Time to get into these new neighbourhood teams

GPs are in a strong position to lead the move to more integration in primary care – so become involved and ensure you get what you wish for. Justin Cumberlege and Robert McCartney set out the way ahead.

What are Integrated Neighbourhood Teams (INTs)?

The concept of the INT, originally introduced in the influential report by Dr Claire Fuller called ‘Next Steps for Integrating Primary Care’, was to look at ways of breaking down traditional barriers within health, social care and other public services.

This aimed to create a single function creating solutions that addressed all the needs of the individual within any given community. The concept has gained traction and been adopted by the Labour government.

But the role of general practice within the INTs is yet to be fully defined or understood. It is important for GPs to be involved in this change and that it is not imposed on them.

Before Dr Fuller’s report the primary care networks (PCNs) were expected to undertake some of this integration. Schedule 7 of the PCN Network Agreement required details of the terms of engaging with third parties.

It was expected that PCNs would expand to encompass a wider range of members beyond the core GP practices. In most cases this did
not happen because PCNs became focused on becoming service delivery vehicles offering services at scale as required under the Primary Care Network Directed Enhanced Service (DES).

How can general practice secure its position within the INTs?

GPs are in a prime position to be central in INTs. As the most consistent part of the wider primary care structure for many patients, they may unite the other elements of healthcare, and give primary care a collective voice at ‘place level’.

This would generally need a population of over 200,000, which would require getting together with other PCNs.

By joining together with other primary care providers, such as the providers of 111, out of hours, community pharmacy, optometry and
dentistry, primary care will have a voice which is counted by the Integrated Care System.

This would make them equal to acute trusts, community providers, mental health providers, social services, education, other council run services and third sector providers across the area.

While 200,000 is a large scale it would be built on the foundations of each neighbourhood which can advise and influence policy based on the experiences in their areas while creating INTs.

Creating an organisation of primary care services – although not necessarily providing them – to ensure the patient pathway through
primary care is efficient and effective, and only accesses secondary care at the appropriate time, if necessary, is an objective cited by Lord Darzi’s report Independent Investigation of the National Health Service in England.

How can this structure be co-ordinated?

Once there is a willingness for the primary healthcare providers to come together, there is a question as to how it will be co-ordinated.

Memorandum of Understanding At the least a Memorandum of Understanding (MoU) will assist in setting out some non-contractual objectives, and how the parties will work together to implement them.

This document will be aspirational, while proposing objectives and commitments by different parties to perform certain tasks.
However, as a non-contractual document, commitment may be low, and it could become a talking shop which may not be of value. Also, it is unlikely that any bid for funding is going to be successful based on an MoU.

Collaboration agreement

A step beyond that is a collaboration agreement, where the parties agree what each will provide for the services, and the organisation of them, much the same as an MoU, except there are usually certain matters which are agreed contractually as there is a deeper involvement of the parties.

This is normally in response to a commissioner’s request for certain services to be provided. A group may come together in a geographical area with the objective of submitting a joint bid and to manage the delivery of this service.

The first step is to agree who is required to participate in the bid, and what their roles will be. For example, one party might agree to provide premises and arrange appointments, while another provides a service and a third another service.

Also, the parties would agree how they will fund the bid and establishment costs. This needs a commitment by all participating parties to ensure the bid is written and a commitment to their roles if it is successful.

Within the wider context of the INT this structure would be a unified voice built primarily around the service on which it was focused.
There is no reason why this type of agreement could not be expanded to bring in other partners from the INT.

An emergency paediatric dental service could, for example, include the local 111 provider, dental practices, GPs, mental health provider,
education services and social services to provide a unique and integrated pathway for service users.

While this would be service-specific the lessons and experience of building this collaboration could be expanded into a wider range of INT services.

Contractual agreement

If there is a vision to create a movement which will have an impact, and which needs a longer-term commitment from the participants, then a contractual agreement would be advantageous.

This would require the parties to co-ordinate their actions, resource the activities, and appoint a leadership team to speak for the group and perhaps carry out certain actions.

There could be restrictions on the participants to protect the activities of other participants. Consideration does need to be given to the anti-competition regulations if there is a competitive market. Restrictions effectively prevent that competition in certain areas.

For GP practices, contractual arrangements could be somewhat problematic, as each individual GP partner is a participating party, and
would also carry personal liability for any breach. This is similar to the network agreements, but on a much larger scale, and could involve areas on which they are not familiar and have little control.

Joint venture company

Mitigating the effects of the risk of incurring a large liability is often achieved by incorporating a company. This would be the next step for participants – to form a joint venture company, a separate legal entity.

The legal entity would typically be a company where all the participants are members. A board is appointed to run it and ensure it achieves intended objectives.

The directors would also participate in the integrated care system, promoting the effective provision of healthcare services by company
members, whose numbers could be expanded to include all parties providing primary, social and healthcare.

A separate legal entity has many advantages. It has the sole objective of pursuing its business objectives and the directors’ primary responsibility is to do what is best for the company.

The company can employ people in its own right, so they are not being seconded from other businesses, although they could be part time for this business.

Data sharing issues are made easier by one company being the organisation receiving, processing and controlling it.

The company would be a place where integrated care is organised. It can draw from the knowledge and experiences of members, directors and management team. They should know what is possible and what the ICB’s priorities for the area are.

It would need to be resourced, initially by the members, and then by any provider contracts it takes on.

CQC registration would be required if it is a provider, and staff access to NHS pensions would require an NHS contract (or sub contract) to provide healthcare services. By careful planning, exemptions should be applicable which reduce or remove the risk of VAT being applied.

A large advantage for the GPs is that there is no personal liability for the organisation’s activities other than the duty to perform the role of a director.

How to get started

There is no need to begin from the ground if there is a GP federation already owned by the practices and which has CQC and NHS employer status.

It may be a matter of introducing members from different providers, and/or having them on the board, and perhaps forming a sub-committee to co-ordinate the integrated service. You face a cultural challenge. The care sector is governed by local authorities, the GPs are subject to a very rigid NHS contract and the NHS commissioners often prefer a public sector (NHS Trust) option if available, even if that is a company owned by an NHS contractor and has been set up as a community interest company (CIC).

But the government push to integrated care, the current dominance of primary health care by the private sector (traditional GP partnerships) and the cost effectiveness of that sector, all provide advantages for integration to happen. GPs are in a strong position to lead this change and building those relationships with the local primary care providers is an excellent starting point.

A unified primary care voice will be more persuasive than individual PCNs representing GPs.

First published in AISMA’s Winter 2024-2025 edition. 

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