMCs). This multi-LMC arrangement was set up by the five local LMCs within the ICB geographic footprint just before the ICB came into existence.

Each Place has been tasked with establishing strong interface links between primary and secondary care. This work incorporates the ICB document ‘Consensus on Primary and Secondary Care Interface’.

The LMC in Cheshire is central to many of these new arrangements as it had existing formal and informal links to the organisations across Cheshire.

Summary

Work on the two Confederations is still in its early phases. All practices have provided a remit for their respective Confederation to act on their behalf in matters discussed with Place and the ICB. Each Confederation has established a programme of monthly meetings involving all local GP practices and PCNs. They have been recognised by the ICB as part of the local engagement and collaborative working arrangements as described above.

Work is underway to put in place a GP capacity in primary care alert system (like the GPAS system used in Devon). This is fed into the two local Place teams and shared with LMC, PCN CDs and GP federations. The ICB has been asked to agree supporting the establishment of the Confederations by providing time from the two Place teams. This has been agreed.

It is not perfect but we do have a functioning way in which all local practices and their PCNs can engage at ICB Place level. The Confederation steering groups can then agree on which part of the general practice ‘family’ can best take the matter forward e.g., LMC/ PCN CDs etc.

One current area of development is a prospectus of what GPs can and will do; what they won’t do; and what they might do if the funding is agreed.

We will continue to learn form our experience and develop a flexible approach to ensure all our practices feel engaged in future decisions and planning across Cheshire.

William Greenwood, chief executive, Cheshire Local Medical Committee.

Last Updated on 30 January 2024