It's Primary Care Jim...but not as we know it!

Below is a post originally written by my colleague and Co-Director in our GP Federation support company - Mike Pyrah: Mike is the ex Chief Exec of Central and East Cheshire PCT and together we have setup 2 not for profit GP Alliances winning almost £3Million in new funding for those practices - we are currently working with 3 other groups wanting to federate. If you are interested - get in touch.

Its Primary Care Jim…but not as we know it…

Over the last few months there have been a range of headlines in trade journals and in national newspapers predicting the imminent demise of primary care, we recognise that primary care is facing significant challenges, and that there is a need for urgent changes to the way we are organised if we are to both meet these challenges and to deliver the ‘transformation’ agenda set by NHS England. The purpose of this paper is not to re-iterate the strategic direction set for primary care but to highlight our views on the actions that practices need to take to make sure they are equipped address the challenges.

It is important to stress that we believe that we should not get fixated on the ‘independent contractor model’. New models may emerge but we believe that the current employment model is very productive, and changing the model will not in itself provide solutions, but simply bring different problems.

Our focus must be on preserving what is best about the practice list model. We passionately support the notion of ‘continuity of care’, we recognise that practices should focus on the elderly and those with long-term conditions, we understand that access issues for those patients without ‘on-going needs’ are also important, but we must not through the baby out with the bath water as we look to provide urgent care solutions.

The following twelve point plan sets out an agenda for how practices can organise themselves to meet the challenges. We believe that this plan is vital for practices, but it is also important that CCGs make this happen!

Ensure the development of GP federations and Alliances. We believe that practices can only meet the likely requirements of the ‘transformation’ agenda if they work together. The key is that practices need to want to work together and not feel that they are being forced to work together. Alliances need to be focused on different ways of delivering services ensuring that patients can access services from a range of premises. We are strong proponents of the ‘federal’ approach, ensuring that you only do centrally what the ‘parts’ deem to be appropriate. The ‘Primary Care at Scale’ mantra should be supported.

Develop Practices, Alliances and Federations as providers. We recognise that CCGs were intended to be clinically led and that GPs are actively involved in leading Commissioning, and indeed are now to be part of the Co-Commissioning of Primary Care; however we believe that Primary Care as a Provider should have a separate ‘voice’ and strength. We pose the open question – how is primary care as a provider represented locally in the determination of policy? A strong Primary Care provider presence will be extremely beneficial to CCGs as they wrestle with their agenda, we do appreciate the importance of absolute clarity between commissioning and provision, particularly as we develop Accountable Care concepts.

Develop Primary Care based provision. We believe that it is vital that we create a strong vision of what services could and should be provided within a primary care setting. Creating a compelling vision must be the starting point for a plan to shift the balance between primary and secondary care. We believe that each CCG should be clear about the services which should always be provided ‘close to home’ and ensure that practices work together to deliver this agenda. Our view is that just as CCGs have a list of ‘services of limited clinically value’ they should have a list of ‘services to be provided in a primary care setting’ irrespective of who is the provider.

Practices must in their alliance models develop new ways of ensuring the right services are provided in the right place at the right time, we expect new ways of: providing community services, providing secondary care from primary care settings and promoting health and well-being. We believe that alliances should clearly ‘set the direction’ and agree robust plans as to how to ‘make it happen’.

Ensuring the Partnership model is fit for purpose. We believe that practices need to think about how to make the independent contractor model work for them. We hear too many stories of partnership meetings being dominated by discussions, for example, on the ‘holiday rota’. We believe that practices need to fundamentally review their management arrangements to reflect the way that partners now and in the future want to work. Primary care is badly managed, this is not a criticism of practice managers but a commentary on the way that Partnerships work. We would question, for example: the role and purpose of senior partners, the way we engage new partners the management of practices, the way we use our managers. We believe that there are ways of making the partnership model effective but it will require partners to recognise that changes are required. There are lessons that GP partnerships can learn from other sectors such as the legal profession.
Finally we should not avoid the ‘M’ word, practice mergers are sometimes the right answer, we believe that there is good evidence that mergers can work to the benefit of patients and partners.

