PCNs and The future ICS
ICSs (integrated care systems) are a new way of planning and organising the delivery of health and care services in England on a larger scale than PCNs. They bring together NHS, local authority and third sector bodies to take on collective responsibility for the resources and population health of a defined area, with the aim of delivering better, more integrated care for patients. The model is seen by NHS leaders as the next step for health and care integration in England. As of February 2019, 14 ICSs are in place but, in its Long Term Plan, NHS England has announced that they are now expected to cover the whole country by 2021.7 The BMA supports the overall concept of integration, which we believe has the potential – if implemented with the full input of clinicians – to improve both patient care and doctors’ working lives. The ICS model could deliver on some of these opportunities. A more controversial model of integration, the ICP (Integrated Care Provider) has also been introduced by NHS England. ICPs involve merging multiple services into a single contract, held by a single provider. ICPs have been subject to controversy and the BMA has been clear that we oppose their introduction, as they increase the risk of privatisation and are incompatible with the independent contractor status of GPs. Only one ICP is known to be in development, in Dudley, and is expected to be in place by 2020.8 ICSs have a specific focus on enhancing the role and scope of primary and community care services. Every ICS will have a critical role in ensuring that PCNs work in an integrated way with other community staff and use integrated MDTs across primary and community care. PCNs are central to the provision of integrated, at-scale primary care, encompassing services beyond core general practice and working closely with acute, community and mental health trusts, as well as with pharmacy, voluntary and local authority services. There is no blueprint that ICSs are expected to follow, so their appearance and approach varies. However, general elements of structure for ICSs have emerged. Every ICS will have to establish a partnership board drawn from commissioners, providers, PCNs, local authorities and third sector organisations within the ICS. Every PCN will have a named accountable clinical director. While they will lead the PCN and oversee the service delivery elements, they will also play a critical role in shaping and supporting their ICS and dissolving the historic divide between primary and community care. The general structure will operate on three levels: ‘system’, ‘place’ and ‘neighbourhood’ (also referred to as locality). Most work within an ICS should occur at the ‘place’ and ‘neighbourhood’ levels, with the remainder carried out at the ‘system’ level. The ‘neighbourhood’ level has a significantly smaller footprint and will be based around PCNs. At this level, practices will continue to provide core services. The new PCN DES gives an opportunity for practices working with partners from the voluntary, social care and community sectors to deliver new services at scale.
At ‘place’ level, PCNs will interact with hospitals, mental health trusts, local authorities and community providers to plan and deliver integrated care. At ‘system’ level, PCNs participate through their clinical directors as an equal partner in decision making on strategy and resource allocation (see page 21 for details on the role of clinical directors). Partners who belong to the ICS and signed up to an alliance agreement ensure collaboration across hospitals, community services and social care, helping to join up and improve care.