Sustainable primary care provides a platform for system change

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In the final blog in our series about the transformation of the Canterbury health system in New Zealand, Vince Barry, Chief Executive of Pegasus Health, looks at how building sustainable primary care creates a platform for change.

 

My week working in the UK with The King’s Fund and NHS colleagues convinced me that the case for change in the NHS is unquestionable. The challenges now are to create system-wide engagement that includes patients and local populations, and ensure that there is sustained capability for change. But how can the system meet these challenges? Building capable and sustainable primary care capacity, as we did in Canterbury, may be the answer.

Looking at the experiences of Pegasus Health, a clinically led, management-enabled primary care network of general practices in Canterbury, gives some hints to how a solution can be achieved. Pegasus Health supports more than 350 GPs in 100 practices within the Christchurch and Canterbury area to deliver care for 420,000 enrolled patients. The organisation has an annual operational turnover of £30 million, mostly from providing an extensive range of health service contracts funded by the District Health Board, and employs 342 staff. Pegasus also owns and operates the 24-hour (non-enrolling) after-hours surgery, which employs medical officers and nursing staff and where GPs contribute shifts as part of their after-hours obligations.

Pegasus Health is governed by a board of ten directors, comprising six GPs, one nurse and three independent directors. A clinical board with representatives from different primary care clinical groups acts in an advisory capacity to the board. The clinical board is complemented by a community board made up of representatives from Maori, Pacific, culturally and linguistically diverse advisory groups and other community members. In addition, there are 11 clinical leaders, primarily GPs, who provide support and clinical leadership for the activities and initiatives of the organisation.

Building on a base of co-operation around out-of-hours care in the late 1980s, Pegasus has developed capacity and capability for system change that is available to the whole health system. At its heart is the Small Group Education programme which is based on the 'most ethical use of finite resources' and recognises that general practice teams often work with 'islands of evidence in seas of uncertainty'. More than 90 per cent of GPs in the Pegasus Health network are engaged with the programme. The programme was extended to practice nurses in the late 1990s and to community pharmacists in 2010. This means that six times a year, more than 700 primary care clinicians receive the latest information on relevant topics and debate them in peer-led small-group settings.

As well as educational opportunities, Pegasus Health provides GP teams across the network with IT support, population health strategies, primary mental health teams and much more. Consequently, GP teams don't have to build that capability and capacity themselves and can get on with the work of providing high-quality clinical care to their patients. 

Pegasus Health also works with GP teams to prepare them for the challenges ahead and is currently working with them at scale to shift their models of care and the experience they can give their patients onto a more sustainable footing. Nurses and social workers within the primary care team work with people with long-term conditions to set up care plans and proactively manage their conditions. Early indications are that all the aspirations of care closer to home and reduction of reliance on hospital-based services are being met, and there has been a 50 per cent reduction in emergency department attendances for people with long-term conditions from these model practices.

Through the Canterbury Clinical Network primary care teams have been able to engage successfully with their secondary care and community colleagues to design population pathways, and these are now showing some really significant system results. The Network acts as a facilitator and co-ordinator for innovation, which might otherwise be stifled by organisational barriers and professional hierarchies. 

So, what does this mean for the NHS?

Well, unless you have a well-supported, engaged and relevant primary care community you will not be able to shift the whole system into a sustainable future. While recognising that primary and community care are only parts of the system that patients and communities come into contact with, as Barbara Starfield, the American paediatrician and advocate for primary care, contended continuity, comprehensiveness, co-ordination and accessibility are hallmarks of a functional primary care system that will ensure a sustainable platform for good patient outcomes.

I’d like to end with the following reflections and challenges for those leading change in the NHS.

  • Find a place where you can engage across the system and ensure you involve patients and focus on patient care. 
  • Focusing on not wasting people’s time can become a great motivator for designing new and effective models.
  • Focusing on good care and the best possible patient experience will deliver efficient and sustainable systems. This takes time and patience is required while new practices and programmes bed in.
  • It is about building momentum, which ultimately leads to system fitness and it is system fitness that will allow us to adapt to the challenges that the future will throw at us.

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