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What does the Fuller Stocktake and Hewitt Review offer primary care?

Professor David Colin-Thomé’s reflections on the recently published Hewitt Review and Fuller Stocktake identified that the recommendations and quotes on primary care contracting are commendably potentially far reaching. The development of teams and considerations on their effectiveness as well as the future of the GP contract model are discussed in this blog.

david colin thome
David Colin-Thomé

I had the pleasure of working with Patricia Hewitt when she was secretary of state for health from 2005-2007. The recently published ‘Hewitt Review – An independent review of integrated care systems’ (ICSs) marries visionary ambition with detail, very much reflecting her style. It is well worth the read beyond primary care, especially the section on healthcare efficiency, a long-time interest of mine.

The section on general practice is inevitably short as not the focus of the review, with one notable exception. ‘My recommendations build upon the important work and recommendations of the Fuller Stocktake, focusing on what more needs to be done within ICSs to create integrated neighbourhood teams and integrate care across the whole patient pathway. I also make recommendations on the changes needed within primary care contracting (an issue not included within Dr Fuller’s terms of reference). The recommendations and quotes on contracting are commendably potentially far reaching.

Let’s talk teams

We have had over the years myriad teams many with a similar purpose, so how can now be different? And more to the point what should be done to make teams more effective? In the generally controlling environment of the NHS, teams are usually formally constructed by the organisation and predominately are of one discipline. Multidisciplinary teams are also usually constructed ‘from above’. Mostly members of these variously constructed teams accept their validity as ‘making sense’ in their pursuit of good patient care. Similarly, I expect widespread acceptance of the sensible sounding Fuller recommendations.

But is that enough for them to be actively effective? I offer some thoughts.

  • Frequently within the team mentality lurks a problem. To quote a brilliant journalist, the late Katharine Whitehorn, ‘The trouble with teams is they want to play against someone’! Maybe the NHS culture of professional authority automatically precludes the patient from the team. I venture that must change.
  • When an initiative is ‘ordained from on high’, there frequently follows the development of a bureaucratic style of management and a consequent diminution of intrinsic energy. Even the most apparently purposeful of teams would benefit from its members feeling a true ownership of it from inception.
  • If only the NHS could advance the concept of participatory management. Then teams could continually allow their members to modify and shape their purpose and ways of working to suit local and patients’ needs. The early voluntary primary care home sites waxed lyrical of energy, enjoyment, fulfilment, good relationships. That’s what our beloved NHS so lacks, admirable though it is in so many ways. There is an increasing staff dissatisfaction not withstanding industrial unrest, and certainly contributing to it.
  • Formal teams especially the potentially bureaucratic ‘team of teams’, must expeditiously choose leaders that marry their technical knowledge with the soft skills that enable even good teams to be better.
  • And they must support local informal initiatives. In my much younger years, academic Peter Pritchard described local purposeful teams for instance, for a cancer patient at home the GP, nurse, patient, and their carer as the permanent team with additions as required. I was inspired to follow his advice resulting in the most satisfying teams I worked in.
  • Key words; participatory, fulfilling, energising, involving with an ownership locally engendered.

And what of the Hewitt Review relevance to primary care?

‘Delegation of all primary care commissioning for the first time, instead of each element of primary care being treated as a separate silo’. Integrated primary care, the Primary Care Home dream. Is the service really ‘up for this’?

‘The contract held by GP contractors for general medical services which is negotiated nationally between government and the BMA, provides far too little flexibility for ICSs to work with primary care to achieve consistent quality and the best possible outcomes for local people. But the experience of local Personal Medical Service contracts revealed the lack of imagination in the service as usually the national contract was locally replicated.

And to emphasise the need for thoughtful integration by a salutary example. ‘Contracts with national requirements can have unintended consequences when applied to particular circumstances.’, citing the denuding of community pharmacist’s consequent to the Additional Roles Reimbursement Scheme.

And echoing widespread current thinking, ‘The Quality and Outcome Framework (QOF) points that were an important and useful innovation twenty years ago are now out of date and are seen by GPs as well as ICBs as an inflexible and bureaucratic framework. As the GP contract is now entering its fifth year of a 5-year agreement, radical reform is needed, and this is the right time to make it happen’. I accept much of QOF now is as described, but the abandoning completely of the indicators on long term conditions (LTCs) could potentially harm patient care. Good LTC non urgent care is all about systems and processes and QOF has been instrumental in the resultant improved care. The Commonwealth Fund undertakes international comparative healthcare reviews. The UK performs well in systems of care for chronic LTC patients, almost entirely due. to QOF. (Incidentally disappointingly the whole NHS, consistently underperforms in healthcare outcomes.)

Other excellent recommendations.

Building on the GP partnership model, rather than sweeping it away entirely. The new contract needs to allow for different models, in particular allowing tailoring to local circumstances in the patient facing offer, while ensuring we capture the benefits of an ‘at scale’. Interesting given current official Labour Party policy.

Practices that are not delivering at a high enough standard need to be supported to improve and, where necessary, to be replaced so that residents in every community receive the support from primary care they need. This should include creating a centrally held fund to buy out contracts or premises, or both, where that is essential to improve access, care, and outcomes in a particularly disadvantaged community.

So, two thoughtful supportive publications well worth the read that provide an excellent platform to necessarily reform and develop primary care, to further enhance its leadership role.

Professor David Colin-Thomé is chair of PCC. PCC provides trusted, practical support to health and care services, including support to integrated care boards enabling a review of where they are with implementation of the Fuller Stocktake and development of neighbourhood teams. For details see www.pcc-cic.org.uk or contact enquiries@pcc-cic.org.uk.

Last Updated on 19 April 2023