What primary care plans lose at their peril

31 January 2019

Two recent publications highlight the importance of general medical practice and its ongoing sustainability within community based care. A view from David Colin-Thomé

The NHS Long Term Plan to span the next 10 years is of course important to the whole of England’s heath and care system and has an overriding focus on community-based care. It is called a plan but like its predecessor the Five Year Forward View, I view the document as a collection of aspirations.

A potential problem with the “plan” label is that it may spawn a host of top down structures and accompanying performance management that could stifle initiative and transformation.

Viewed as another forward view the plan is very good and the increased funding and commitment to community based care are hugely welcome. Transforming community-based services is a prerequisite for a wider service transformation. We should be grateful that NHS England under Simon Stevens’ leadership has consistently and uniquely prioritised primary and community care.

The GP Partnership Review, which was also published in January, was a year in gestation. It promised much but to me somehow fails like most policy and management publications to capture the hope and aspiration necessary to engage the spirit. So many of us forget that without capturing hearts we cannot capture minds.

The review extols the virtues of the traditional GP partnership model with which I agree, but many prospective and indeed existing GPs do not. If they did, the previous secretary of state, Jeremy Hunt, would have had no reason to order the review.

In a typical trade union style, the publication lists many specific things required of the government to aid practices and GPs, thereby ceding some of the very autonomy that it proclaims for the partnership model. In the main document there is little exploration of the diverse ways that practices can innovate and thrive. The accompanying publication describes some excellent case studies but somehow the two parts appear disconnected.

So what of the future and how do we get there? Existing primary care homes (PCH) and super practices seem to succeed as they have a strong internal locus of control; networks led or facilitated by CCGs less so.

Setting aside the list of must-dos for government, the partnership review’s 12 case studies exhibit some common principles which provide a good basis for developing sustainable primary care networks:

  • Organisations that are both small and local and big and strategic. When I originated the concept of the primary care home ten years ago, I envisaged a “local population budgeted community-based provider entity able to ultimately provide an alternative to current NHS hospital centricity”.
  • Sound governance, of which devolution and relationship governance are key principles in contrast to the compliance focused traditional NHS governance approach. A useful mantra is “We need to have relationships underpinned by contracts, not relationships defined by contracts”.  
  • Underpinning all the successful examples is of course leadership – a leadership that goes with identifying and working with the enthusiasts, the energetic, the aspirational and the positive. Misguided arguments for achieving equity by working at the pace of the slowest often stifle the innovators. If innovation is successful it must then be spread, as equity is of course fundamental to our value-based care services.

Finally the practice and the PCN are both equally important so we need an alternative to hierarchical management. Clinicians in existing successful networks describe enjoyment, emancipation, fulfilment and self-realisation.

Lose that at our peril.

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

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