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Emerging integrated care boards – the GP federation perspective

In the third of our interviews about the emergence of integrated care boards, we talk to Dr Rishi Chopra about his experiences of working as part of a federation across a number of PCNs.

Rishi is a General Practitioner in Central London based at Paddington Green Health Centre for the past 15 years. He has a number of current leadership roles, including being the Clinical Director for Regent Health Primary Care Network – a network of eight practices, providing care for a population of around 60,000 patients, as well as being a board director for Healthcare Central London, Westminster’s GP federation, managing care for 250,000 Westminster residents. He is an experienced educator, teaching medical students from Imperial College, Junior Doctors, GP trainees, appraising GP colleagues, and teaching A-Level students who are interested in becoming Doctors. Additionally, he is the Westminster Primary Care Training hub clinical lead. He is also the borough COVID vaccination lead for care home residents, housebound patients, and pop-up sites.

Rishi Copra
Rishi Copra

Can you give us a little background to Healthcare Central London (HCL) and its primary care networks (PCNs)?
Westminster is a fairly unique place. We’re very small geographically, with approximately a quarter of a million patients including two very large universities with around 30-40,000 students registered with two student practices. We look after some of the wealthiest people in in Britain and some of the most deprived immigrant communities who often find their way into Westminster.

I hid behind the uniqueness of Westminster for a long time because our data on outcomes is quite often skewed for several reasons. We have a transient population. We have a commuter population. We have lots going on in Westminster and that’s why our urgent care rates are so high.

Four years ago, our Commissioners piloted a new contract, which was basically an out of hospital contract called Partnership in Practice, or PIP, which covered additional things that General practice wasn’t funded for that could be offered at scale. Our then federation became the contract holder and that was the precursor to primary care home delivery of care. In terms of performance management, it fell into units of about 50,000 patients and Westminster divided into four neighbourhoods which ultimately became the four PCNs. Because of this, delivery for us had happened at “place” level, and so we proposed that we should have a clinical director of each PCN on the board of the federation, because that’s where delivery happened as opposed to at network level.

About two and a half years ago, our federation transformed into Healthcare Central London, a limited company with every single Central London or Westminster practice, of which there are 34, becoming shareholders based on their list size. This meant that everyone has got buy in, pride and a financial incentive to make sure the vehicle works.

Why don’t you have your delivery model at PCN level?
The key point is for us is that a patient in my network may live next door to somebody who’s registered at a different practice in a different network who may live next door to third practice who’s in a different network because our footprint is so small. We felt it unfair and not at all equitable if the offer to that patient is different to their next-door neighbour.

Obviously, relationships are really key, so the four primary care network clinical directors (CDs) of Westminster are so in tune, and the vision is so similar that work becomes easier. We think about everything together but still allow for some autonomy to reflect specific needs when needed more locally.

What support has HCL been able to provide across PCNs in delivering the network directed enhanced service (DES)?
There are lots of opportunities for federations to provide support, an important one is around workforce both for the additional roles reimbursement scheme (ARRS) and wider staff groups. Our ARRS will be delivered pretty much at federation level because on the whole most things can be delivered equitably across the entire patch. An example would our clinical pharmacists of whom we employ 14 with a plan to have about 30. We’ve modelled our numbers to say we think every 10,000 patients needs a full-time clinical pharmacist to do a defined list of work whilst allowing some practice autonomy. Again, every patient gets the same offer from a clinical pharmacist across the four PCNs. This kind of strategic planning is much more manageable for us because of the scale working across four PCNs provides.

How have you avoided conflict across the PCNs?
We’ve tried to make the Federation and the PCNs feel like the same organisation with Federation issues being a rolling agenda item at PCN meetings. Things that come up in each PCN are then fed straight to the Federation board. This allows a PCN to identify their specific needs, mainly around the use of the ARRS, which can be discussed and then added to the workforce plan.

How primary care can get its voice heard and influence the ICB?
I think the ICB wants innovation at place, or network level, and ultimately improved outcomes. If you can deliver outcomes that are demonstrable across the wider population and are transferable to other areas, you’ll get people listening. So I think that demonstrating innovation at the coalface is the best way to show what we can do.
I also think that currently the integrated care place is a maturing at a rate faster than the ICB as they are still in the process of making Board appointments. I would like to think that as a result, local primary care has an opportunity to get recognition at ICB level for work already undertaken.

What positive examples do you have of initiatives to integrate care over the last two years?
The biggest one is the vaccination campaign. We were the borough with the lowest vaccine uptake in the country at one stage, and although the emphasis was on delivery at PCN level, we decided on day one to deliver it at federation level because that made sense given our geography. One of the highest profile examples of this was when we set up a vaccination centre at Lords Cricket ground twice a week and at the peak we were delivering 3,300 vaccines a day. We also identified that there were certain communities who were scared or hesitant about the vaccine and so we did pop up clinics in local community and religious centres and also involved the local authority and public health to support us with other initiatives like a vaccine bus that targeted specific neighbourhoods.

Those relationships with public health and the local authority have now enabled us to think about bigger initiatives looking at things like why there are differing life expectancies in different areas and what can we do collaboratively to bridge the gap.

Although this collaborative working would have happened over time, Covid has definitely been a catalyst to get us in the same room at the same time with a common, unified focus and vision. And that’s key, because otherwise you get conflict where everyone’s agenda is different and transparency, honesty and openness doesn’t necessarily come out.

What do you think the most significant achievements of CLH have been?
I think again, it has been the vaccination campaign. We’ve rolled it out wider than just for our patients and helped colleagues from outside our borough because people come into central London for lots of reasons and as we’ve been set up to be able to give them a jab while they’re here, it’s a bonus for everyone.
But equally the way the federation has matured with a clear and shared understanding of our strategic vision has really gone well over the last year or two. We’re working really closely together and have formed great relationships with other providers in the patch. We have recently rebranded the Federation with a new name and an entirely new board so that members feel part of a new organisation that they all own and have a say in what is being delivered.

What do you see as the biggest challenge facing primary care in the ICB?
I think it’s important to remember the goodwill that exists in primary care. The minute one starts trying to itemise every line of work that every provider does, you’re going to run into problems because you’re going to see there’s so much that people do without the remuneration and financial reward. So the minute you start trying to itemise every piece of work that goodwill will start to go, and patient relationships become purely focused on ticking boxes which is a real worry. I acknowledge that people should absolutely be remunerated for work that they do, but I flag this as a risk.

How do you plan to develop relationships with the wider primary care team?
Relationships with the community pharmacists have always been very strong, as we’ve done lots of collaborative work informally with our local chemists for years and now we have the community pharmacist consultation service (CPCS) which has formalised much of what had been done as informal referrals till now. I think that relationships with optometrists and dentists will take time and we all need to understand the pressures within the system and develop our relationships to address them together.

What is your key message for primary care right now
I think the relationships between PCNs and the ICP that then feed into the ICB are key. Our four PCNs are so aligned that their voice at the ICP is four times stronger and more trusted. If you’ve got networks who have very differing views, their voice gets diluted, or it doesn’t get heard at all. So, the more collaboration at place level that you can do, the more likely it will be that innovations and local plans will get adopted.

Last Updated on 31 January 2022