Support organisations also need to step up if primary care networks are to fulfil their potential

8 March 2019

By David Colin-Thomé

David Colin-ThoméThe NHS Long Term Plan heralds a fresh, and to me welcome, approach to healthcare in England. 

For many years there have been promises of a primary care led NHS but funding of primary care has continued to fall as a percentage of NHS spend. Workload in the meantime has continued to rise.

The Long Term Plan directly addresses that problem with primary care  networks. These provide a newish twist on an old idea: that by working together general medical practices and other organisations can secure their own future and provide a better service to their patients.

Development of national policy often seems to perpetuate behaviours that frustrate the purpose of the policy. I have a fear that the plan for universal coverage of primary care networks will suffer a similar fate unless primary care clinicians and NHS managers truly own the radical options on offer.

The late GP Julian Tudor Hart once said of GPs that “we claimed as our own, territory we were unable or unwilling to occupy”, a charge that applies not only to GPs.

Primary care is being offered a leading role in developing and delivering sustainable value based healthcare. The fulfilment of the potential of primary care and particularly of general medical practice depends on the seeming paradox of being both small and local and yet also larger for more strategic importance, hence the importance of general practice working together with the new primary care networks. Small and big is a classic paradox which can be managed, but if NHS professionals perceive it as a dichotomy the inevitable result will be a narrow mechanistic delivery programme. 

Do enough GPs wish to work in such a way? Many seemingly do as witnessed by the success of the burgeoning primary care home approach. As such a way of thinking and doing is possible, will all levels of the NHS help to achieve it?

I see no widespread evidence of such thinking at integrated care system (ICS) level (with some honourable exceptions) and yet ICS are tasked with the primary care networks development programme. Their focus is usually solely on the important but narrow aim of improving access to GP rather than enabling a wider, exciting primary care offer.

I have seen a proposed integrated care partnership plan aiming for better care of long term conditions with a scant mention of general practice. Yet general practice happens to be the only place based provider of NHS services with a defined population responsibility.

Primary care networks working with their constituent general practices are seen at NHS policy level to be the vehicle for NHS transformation through enhanced primary care. Of the circa 1400 primary care networks that will soon be formed, many could not even be described as nascent, which suggests a wholesale rush to set them up anyway anyhow.

A hasty, solely functional implementation will likely damage not only the role of primary care networks but will also demotivate clinical professionals who are essential to creating the energy widely seen in primary care homes, super-practices and some GP federations. Already we hear of a CCG who states a successful, functioning primary care home will not qualify as a PCN for some minor excessively bureaucratic reason.

So even if GPs show willing and enthusiasm, the NHS seldom concurs let alone meaningfully supports. My mantra is “do not put off (or words to that effect) keen people”, yet we frequently do.

The Five Year Forward View (2014) said: “The foundation of NHS care will remain list-based primary care.” The newly published NHS Long Term Plan goes further: “We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services” and “Local NHS organisations will increasingly focus on population health”.

All organisations within and outwith the NHS with responsibility for support and development have a responsibility to build on energy, vision, commitment and success in primary care to create the enhanced population based primary and community entities to ensure a community centric NHS.

Hospital based care should only be for emergency and much of urgent care with referral only for those conditions that are too uncommon to maintain competence in primary care and rare or unusual manifestations of ill health. But we do need hospital clinicians’ input to community based services as described in my original primary care home paper of 2009.

So that is the fundamental task of support organisations. Transforming care will require transformed support that encompasses primary care networks, constituent general practices, other relevant provider staff and the managers responsible for the network’s success.

NHS England will require evidence of achievement to earn the next tranche of monies – a maturity model. Lack of joint vision, energy and a trusting ownership will not augur success. 

An unwanted outcome of integrating services is creating the biggest “provider capture” ever with less choice and responsiveness to patients. These could become the new centralists; new collaborative models as the new silos. Avoiding these unwanted outcomes is a further challenge for support organisations delivering the “new primary and community care”. Others are how to create seamless primary and community nursing, accommodating primary care based and community pharmacists, and integrating digital and place based general practice.

This is a fulfilling yet challenging role for support organisations such as PCC. The successful will be ahead of the curve now and part of the offer should not only be supporting a leadership role for local providers and commissioners, but also to enable NHS England to deliver its policy.

Like GPs, support and development organisations should not want to be claiming territory they are unable or unwilling to occupy.

* David Colin Thomé is chair of PCC and a former national director of primary care with the Department of Health.

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