Managing capacity and demand. We believe that capacity remains our biggest challenge. We need to ensure that Primary Care is ‘open for business’ and that we change the perception of access difficulties. We believe that there are potential capacity solutions which will not reduce partnership income. The answer is often to learn from other practices, and to work effectively in alliances and federations, for example could an alliance organise to provide services from one practice on a Saturday that can be accessed by patients from a range of practices? We need to collaborate to make effective use of our resources. It is also essential that we find an effective and efficient way of quantifying demand and capacity. We know that there has been much greater investment into secondary care rather than primary care; one of the main reasons for this has been our inability to quantify what we do, and the increasing demand and workload. We believe that we need to create a simple Primary Care ‘dashboard’ highlighting demand and capacity.

Effective patient engagement. We are concerned that the drive for better Patient Engagement has become a bit like motherhood and apple pie. We believe that practices need to work together to develop practice and alliance based approaches to engage with our patients. In short we need to realise that Healthwatch and CCG initiatives are laudable but that real patient engagement should be led by the practices. We need to ensure that we understand (and are driven by) needs and wants, and that we recognise our ability to influence and change behaviours.
Utilising our ‘Estate’. We believe that one of the barriers to the development of primary care has been the poor quality of the Estate. It is therefore really important that where investment has been made into the Primary Care facilities that this investment is maximised and the estate is used to its full potential. Within alliances there are ways of utilising the estate in a way which benefits all practices, we need to be innovative and most of all we need to be ambitious, particularly as we consider the wider primary care provision of community services, pharmacy, optometry etc.

Our Primary Care Workforce. We believe that there is a crisis in our primary care workforce. In some ways the crisis is being talked up by the usual polls indicating something like – 70% of GPs are going to retire in the next five years – however we do know that it is increasingly difficult to recruit GPs and that there has been a serious reduction in community nursing provision. We do not believe that there are easy ‘local’ solutions which are in the gift of practices; however we do think that there are actions which will make some practice posts more attractive than others. These actions include the inter-practice training and education, co-ordinated research activities and secondment and development opportunities. Most important of all however is that we feel that potential applicants will be attracted to practices that are doing all the things on our list and are working effectively in alliances.

Utilising IT and social media. We believe that practices have not as yet scratched the surface of the potential of IT. We know that most people use technology as an integral part of daily living however healthcare provision remains, in the main, locked in the last century, where we are thinking of using technology this is usually as part of the traditional way we provide services. We need to take a radicle approach and utilise the potential of technology and social media. Finally we need to recognise and challenge the limitations of the national SOC policy, we believe that this policy is significantly hampering the roll out of innovative IT solutions.

Fostering Innovation. Innovation is not just about IT, we believe that there are a lot of innovative developments happening across primary care in this country and abroad, practices need to find the time to ‘look up’, we recognise the difficulty in doing this but believe that there is potential to use the alliance model to create a vehicle to foster innovation, and to ensure that practices are part of a constructive ‘learning alliance’.

Utilise the assets in the communities we serve. We believe that there is lots of potential for primary care and the third sector to work more effectively together. The majority of third sector provision is focussed on health and well-being, we recognise the need to establish systems to enable primary care services to both signpost patients but to also develop integrated provision, in particular we support the development of practice facing services designed to meet the social determinants of ill health.

Creating our advocates for the future. We need to create a new cadre of GP leaders who believe in this plan as the way forward. Whilst we have a number of GPs who are active in respect of CCG commissioning, the majority of the rest are either planning for their retirement or too busy ‘doing the day job’ to consider changing the way that primary care works. We need to find a way of enthusing colleagues to lead us to develop our new ways of working.

Our vision for the future is based on groups of practices embracing the need to work together to develop services that meet the access, and service, needs of those we serve. We believe that if we can follow this model primary care will not be the ‘problem’ but will be the ‘solution’.