Reforming primary care: culture must trump the rules

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'Without a profound reform of out-of-hospital care the NHS is unsustainable.'

It's a pretty safe bet that few in the audience at our recent primary care conference disagreed with Jeremy Hunt's opening comments. The drumbeat for reform is getting ever louder, with NHS England launching a review of primary care as part of their 10-year strategy.

For me, the conference provided two standout examples of what reformed primary care could look like. The first came from across the pond. Dr Robert Reid from Seattle described the work and development of the medical home model developed at Group Health – the integrated health care insurance and delivery system that serves a population of 675,000. Its beginnings eerily echoed headlines about general practice today, with Rob reflecting on the comments he had heard frequently from the primary care workforce:

'the way in which [care] is structured, it has shifted such an increased amount of work onto primary care that it is not sustainable...I am actually looking to get out of primary care because I can no longer work in this place.'

'the burnout rate among my colleagues is huge'.

First developed as a prototype, the Medical Home model has since been rolled out across all 26 of the Group Health practices. At the heart of the model is an ambition to move from a reactive to a proactive model of care. For example, each patient's case is reviewed before their visit to ensure that they get the most out of it (so, for example, tests are ordered and results are secured in advance) – or to see whether a visit is necessary at all. Phone and email consultations are used extensively and have enabled GPs to significantly lengthen their consultation time. Staff no longer feel burnt out: in the first year alone the emotional exhaustion experienced by staff fell by half.

A striking difference between Group Health and primary care in England is the staff skill mix. For every 10,000 population, Group Health has about 6 GPs, 5 nurses/physician assistants and 7 medical assistants (who perform routine clinical and administrative duties under the supervision of a physician). According to the latest NHS Information Centre data, the equivalent figures for England are 7 GPs, 2.5 nurses, 1.5 healthcare assistants, and 10 administrative staff. I am with Mike Bewick, Deputy Medical Director at NHS England, when he told the conference that it is not clear how many more GPs are needed to serve the growing demands. The Group Health model suggests that a different skill mix could provide a solution for the projected workforce gap in primary care.

The second example at our conference was Bromley by Bow. I know this has been on the policy map for years, but like Group Health it has continued to evolve. Sam Everington and his ever-widening team continue to offer a thought-provoking and inspiring vision of how primary care can be the portal to holistic care that focuses on the individual not the disease. The image that said it all for me was a group of white-haired ladies sitting in the sun arranging flowers – this was the leg ulcer clinic. The community nurses had recognised that social isolation was a key driver of their patients' immobility and thus ulcers. The flower arranging class with accompanying nursing input was helping to tackle both. A focus on 'population health' is core to Bromley by Bow's mission. I have previously argued that GP federations could be part of the solution to the issues facing primary care. At the conference, Dr Everington argued forcefully that any federation of general practice should be based on geography, not on like-minded practices or even opportunistic groupings that stretch across large areas.

The challenge then is how we get from here to there: from isolated professional practice, staff burn-out and a medically focused model to a strong multidisciplinary team focused on population health and wellbeing. Dr Hugh Reeve, drawing on his experience of developing primary and integrated care in Cumbria, argued that there is a need to focus much more on change rather than on organisational models. He reminded us of Don Berwick's words, that culture will always trump rules, and that the NHS must be a system devoted to continuous learning. Sadly, the message from last week's conference was that the bodies charged with learning and development in primary care – NHS England's local area teams – are simply not up to the task. They are too remote and lacking in capacity and this places the clinical commissioning groups centre stage of any primary care reform. Let us hope that Don Berwick is correct and that the emerging culture of primary care collaboration within CCGs does trump the 'rules' that currently stand in the way.


Stephen Morgan

Comment date
20 September 2013
I suspect District nurses are not included in the NHS nurse/ physician assistant numbers in the article which I suspect they should be to make a fairer comparison. With those included the numbers may be rather similar in the UK and the US Group health model.

It may well be a good idea for the 'Attached staff', which include district nurses, to work more closely aligned with the practices, rather than relatively independently as seems often to be the case at present in the UK.

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