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I’m only a GP, m’lud

Our diarist is posed with some very real integrated care organisation scenarios - including how to spend budgets so as to stay out of prison.

The story so far

Dr Peter Weaving is a GP and locality lead for Cumbria PCT. His area is now forging ahead with ambitious plans that will integrate primary and community services – while at the same time trying to stay within budget...

‘£800m? Sounds like you're going to prison for a long time,' our critical friend said.

NHS Cumbria is in the dock with two heavyweights prosecuting. We are roleplaying, to learn to think on our feet about our ICOs. Paul Corrigan and Laurie McMahon are challenging our plans for devolution down to ICOs, localities and sub-localities by setting us some real problems and making us sweat to solve them. Paul, the architect behind foundation trusts, has, as Laurie puts it, ‘his head in the policy jetstream' – while Laurie himself is professor in health policy at City University, London, and co-founder of the Office for Public Management. Tough cookies indeed.

One of our first charges was loose terminology – when does a locality group of practices become an ICO? What is the difference between a sub-locality and an independent general practice?

They then pitched us into some very real scenarios – you know the sort – from an overspent local acute trust to hospital closures to social services on a go-slow about accepting people for residential care. We had to come up with real-time answers, decisions and, more difficult, explanations for the public about our actions.

A further scenario pitted one ICO against another. Locality blue was struggling and wanted a loan from locality grey who, through careful resource husbandry, had amassed a small surplus with which it wished to pump-prime a community densitometry service. This led to the debate about who, in the respective organisations, held accountable officer status.

The answer for the poor GP leading the ICO was that they did – and jail time was a consequence of the Treasury not being happy with its ‘line of sight' of where the money had gone. ‘I'm only a GP' was not an adequate defence in this brave new world of real clinical leadership and organisational responsibility.

Seriously, it was good team building and a challenge for the clinicians and managers who wish to staff the ICO of the future. We started with a reasonable framework but the prosecution's attack exposed some important structural weaknesses:

• Decision making – who in your group is calling the shots? Are they appointed or elected? Clinical or managerial?

• Financial rules – what are the consequences of failure? Are you autonomous or linked to fellow ICOs?

• Sensitising providers – how can you make a trust do what you want, particularly if you are now smaller than your parent PCT?

• Communication – with everyone! Your colleagues, patients, third sector, partners such as local authority, social services.

• HR – who is employing community staff? How can you protect them, their morale and their rights during another reorganisation?

• Governance – how do you keep the regulators happy and yourself out of jail?

By the time you've answered all those your enthusiasm for change is tempered by the realisation that you are one of only two PCTs in the country integrating primary and community services. Start the experiment, Professor, we need a bold solution!

I'm only a GP, m'lud