Closing the gap between primary care and STPs

9 February 2017

In the wake of the Five Year Forward View there are two opposing forces: one is a push for locally determined solutions at user-friendly scale, the other a push towards bigger systems (STP areas) able to compel the organisations they contain to make the changes necessary to keep the NHS running through the toughest period of the forward view, the next three years, and beyond.

Steve Kell has worked at both ends of this tug of war. He resigned his role as clinical chair of Bassetlaw CCG and his other role as co-chair of NHS Clinical Commissioners this time last year to concentrate on his GP practice in Bassetlaw.

Dr Kell‘s practice is taking part in one of the 15 pilots for the primary care home (PCH), a concept similar in many ways to the multispecialty community provider (MCP) model sketched by the Five Year Forward View, but different in important respects. PCH has a smaller population footprint (30,000 to 50,000) and avoids the surrender of contract questions that the soon-to-be published MCP contract will struggle to resolve.

These differences are part of its appeal to GPs who can see a new care model that grows organically from existing general practice. The PCH model is being developed by the National Association of Primary Care and is getting increasing support from national leaders. An expansion of the existing pilots to a number of new sites is under way.

The appeal of the PCH for all concerned is that it provides a more evolutionary path to the grand designs of the Five Year Forward View. It capitalises on developments in primary care that in many cases were already under way.

What is also clear is that the model itself doesn’t solve the problems that PCH sites are setting out to address. That is a function of relationships, the willingness of GPs and clinical colleagues in secondary care to work together, the support they get from commissioners or the backing they get from hospitals. And as Steve Kell makes clear, whether or not these conditions apply varies from case to case.

He gives the example of working in partnership with local community services and the voluntary sector to provide a wider offer for patients, allowing GPs to deal with issues such as loneliness and debt beyond the traditional medical model. This is turn reduces workload, prescriptions and has developed a real team spirit in the practice, he says. 

But there are also significant barriers to improving care and finding efficiencies.  For example, three local GPs ran a trial dermatology service, which involved adding six extra appointments a day. In three months the pilot produced evidence that referrals could be reduced in one area from circa 26/1000 to 6/1000 head of population. Without support from commissioners and local consultants, the service was not extended and Dr Kell believes this is as a result of a wariness regarding innovation in a time when financial grip and targets are the focus centrally.

The practice is also hoping to work with local physiotherapists to reduce MSK referrals, morbidity and prescribing, and is keen to develop an incentive scheme that allows them to release savings and reinvest in local services.  Despite the real need to innovate, progress can be frustratingly slow.

Kell takes two lessons from these experiences. Firstly, how difficult it can be align incentives. Developing new pathways is something the practice is keen to do, working in partnership with others, but there is no clear mechanism to reinvest any QIPP savings. Secondly, what may be a local clinical need is sometimes not a financial pressure or will take a year to deliver.  The need to balance annual budgets can result in providers and commissioners focusing on the short term.

The skill is in navigating these variable relationships and being prepared to nurture a stock of small victories in the hope of building something more substantial. There is a real sense of opportunity to achieve the three aims of the Primary Care Home: staff support, better patient outcomes and efficient ways of working. For the first year, Dr Kell fells there has been real progress.

Savings so far include a £230,000 prescribing cost reduction and the practice pharmacist has reviewed 230 people in care homes and made over 350 prescribing improvements, as well as improving compliance and safety. The cost of emergency admissions has reduced by approximately £130,000 in the first half of 2016/17, with GP admissions reduced by 17%.

The secrets to making it work, for Kell at least, are “a focus on the local population and strong relationships with local partners”. A monthly steering group has been meeting for the last year, with increasing membership and an ability to improve sustainability and care.

“Improving the service doesn’t necessarily mean change of contractual flows, just a better way of working,” he says.

