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Strengthening relationships in primary care and community services

The government’s recent Health and Care white paper, sets out the ambition for more integrated, innovative strategies to address the challenges posed from populations presenting with multi-morbidity. This, together with primary care networks (PCNs) having access develop the primary care workforce through the additional roles recruitment scheme (ARRS), presents an opportunity for community providers to forge partnerships and strengthen relationships with primary care, and develop models to deliver more proactive and co-ordinated care for patients. Community teams can engage with PCNs to support them in their development of the primary care workforce.

Andrew Paterson

National Context

The NHS Long Term Plan set out an ambition to dissolve the historic divide between primary care and community services. The development of primary care networks (PCNs) and anticipatory care requirements are central to that goal.

With the UK population both increasing in size and steadily aging, the proportion of over the age 65+ UK residents has been increasing up to the Covid 19 pandemic , and consequently this brings challenges for healthcare systems through multi-morbidity. The number of people with multiple long-term conditions is rising, more than one in four of the adult population in England lives with two or more conditions , and evidence suggests that individuals with multi-morbidity are more likely to have poorer health, poorer quality of life, and place greater demand on healthcare services. Such individuals, with rising complex needs and escalating risk pose an increased demand not just within primary care but also within community and social care, and they occupy a significant majority of hospital beds.

The government’s recent Health and Care white paper , sets out the ambition for more integrated, innovative strategies to address the challenges posed from populations presenting with multi-morbidity. This, together with the emerging PCNs having access develop the primary care workforce through the additional roles recruitment scheme (ARRS), presents an opportunity for community providers to forge partnerships and strengthen relationships with primary care, and develop models to deliver more proactive and co-ordinated care for patients.

Community teams can engage with PCNs to support them in their development of the primary care workforce

By working at a PCN level, joining up GP services with community teams, it is possible to improve patient outcomes and value for the NHS by introducing more proactive and co-ordinated care for patients, through agreeing interventions that support people where possible to remain at home. Community providers have the infrastructure and back-office functions to create innovative propositions for developing PCNs. This might be through offering to act as the host employer and day to day management support, to workforce development, offering access to human resources and learning and development solutions.

PCC was approached by Coventry and Warwickshire Partnership Trust to support them to work through national policy and strengthen local partnerships by developing integrated community teams with its PCNs. The aim was to maximise the use of the ARRS and ensure that the combined workforce was fit for purpose to deliver proactive, anticipatory care by developing an engagement strategy for the community trust to engage with PCNs to better support out of hospital working

What we did:

Undertook a series of engagement exercises across primary and community care to develop an understanding of what ‘good looks like’ for integrated working, and identify how together, they will measure progression.

By accessing a range of data sources, including NHS Viewpoint to interpret existing data sets for Coventry, we identified differences in demographics, disease prevalence and resource utilisation, across the PCNs. This enabled the community provider to use these insights to propose interventions which could be delivered by both primary care and the community teams. This was supported through PCCs connections with national exemplar sites, to provide added insights and guidance.

The support culminated in holding a series of organisational development workshops for the clinical leads appointed by CWPT and the community teams, to achieve integrated working, agreeing a collective vision and leadership behaviours, for the team to adopt.

Jane Hill, clinical director and interim associate director of operations, Coventry and Warwickshire Partnership Trust said “The support provided us as a community provider with the opportunity to look at how integrated working can look moving forward from both community and primary care perspective. We have progressed engagement with primary care with GPs actively involved in the integration work we are progressing. This included shared sessions with GP colleagues along with being linked with a local exemplar site.”

Potential opportunities going forwards:

Looking ahead, PCC can support both community providers and primary care networks in developing future anticipatory models of care for individuals with escalating risks. Anticipatory care is not something that either community providers or GP practices can deliver in isolation. Instead, this approach can only be delivered by a fully integrated community-based teams.

With the multi-morbidity healthcare challenges likely to continue for some time to come, such innovative approaches will become ever more important to support populations to age well and feel supported in their place they call home.

Contact enquiries@pcc-cic.org.uk to discuss how we can support you.

[1] ONS Living longer: how our population is changing and why it matters; 2018
[2] Academy of Medical Science’s 2018 report
[3] Health and Care White Paper 2021: https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all

Last Updated on 27 September 2021