Delivering a neighbourhood health service

Dr Joe McManners 
Clinical Director, OX3+ Primary Care Network

The ambition needed

The NHS has become a highly hospital-focused ‘sickness service’. For various reasons, resource and investment in primary care has dwindled as we seek to fund the consequences of our failing system. We need to build a different future, one that creates a healthier nation through a primary- and community-centred health system.

The characteristics of the new model build on the foundations of excellent primary care; population based, patient-centred, comprehensive, multi-disciplinary, with the clinician-patient relationship at its heart. As well as delivering modern, technology-enhanced personalised care, it will focus on prevention, tackling inequality and solving the root causes of ill health. It seeks to combine the best of small autonomous local teams with the benefits of larger-scale working.

If we get this right, we will see a better value and higher quality sustainable NHS. We can reverse inequalities, flip the death spiral of ever-increasing hospital resource use, improve long-term outcomes, support economic growth and enrich the lives of those living with chronic illness. Most importantly, we will see the hope of an exciting future, not only for patients, health professionals and teams, but for the health of the country.

Future model for primary care

This paradigm shift will not be realised by accident: how this happens is vital. Getting the framework, structures and policy levers right is critical to realise the vision and unlock innovation. The new model needs resource and support to be able build the structures, capability and capacity to allow the shift from the hospital to the community. We need to consider what the geography of this new environment looks like and we need to describe the financial, leadership and cultural ways that helps this change happen.

The neighbourhood health service

In this model there are two key components to delivering a neighbourhood health service.

1. Neighbourhood health network (NHN) – consisting of:

a. Expanded primary care network:

• GP practice units, including additional roles
• Primary care teams (those not part of GP teams), including community nursing
• Local social care teams. 

b. Physical network of neighbourhood health centres – hub and spoke 

c. Network of local council services, community and voluntary groups.

2. Neighbourhood health provider organising and supporting local network of NHNs

Neighbourhood health networks

Neighbourhood health networks (NHNs) are formal health and care networks that will enable the new community-based health model. They will bring together the health and care teams that work within natural geographies that are recognised by residents and teams that naturally would work together. They need to be large enough to have benefit of scale, but able to be sub-divided into workable operational clinical teams. They represent a coming together of public services and local communities. The NHN may well have multiple smaller neighbourhoods within it. 

The NHNs are an evolution of the primary care network (PCN) model and based on similar populations. GP practices and their teams are the key building blocks, but only one part. The NHNs will include the public service teams that work most of their time in the neighbourhood, such as community nursing, health visitors, mental health workers, as well as the contracted services, such as pharmacies and opticians. They will include housing teams, local social care, public health and the voluntary sector. Being an active part of a NHN will be an essential part of a public service contract.

Neighbourhood health providers

The NHNs are supported by new NHS primary care organisations. These neighbourhood health providers (NHPs) are locality-based umbrella organisations that support a network of NHNs. They should not be too big or risk becoming overly cumbersome and institutional, but they need to be big enough to employ staff and hold contracts. They should not be part of existing large NHS organisations due to the risk of diminishing the role of primary care and being stuck in existing institutional problems. Existing collaborations and federations can evolve into these or be merged with them. The NHPs will employ staff that are not able to be employed by the organisations within them. The NHPs will also provide a potential vehicle for delivering more services out of hospital.

The leadership, constitution and governance of the NHPs will be collaborative and made up from leaders of the organisations within the NHN to build in ownership and alignment. There will need to be input and accountability to local communities and system partners.

Networks and organisations

The binding together of the neighbourhood health network is via contracts and memorandum of understanding (when a contractual route is not workable or appropriate). The neighbourhood health provider can hold contracts across larger areas and hold subcontracts as needed.

The NHNs will be given key objectives, including contractual outcomes that attract financial incentives and allow for resource to be given to teams and services that can meet the agreed objectives.

The NHN will contain ‘integrated teams’ that can deliver better and expanded complex care outside hospitals (see below). Those teams wrap around patient groups and are made up of the individuals and teams in the network, working with teams across multiple networks (for example, specialist palliative care). The teams include social workers and mental health workers, and each one is supported by a named medical specialist from the local hospital, who has dedicated time to do this.