Staff support is essential.  Dr Kell says: “We got 20 district nurses together and told them they could talk about anything – do what you want. They identified 17 improvements to services – most of them cost-neutral. One district nurse said the joint working meant she had never felt as valued. The practice has been able to recruit three excellent new GPs partly due to the team approach and support offered.  Being able to plan end of life care with a community nurse, or discuss options with a voluntary sector advisor offers an attractive way of working for GPs in a time of recruitment challenges.”

The PCH pilots tell a comforting story of new care models emerging somewhere between the cottage industry of general practice and the local supermarket ambition of the vanguards, they will need to co-exist with sustainability and transformation plans (STPs).

In theory STP areas provide a forum in which local areas can pool ambitions and bury differences. The idea was to forge common purpose fuelled by the most powerful force in the system: financial necessity.

In theory, STPs are just the thing to achieve the vision of broken boundaries and liberated silos. In practice, they may just provide a bearpit in which the various organisations in the system slug it out for resources.

According to Steve Kell: “Grip is tightening at the top and being passed down the line from NHS England to local offices, from them to CCGs and from CCGs to providers. It’s more important than ever to let go.”

Kell sees the shadow of STPs looming over local health innovation, and the ability to implement changes rapidly was one of the main attractions in the Primary Care Home model.  It’s cost effective (at approximately £1 per patient) and not slowed by some of the processes around early vanguard schemes.

“STP assurance, as with most assurance models in the NHS, is template based – is GP/primary care engagement on the template? If not, it won’t happen,” he says. Kell tested his theory with a straw poll on Twitter. He asked GPs and practice staff if they were aware of the primary care content of STP plans. Of 116 who responded, 84% said they were not.  

“It is more important than ever that STPs embrace primary care innovation, at populations of 30-50,000, which will enable delivery.  STP footprints may balance risk but without local delivery they are likely to fail,” he says.

Jonathan Griffiths, a GP and chair of Vale Royal CCG, agrees that GPs are not engaged is his area’s STP, but makes the point that they may be a matter of choice on GPs’ part rather than a deliberate policy of exclusion by other players in the STP.

“I still maintain that it is important to be involved, I also would agree that some have chosen not to engage with STPs, and that is a mistake in my view.”

Griffiths sees the trend to more out-of-hospital care as inevitable but says primary care has to be prepared for what’s coming their way. “GPs are rightly concerned that STPs will move work out of hospital – this is the only way in my view to make the cost efficiencies required. We need to ensure that any such shift of work is matched by a shift of resource.” 

Griffiths admits to being less than thrilled by his area’s STP, but he acknowledges that the STP is likely to be conduit for funding in future. In a blog aimed at fellow GPs, posted shortly before the publication of the Cheshire plan, he wrote:

“I have seen lots of GPs expressing dissatisfaction with the STP process, commenting in particular that STPs have no statutory status and no political mandate. I wouldn’t disagree. 

“Whether you like the existence of STPs or not, they are here, and I would suggest you disengage at your peril.”

Griffiths goes on to argue that while STPs may seem too big to engage with, in reality they will depend on the co-operation of smaller units of activity. Individual practices are clearly too small to have a voice, but other organisations such as LMCs could be influential, as could the de facto organisations forming around new care models. Griffiths’ Winsford practice is also part of a Primary Care Home site.

Winsford is one of five locality groups or “care communities” in central Cheshire. These groups, Griffiths argues, are at small enough scale to connect to local practices, but large enough to influence the bigger entity of the STP.

As he wrote in his blog: “Locally I think I can see a clear line of sight from STP to [the locality] and our Primary Care Home.” 

It’s a safe bet that this optimistic view of a continuum from local primary care hubs to STP footprints would delight policymakers. In the absence of further largescale investment in more vanguards (which is highly unlikely), it also suggests the trajectory of new care models from PCH pilots today to MCPs later and accountable care style organisations serving populations at STP scale some time after that.

In any event, it is clear that there is no blueprint or model that will make this vision work without the engagement of primary care, the right balance of local and wider interests and relentless attention to the relationships that will keep it all together.

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