Transforming primary care: let's start with the basics

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Part of Time to Think Differently

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.

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Comments

Richard Fieldhouse

Position
Freelance GP,
Organisation
Pallant Medical Chambers
Comment date
02 January 2013
It's a lovely vision, and interested to hear what your thoughts are on balancing the quality of the delivery of primary care with a motivated clinical workforce. With more and more GPs being taken out of direct patient care, what can be done to ensure patient needs are still being met?

Sarah Fraser

Position
Consultant,
Organisation
SFA Ltd
Comment date
02 January 2013
I like your approach of "general practice must take seriously the health of its registered population". This is a mindset change and could be very effective.

From what I read about what's happening in Cumbria I think I'll move there! Seriously though, I expect in time, the effectiveness of primary care will, for someone moving house, be as important as the access to and quality to schools.

James

Position
GP,
Organisation
Downland Practice
Comment date
02 January 2013
I don't think GPs need any prompting to understand the need to change, nor do I think you will find many who would be the least undermined or resistant to the changes you suggest. It is the health, social, local government and national governement that most needs to change attitudes. For the Nat Gov the NHS is all about hospitals, Primary care is all but absent in voice at higher tables- particularly at Richmond House and Quarry Hill. Local government would rather set up services outside primary care than integrated within them, public health sits elsewhere coming out from time to time to offer a needs assessment. The mindset needs to change in the system. GPs don't just to viruses!

flobach

Position
Paramedic,
Comment date
02 January 2013
An important and integral profession within healthcare has unfortunately not been mentioned once here - the Paramedic Profession. Often forgotten in healthcare debates, yet omnipresent on our roads, hospitals, and homes.

Paramedicine has moved on from the old "Ambulance Driver" adage. Now, Paramedics provide high quality critical care in the (mainly) out of hospital field. Over the past decade, with the introduction of Extended Care Practitioners or Paramedic Practitioners, Paramedicine has officially extended in to the sphere of Primary Healthcare - rather than take everybody to hospital, Paramedics can initiate treatment at the patients home, and organise follow up care if required.

This concept has proved popular and useful amongst not only NHS Ambulance Services, but also started a worldwide trend, spawning similar initiatives in the US, Canada, Australia and other countries.

And with good reason, too. There have been a number of research articles written on this topic, with the latest one again in favour of at home rather than in hospital treatment: http://flobach.com/2012/12/12/hospital-care-in-or-out-of-hospital/

Paramedics are very often the first healthcare professionals that patients see for an any health issues, with the added benefit of seeing the patient in their home environment. This allows them to gather important and, compared to hospital-based staff, exclusive information which can dramatically impact further decision making for the patients healthcare needs.

With their education, experience, nature of work and working environment, Paramedics are ideally situated within the healthcare system to have a great and positive impact on primary health within the community.

Integrating Paramedics further in the healthcare system, especially in Primary Care, is a high quality and cost effective solution, and one that we will be seeing even more of in the future, within the NHS and internationally.

Harry Longman

Position
Chief Exec,
Organisation
Patient Access
Comment date
03 January 2013
Agree with Hugh on the centrality of the doctor patient relationship, and the question is how to cut away everything that has intruded. It is a long list, as Hugh outlines above. The intrusions have largely come down through policy initiatives and the flow doesn't stop. Perhaps that is the first step, to get our NHS and political leaders to understand the healing capability in that relationship. The how of delivering change follows. There is no point delivering more system change in the wrong direction.

Patrick Newman

Position
advisor,
Organisation
the 3e's partnership
Comment date
03 January 2013
Joint working across practices is long overdue and now the technology is there to facilitate it. Add in the very valuable comments about paramedicine to deal effectively and efficiently with 'coughing grannies and injured kids' and more and you get a 'manifesto' for CCG's. However GP's and CCG members do have their day and evening jobs so resources please.

Gavin Routledge

Position
Concept Developer,
Organisation
Fitladder
Comment date
03 January 2013
I'm very interested in Hugh's question about 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?"
We're building a web-based, mobile compliant, social platform designed to help people change their habits around the Big Four health behaviours, based on the Theory of Planned Behaviour and the Transtheoretical Model, and incorporating social support - anyone out there interested in being involved in trialling it?
Is anyone currently using a similar model?
Thanks
Gavin

Elizabeth Angier

Position
Gp,
Organisation
Chair Of RCGP Sheffield faculty
Comment date
03 January 2013
My first comment would be it is good to see a gp blog on the kings fund site .
I agree with your insightful thoughts Hugh and although I'm proably more involved with thinking about the federated models and integrated care you are right ,certain basics need to be tackled first .
There are however workforce issues here and good multidisciplinary care is vital .I also think there needs to be more encouragement and support of sessional drs- salaried ,locum, , gp returners etc in the development of the new structure they are currently not well represented . The CCGs should also look at how to provide more flexible working conditions for staff to make these changes work .

Sarah Cowling

Position
CEO,
Organisation
HealthWORKS Newcastle
Comment date
03 January 2013
Gavin - I wonder if you've bumped into Community Health Trainers along the line anywhere? They're a non web based platform, local people trained to support local communities to improve health literacy, take more control and responsibility and tackle health behaviour, one goal at a time... 'Support from next door, not advice from on high'. They're also an effective way of improving self management of long term conditions.... We are committed to reducing health inequalities in Newcastle and our Community Health Trainers are a pivotal part of our work here in Newcastle Upon Tyne. We believe that people respond best via relationships with trusted others - as Hugh mentions. Web based platforms have their place but the people we work with are not likely to turn to the Internet for support on issues around difficult and challenging lifestyle issues.

lisa

Position
commissioning manager-LTCs,
Organisation
Nene CCG
Comment date
04 January 2013
Really interesting blog and some well made points.

