New Zealand (NZ) and the UK are about as far apart geographically as it is possible to be while remaining on planet Earth. Yet for much of my time in the UK, as I spoke to GPs, clinical leaders, trust chief executives and commissioners, I could have been in a meeting in NZ, discussing systemic barriers that prevent enhanced primary health care from being the centrepiece of the health care system. Both countries have an ageing GP workforce and both face similar challenges posed by older populations with complex long-term conditions; increased consumer expectations; digital innovations; and persistent health inequalities. Both countries have also committed to shifting investment from hospital care to primary and community care, and both have struggled to achieve that shift.
I found a lot to like about the new NHS England five-year GP contract. It is a well-crafted attempt to simultaneously scale-up general practice, enhance primary care team capability, enable community health service integration, and manage GP workloads. It delivers medium-term funding certainty, is universal rather than being yet another pilot, and provides a tangible demonstration that policymakers value primary health care. It should give young doctors some reassurance about the sustainability of general practice.
While impressed by the clarity of vision, and the stated commitment to rebuilding the health system around strong community-oriented primary health care, I was left with a few questions around implementation.
Where is mental health?
Mental health conditions such as anxiety, depression, and substance misuse, are significant drivers of GP workload. In New Zealand at least, GPs diagnose and treat more mental health conditions than all the specialist mental health services combined. Embedding behavioural health practitioner roles in general practice teams has worked well in the Nuka health system in Alaska, and elsewhere. In recent New Zealand pilots these roles are paired with health coaches, who are also embedded in general practice teams. Funding roles like these would arguably be more immediately useful than funding physician associates or paramedics, but such roles are strangely absent from the five-year contract.
How will continuity of care be maintained in an enhanced GP team environment?
General practice will need some time to bed in the new roles funded through the five-year GP contract. Extended GP teams will need to develop new ways of working and agree clinical pathways to save patients from having to make multiple appointments, or to tell their story multiple times. Online appointment booking screening systems will be helpful here, but they need to be very easy to use to encourage consumer adoption. In developing the enhanced team workflows, the challenge will be to ensure continuity of care is maintained – especially for frail and complex patients. There is a real risk that general practice could turn into an outpatient style service – increasing comprehensiveness but losing the person-centred elements that give it most value.
Who supports the primary care network leaders?
A nice bonus to being hosted by The King’s Fund is exposure to current thinking about teams and leadership. Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, speaking at The King’s Fund Ninth annual leadership and management summit, made a useful distinction between teams and teaming. Teams have consistent membership, common goals and tasks, stable relationships and common perspectives. She defines ‘teaming’ as ‘teamwork on the fly’ across boundaries and without the luxury of stable team structures.
When general practice staff get together with other practices in their network they are probably ‘teaming’, rather than working in ‘teams’. Similarly, the process of community health services ‘docking’’ with general practice is also likely to involve teaming, rather than stable teams. This implies that getting people out of their default silos, and into joint problem-solving mode will require resilient and highly skilled leadership. That’s a big challenge for the 1,300 new clinical directors of primary care networks, and they will need advice and support.
What about health informatics?
Neighbourhood-level population health improvement requires good, timely data. In Scotland, every GP cluster is allocated a specific analyst to assist in developing and interpreting quality metrics. In Denmark, where a similar approach is being trialled, a national dataset is being developed to provide localities with information. In NZ, primary health organisations provide data to support clinical quality improvement. In some areas of the NHS, data is available through clinical commissioning groups or other entities, but in other areas it is not clear who will provide analytical support to primary care networks.
I was hugely impressed by the energy and desire the clinical leaders I met had to make a difference. But as Winston Churchill wrote in 1935: ‘Nourish your hopes, but do not overlook realities’. I have no doubt that given the right resources and enough time and space to make use of them, primary care in England could achieve an enormous amount over the next five years. My question is whether funders will give primary care leaders the backing they need for the length of time they will need it.