Cheshire takes its own steps to primary care at scale

8 May 2017

The Cheshire Local Medical Committee and PCC recently brought together local GPs and practice managers to consider how to make a reality of NHS England’s vision of primary care at scale.

The half-day session was intended to outline a sensible step-by-step approach to delivering on the clear direction of travel coming from the centre. This was outlined in the Next Steps on the Five Year Forward View and the GP Forward View documents.

Speakers noted during their presentations and workshops that there are significant challenges in achieving the aims of collaboration and integrating care to move resources from the acute sector into the community.

They highlighted how some recent responses – including in some cases the rise of GP federations – have not been universally successful.

We outline below some of the pitfalls and possible ways of navigating around them.

That includes considering:

  • A clear vision of the purpose of collaboration focused on the genuine reasons for doing it, as distinct from external pressures from the CCG and others
  • The appropriate level at which to collaborate – eg a cluster of practices, a clinical commissioning group or a sustainability and transformation plan footprint
  • The right organisational form – which does not necessarily have to be a new legal structure.

In her opening remarks, PCC chief executive Helen Northall emphasised the range of functions that collaborative working or primary care at scale can potentially achieve.

These include:

  • Building the resilience of primary care by achieving efficiencies through a better skill mix and shared back office functions
  • Moving resources and staff to the community at locality level
  • Provide a platform for more devolution of population-based budgets
  • Show GPs what the locality can do for the practice and what the practice can do for the locality
  • Equip GPs with the structures and climate to become full partners in new models of care.

What do we want to achieve?

When a direction of travel seems logical and is the clear wish of those who hold the purse strings in Westminster and Whitehall it is easy to rush to arms.

However, several speakers at the event emphasised the need for clear heads and a clear vision.

And that starts with agreeing the purpose of collaboration or local new models of care.

Several speakers pointed out that not all collaborations require a new legal form. Additionally, often the right organisational form only becomes clear once the purpose has been agreed.

Mike Smith, London GP and chief executive of Haverstock Healthcare, urged GPs and their management teams to consider:

  • What is the exact purpose that your collaboration has formed to address?
  • Is this a purpose that is shared by everyone in the collaboration?
  • How have you captured this and how will you hold everyone to account for this?

Having almost accidentally prototyped the GP federation model nearly a decade ago, Smith said that too many federations are now struggling or even “going bust” because they were formed for the wrong reasons. These, he suggested, had included “to finally make some money”, being given cash by the CCG to form a federation and “because everyone else was doing it”.

Another federation trailblazer and GP, Dr Phil Yates, noted that by collaborating practices were following a trend for larger provider organisations - citing the example of out-of-hours services in his home area of Gloucestershire where large scale collaboration between providers has developed. He questioned whether the merger of two practices each with a list size of 5,000 delivered the economies of scale that were being sought by NHS England and ministers.

“We have got to reverse the flow of cash that has been sucked into acute care by payment-by-results over the last 15 years and move resources into the community. The government is certainly thinking about practices joining local care networks or similar but you shouldn’t jump into bigger organisations until you can get the cash to go with the new ways of working.

“You need not just to look at the sort of contracts federations have been going for but at core general practice work. Discussions about the Primary Care Home (PCH) model have touched on gainshare. If we are going to step up and do more, that needs to be recognised somehow but I have not heard how.”

Other drivers, he suggested, include the “prohibitive” contracting costs for small organisations and the inevitably restricted legal, finance and strategic expertise in primary care.

Where it’s working

Smith suggested that in New Zealand necessity had proved the mother of effective invention.

Following the devastating earthquake in Christchurch, the provincial capital of Canterbury, in 2011 the local health system was transformed – with plans for a new, bigger hospital ditched in favour of health promotion, primary care and community services. It also emphasised the need for workforce development.

Three “strategic goals” set out in a surprisingly short strategy developed by six doctors and a high court judge have been built on to develop more than 500 care pathways in Canterbury.

The strategic goals, each supported by a statement of around 20-30 words, were:

  • People take greater responsibility for their own health
  • People stay well in their own homes and communities
  • People receive timely and appropriate complex care.

Such thinking is having an impact in some places in England, Smith suggested – including some of the early rapid test sites for the PCH model developed by the National Association of Primary Care (NAPC).

An NAPC board member, Smith said: “The primary care home model is not particularly complex and by serving a population of 30,000-50,000 you tend to get some geographical and philosophical alignment between practices.”

He pointed to the results already achieved in Larwood and Bawtry PCH in Yorkshire.

Local practices and their partners used the PCH approach to develop an integrated primary and community nursing team, appoint a dedicated care home pharmacist, follow an  integrated approach to urgent GP care and focussed on pathway redesign with an emphasis on community and primary settings.

He said the early outcomes included:

  • Higher patient and staff satisfaction
  • A fall in A&E attendances and emergency admissions
  • Lower prescribing over 6 months (compared to the previous year)
  • An overall reduction in commissioning spending of £440,000 in six months (compared to the previous year).

What makes for success?

Practices working at a neighbourhood or locality level can be a good building block for collaboration with other providers, speakers suggested.

Smith pointed to Salford where practices have come together in six neighbourhoods. Each neighbourhood nominates a member to sit on a joint neighbourhood board which acts as a strategy and advisory group to a board that is actually the legal entity for the provision of services.

Speakers also suggested that it is important for new partnerships and collaborations to have a manageable set of aspirations and goals. 

That has been the hallmark of a Cheshire PCH rapid test site, Winsford.

Dr Judi Price, the GP lead for the project, told the LMC/PCC event: “We felt that primary care locally was in a mess two years ago. There was burnout and we never saw a district nurse. We had the lowest one year cancer survival rates in the country and integration teams just seemed to be people sitting in a room talking.