I wholeheartedly agree that this is about transformational change in primary care but would resist the word 'preserve'. Preserve suggests nothing changes, or an existing model is built upon. Haven't we done enough of this altready in the NHS?
Fundamentally this is about a group of people having to change from the inside out, and being supported by the NHS. It means the creation of a different relationship with your patients, and one that focuses on personalisation and active health promotion.
Also the use of 'expert change agents' to support practices in the change -yes, but in our cash strapped times, I cannot help thinking that asking for further investment is cheeky. Surely its more about practices dis-investing to re-invest, and by working with your practice population to achieve this?

Hugh Reeve

Comment date
06 January 2013
Thanks for the comment Flobach. You raise excellent points re paramedics and an expanded role. My experience is that the governance arrangements in ambulance trusts often preclude a wider role.
You may have noticed that many other community based professionals weren't mentioned in the blog - paramedics and others captured under the umbrelaa of "statutory providers".
Hugh

Hugh Reeve

Comment date
06 January 2013
Richard and Elizabeth highlight workforce issues.
Attracting the right people into the primary care workforce and then providing appropriate training is crucial.
If it's a challenge in Cumbria - our inner cities are approaching crisis.
We need a mix of opportunities, but if we have too many undertaking portfolio careers (esp GPs) where does the practice leadership come from, and how do we provide continuity to those with complex LTCs. A greater role for nurse practitioners perhaps but we need GP clinical leaders at practice level. Bit choice this statement coming from someone who now only does 2 clinical days a week I know!

jo holmes

Comment date
06 January 2013
Hi Gavin,

can you direct me to where I can find out more about your initiative?

Jonathon Tomlinson

Position
GP,
Organisation
The Lawson Practice
Comment date
08 January 2013
Continuity of care is still at the core of safe, efficient general practice. Every extension of opening hours counts against this. Most healthcare provision is non-urgent and much of it is complex, needing time, experienced physicians and consultation with allied health professionals. Some healthcare is urgent and much of it is straightforward. There are significant opportunity costs to extending the opening hours of General Practice, but there are also signifiant improvements to OOH care. Shared clinical records, expert paramedic care and rapid reassessment by a known GP could significantly improve quality and reduce errors.
Judging a practice by the behaviour of its patients would be fine if there was any evidence that GPs were able to significantly affect the behaviour of their patients. It doesn't account for the social determinants of health and could easily worsen the already prevalent (and distasteful/ immoral) behaviour of GPs who exclude patients who do not do as they are told.

Hugh Reeve

Comment date
08 January 2013
Thanks for the comment Jonathan.
I purposely did not write about "judging practices" by the behaviour of their patients. It might seem a subtle difference but the question I posed was "what would be the impact if practices measured their success by the numbers of patients who ..." and the success they would be trying to self assess, using some fairly unsophisticated data, is how well they worked with others to improve the wellbeing of their registered population - this is clearly something that moves us way beyond what general practice on its own can deliver. 600 words is not enough to develop such ideas!
Hugh

Gavin Routledge

Position
Concept Developer,
Organisation
Fitladder Ltd
Comment date
09 January 2013
Hi Jo,
Best to email me directly gavin@fitladder.com

Sarah, thanks for the suggestion. We're based in Scotland, but very aware of the substantial changes going on in England. We're excited about the move to regional health promotion; behaviour change needs to be contextual. What's pertinent in an ex-mining village in cumbria is very different to Milton Keynes. The behaviours we wish to trigger may be the same, but most other things are different. We've built the platform so that it can be "re-skinnned" for different target populations.

ALAN ALEXANDER

Position
Chair,
Organisation
Cumbria LINk
Comment date
13 January 2013
(Speaking as an individual)
Hugh is certainly saying all the right things and in fact Cumbria PCT/GPs have been proud of their Closer to Home strategy for over 4 years. However vision is not enough and turning this tanker around will take considerable effort. So my question is here's the vision what are the outcomes?

Don Ismay

Position
Nurse Practitioner,
Organisation
CPNHSFT
Comment date
18 January 2013
As a nurse practitioner working in Cumbria within the mental health field I would agree with Hugh on the importance of Nurse Practitioners, since we can work across different areas of practice. I currently work across an inpatient 'general' ward, mental health assessment and review clinics and a local GP practice. An Integrated clinical information system which is common to all these areas would be fantastic, as I could potentially see the same patient in any one of these 3 areas.

Nick Owens

Position
Investment fund-raiser and project manager,
Organisation
Owens Insight Ltd
Comment date
21 January 2013
Hugh's first element is to achieve an integrated clinical information system that allows the patient record to be shared. This requires investment and managed delivery. In today's financially tight times, an investment that shows cash payback - i.e. a sound business case - is very often necessary. However, on its own the integrated system may not clearly be such an enabler. To resolve this, I suggest, adding functionality into the investment case and scope that keeps patients out of hospital. This may perhaps involve telehealth and tele-care (and may require good broadband which in parts of Cumbria may be an added challenge just now?) By phasing the investment and delivery of results, cash returns in 1 - 2 years may be achievable. Would be interesting to hear Hugh and Don's thoughts on this.

Chima Olugh

Position
Public Health Programme Manager,
Organisation
Royal Borough of Greenwich
Comment date
01 December 2014
This is very informative.
With regards to transforming primary care what are the basic must do (nuts and blots) for a CCG to successfully implement and deliver a primary care strategy?

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Position
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Organisation
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Comment date
26 January 2015
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