Transforming primary care: let's start with the basics

It seems as if the world has woken up to the fact that we must transform primary care, and that unless this happens the NHS will struggle to deliver the patient-centred, joined-up services and the financial efficiencies that our patients – and the public purse – demand.  I have argued for some time that the key challenge for clinical commissioning groups is to deliver a transformed primary care system, and to do this in a way that preserves the relationship between a patient and their primary care clinician.

In her recent blog for the Time to Think Differently programme, Christina Patterson argued that patients with ongoing ill health need a relationship with their doctor or nurse at their local health centre that focuses on keeping them well. She also called for routine access to clinicians at weekends and in the evenings, and online access to her records and to book appointments. These perfectly reasonable expectations clash with a primary care service model that hasn't really changed in the past 40 years.

I would add that in addition to transforming the way we interact with individuals, general practice must take seriously the health of its registered population. This means going much further than the Quality and Outcomes Framework: it involves working in partnership with statutory and non-traditional providers to improve the wellbeing of the population. What would be the impact if practices measured their success by the number of patients who exercised regularly, ate their five a day, didn’t smoke, drank alcohol responsibly, were not overweight and were happy?

GPs and their teams are the NHS front line when it comes to dealing with the increasing pressures resulting from our ageing population (such as the rising numbers of people with long-term conditions, increasing frailty, dementia, and the number of people now living with cancer). Add rising expectations from patients, downward pressure on finances, and the shift of activity from  hospital to community settings, and my colleagues feel as prepared as Dad's Army facing a German invasion.

So what needs to change? Most practices are running flat out already, so exhorting them or incentivising them to work harder will simply cause more cracks to appear. Sadly the NHS has an appalling track record of supporting system change in primary care, which is in stark contrast to the resources and energy directed at improving secondary care services.

In Cumbria, our approach is to start with the foundations and develop a common platform across the county on which to build. The first element is an integrated clinical information system that allows the patient record to be shared across primary care (in- and out-of-hours), between health and social care and between primary and specialist care. This also supports the sharing of significant back office functions across practices, and allows clinicians to work across teams.

The second element is supporting redevelopment of the primary care workforce:  GPs, nurses, health care assistants and administrative staff. This needs to be done in a structured way across the whole system, ensuring consistency of standards between practices. Communication skills in particular will need to move to another level.

A third element is helping practices change the way they work – reducing waste and inefficiency, and moving from reactive to far more anticipatory care. This is fundamental stuff, and at the moment there seems to be an expectation nationally that practices will somehow achieve this while getting on with the day job. I believe considerable investment is needed to support practices in doing this.  Clinicians need the space to reflect on what must change, and then they need support from expert 'change agents' working with them in their practices to implement these changes.

As I began this blog post I expected to wax lyrical about practices working in federations, integrating with community and specialist services, and the need for clinical commissioning groups to have greater influence over the GP contract – all potentially controversial and sexy stuff.  But on reflection, I think the challenge is to support system change at scale – getting the infrastructure right, raising standards across the whole primary care workforce to reduce unwarranted variation, and helping practices change the way they  work. If we get this right, the federations, the integration and the contractual stuff will follow.

Hugh Reeve is a GP in Grange-over-Sands and Clinical Chair of Cumbria Clinical Commissioning Group.  He is leading the implementation of the CCG’s long-term conditions strategy, which at its heart involves the transformation of primary care.