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What now for primary care

By Professor David Colin-Thomé, OBE, chair of PCC and formerly a GP for 36 years, the National Clinical Director of Primary, Dept of Health England 2001- 10 and visiting Professor Manchester and Durham Universities.

At a time when Government policy is more primary care focused than at any time in my lengthy career. Will primary care use or lose this opportunity? The key question for primary care is how to retain its current strategic importance in the NHS and ideally beyond?

It is imperative for primary care to create a position of indispensability to NHS transformation even beyond its current importance in order to ensure its ongoing centrality to all facets of the NHS. The focus with acknowledgement to Donald Berwick’s original work should be a specific triple aim for primary care. To level up quality and increase the range and scope of primary and community service provision. – To significantly contribute to reshaping hospital services which acute providers and commissioners have failed to do. – To have a central role in health and wellbeing beyond healthcare by developing a public health for primary care.

How can primary care expand its range and scope of services?
It is now for community professionals to seize the opportunity and offer solutions in the dire Covid-19 situation rather than add to the accumulating misery and despair. My life’s work such as it is, has identified that positivity and hope when all seems hopeless will be welcomed at a senior level and influence will surely follow.

The individual PCN must remain the building block. Integrate care in its widest sense including social services and the voluntary sector. Integration is always best delivered locally where trust and relationships make it the optimal place for tackling complexity, paradox and ‘wicked’ problems. And integration has no value unless individual patients demonstrably benefit, otherwise integration only serves more extensive ‘provider capture’. The next steps should be reshaping hospital care by redesigning pathways so that care is delivered ‘closer to home’, reducing the system’s current dependence on hospital in and out-patients services.

The NHS needs its hospitals but not often as they are. Hospital care is changing both rapidly and radically. Innovations in technology, care delivery and in system working require future hospitals to be very different from those of today. And yet UK hospitals seem so resistant to change, seemingly preserved in aspic as the model is virtually unchanged over decades despite enormous advances in investigation and treatment. Hospitals are also the most underperforming sector according to the Care Quality Commission. Surely a strong case for different thinking and doing in the hospital sector. The ambition is that the integrated care systems although currently non statutory, will facilitate the spread of such developments or other hospital transformational initiatives. Hospitals however large and ‘egocentric’ need to work in multi hospital systems to provide the range, knowledge, expertise and patient responsiveness modern care requires and yet also in a local system with community based services in the geography within which each hospital exists.

There are many aspects of hospital activity – as in all parts of the NHS – which are of low value. The current reality is much of care presently undertaken by hospitals does not need to be delivered in hospital settings. Current outpatient care described by Professor Muir Gray as a ‘relic of nineteenth century medicine’ of which 2 of every 3 outpatient appointments are patient follow ups, whilst total hospital outpatient attendances have increased to 94 million over the past ten years at a cost of £8 billion a year. The NHS Long Term Plan highlights the move away from traditional outpatient service provision and redesigning the way necessary outpatient care is delivered. The shift away has already been prompted by the current Covid-19 crisis.

Primary Care does not have to do it all. For primary care to achieve its own triple aim a partnership with commissioners is essential. They need to ensure all providers take a population responsibility; they should be partners yet holding providers singular and networks to account with ideally providers setting their own stretching ambitions and indicators of success. However, the individual PCN must remain the building block or we may get drift to larger population size, more impersonality and alienation with a reversion to a top down culture which has bedevilled the NHS and badly served primary care. Transformation of care has started; it’s now the time for PCNs to play their hand.