“We wanted a single team approach that involved having personal relationships with colleagues such as the district nurses. We wanted people with the right skills giving care in the right place first time.”

Less bureaucracy through a single information system and less referral paperwork were amongst the goals – together with more services available to people without leaving their own home or Winsford through better collaboration.

“Our PCH set in stone an agreement for community services and we hope it is going to do that for an accountable care organisation. We are now seeing district nurses. We’ve made small changes that have made a big difference such as an emergency children’s clinic at the end of each day after parents pick the kids up. People with MSK problems take up 20% of our appointments and we realised we could free up a lot of GP time if they were first seen by a physiotherapist.”

The physiotherapist is amongst several staff to be employed by the acute trust but managed by the locality.

The five Winsford practices decided not to embark on either a time-consuming merger or developing a large new structure.

However, Price cautioned that the PCH process was time-consuming and required much energy.

“Local politics took a lot of time but most people can see the benefit. We would also have benefitted from more project and business management skills. We do have really good practice managers but we don’t have the level of project management that some larger practices have.”

When federations became the must-have primary care fashion accessory 3-4 years ago those running them assumed they would bid for CCG contracts. However, Smith said his experience suggests that new collaborative vehicles should be thinking more creatively in looking for opportunities to work differently (and secure resources). They should be talking directly to their local acute trust.

Smith cautioned that “federations are going bust” and that CCGs and acute and community providers are “losing faith” in federations in some areas after being scarred by initial collaboration or contracts that went wrong.

One federation, he said, had employed a bid writer whose fee was higher than the value of the contract they were bidding for.

He and Yates urged practices and their new, larger provider organisations to look beyond CCG contracts.

“Don’t wait for money from your CCG,” Smith said.

Haverstock Healthcare has helped its local trusts improve A&E performance by effectively siting a mini-GP practice at the emergency department’s front door.

Staffed by two GPs, a nurse and an admin person, the centre redirects up to 30% of patients back to the community. They redirect or treat 44% of all the patients arriving at A&E while the centre is open. The centre’s team has also helped 4,000 people to register with a GP practice.

Yates added: “The CCGs are not procuring anymore: look at the data and identify where the acute trust has a problem and then tell them how GPs can help them solve it. Don’t involve the CCG because they will project manage it – just do it.”

Participants heard that a GP federation ran a medicines management service for care homes that reduces the number of outpatient appointments required by older people – around one-third of which involve medication issues.

However Yates said that federations can be constrained by the level of commitment and ambition of each member.

“Practices only do what the federations want if they like it and that makes it difficult for a federation to go to an acute trust and say ‘general practice will do this for you’. We move forward at the pace of the slowest and the work we do often has very low margins.

“Federations have a role but they may not be the solution when it comes to delivering primary care itself.”

The models – such as primary care home – that serve populations of 30,000-50,000 have the advantage of allowing practices to second in management expertise and a range of healthcare professionals, Yates said.

“That sort of working together as a group of practices does need ground rules to ensure each practice is putting an equal amount of commitment and effort in.”

Yates noted that many GPs are concerned at the prospect of losing independent contractor status but he asked whether there are alternatives that could give GPs back their job satisfaction while benefitting patients. Models such as those being tested in Wolverhampton and Nottingham in which acute trusts are running practices directly have the appeal of allowing GPs to concentrate on medicine rather than estates management or business risk.

Arguing that no single model of general practice at scale would be the answer for every community, Yates listed a series of issues he said local primary care leaders need to consider when deciding the best route for their local health economy.

These were:

  • Ownership and leadership of the new provider organisation
  • Its vision, organisational culture, values and ethos
  • The skillet of the management board’ skill set
  • GP representation and how this linked with the new organisation’s legitimacy, authority and accountability
  • Risk appetite, profit split and gain share
  • Relationships with commissioners
  • Potential alliances with other providers – such as community trusts
  • Sustaining the organisation’s income
  • Making time to plan for change.

With primary care providing more services, he said, there was a chance for both primary care clinicians and managers to develop expertise in particular fields.

“In grouping practices you can look at the different skillsets and management styles and draw on them for practical solutions,” he said.

Managers could specialise in human resources, finance or Care Quality Commission liaison issues and work across a group of practices.

In his own organisation, GP Care, GPs have developed a special interest in fields such as diabetes, audiology, end of life care and urology. GP Care provides the urology service for Bristol’s population of 1 million. Consultants from the acute trust and a private clinic work in specific GP practices that are designated as centres of excellence for urology.

While large primary care providers may centralise some functions, Yates suggested, individual member practices are able to offer more specialist services such as physiotherapy and ultrasound.

Responding to a GP’s query about where junior doctors are trained in urology, Yates said: “Training will have to happen in the community if that is where services are going to be provided but we have not yet fully got to grips with the implications of that.”

He said: “We are still in the 19th Century when it comes to our model for outpatients. We are not using technology as we should. Many of those services should be moved out of hospital but redesigned to be more patient-friendly. I think hospital colleagues are aware of that. Dealing with things in general practice is the right thing for patients and speaking as a CCG chair I can say it is the right thing for everyone but there has to be a shift of resources.”

Yates also suggested that new primary care provider organisations should consider the Belbin management philosophy which looks at team roles. Everyone, the philosophy suggests, brings positive personality traits that can help teams achieve their goals but in each case they also have less favourable traits that can impede progress.

He said it was important that management teams include a mix of personalities and they draw on the strengths of each individual.

Whichever form and structure local primary care leaders pursue, Smith said, it is important they “go with a coalition of the willing” and meet both GPs and patient representatives regularly to build trust. He urged them to share information in a transparent and to “speak positively and act positively towards your colleagues”.

For information about PCC’s support for primary care development, contact enquiries@pcc-cic.org.uk

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