Funding and contracts

Funding for primary care will be population based on an ‘onion’ model with three layers.

The first layer pays for GP practices. A reformed GP contract will provide a consistent core funding capitation to hold a list of patients with a named GP at its heart. The capitation will fund a minimum level of GPs/1,000 patients, prioritised towards continuity, GP-patient relationships and holistic care. The contract guarantees the increase in funding to have a minimum agreed number of GPs, but also requires it.

The next layer is extra staff and services paid for on top of GP funding, weighted to need. Staff that work in GP practices will continue to be multi-disciplinary and include nurses, care coordinators and paramedics. Funding for staff will increase and be ringfenced to ensure equitable services and proportionate to need (for example, reversing the inverse care law, levelling up not down).

The final layer of funding goes to the NHN as an extra capitation funding model tied to outcomes which are determined nationally and locally. The usage is up to the NHN.

Wrap-around funds are given to the NHN to manage and to provide an enhanced level of primary care. The fund is allocated according to population need (for example, extra funding for diabetic patients, for those over 75 years, or higher in deprived areas). The funding is to provide proactive care and support populations to prevent worsening ill health.

The overall NHN is not-for-profit, but within it individual teams can have agreed performance-related payments for keeping within budget and achieving key objectives.

Leadership

The leadership and management of these NHNs is vital. They need to have dedicated time of senior managers and clinical leaders, supported by the NHP management teams who have capability and capacity to run services and manage contracts and finances. The NHP holds a contract with the integrated care board. The NHP funding is a ‘pass through’ ringfenced fund for each NHP from the ICB, with no top slicing, but the local objectives and outcomes are agreed with and monitored by the ICB.

Infrastructure

The NHNs will work from a ‘hub and spoke’ of estates – neighbourhood health centres. They will be highly technologically powered, with very modern digital systems and equipment. Each NHN will have a ‘neighbourhood health hub’, which ideally is a large building where staff can work together, as well as a digital virtual hub. Realistically, this is likely to need to be mainly virtual until a large-scale estate plan catches up. The ‘spokes’ are key: these are physical buildings where patients can be seen and includes the network of health centres, local authority buildings and new facilities (such as ‘Health on high street’ shops and space in community centres).

Functions

The NHNs will have a number of functions: 

• Integrated neighbourhood teams, whose objective is to provide proactive joined-up care for higher need groups (such as frail elderly, multi-morbidity, at-risk children, frequent attenders, serious mental health) — made up of NHN management, community health teams, specialised GPs, care coordinators, social care, hospital outreach support and more — the actual membership of the INTs is fluid and will reflect the professionals needed to manage the identified needs of patients but will have consistent leadership and coordination.
• List-based general practice, providing named GP continuity of care, especially for higher-need groups and long-term conditions.
• GPs will have dedicated list time for ‘enhanced care.’
• Same-day triaged access for urgent problems, delivered by network, includes pharmacies, opticians, dentists within the network. 
• Running advanced digital systems to allow self-management and comprehensive personalised health plans.
• Preventive health programmes (such as hypertension screening). 
• Intermediate health services outside hospitals, such as diagnostics and dermatology.

The changing role of the GP and team

In the reformed system, the role of the GP is core. The new model of care should be designed to ensure GPs remain in the profession and are positive and enthusiastic about the future. This will retain, recruit and best use highly trained, experienced and trusted professionals.

Their future role includes: 

• Dedicated and funded leadership roles within GP partnerships, NHNs and NHPs
• Portfolio work: ‘complex care’, ‘named’ GP time, specialist GP work within NHN services, as well as leadership roles and areas of interest (such aspublic health, digital)
• Less bureaucracy, better digital systems and more; ‘let GPs be GPs.’

The new organisational structures mean that GPs will have options of employment by NHP or within organisations within the NHN, including partnerships in the GP surgeries. GP pay will be transparent and reflect roles and responsibilities. Negotiation with the profession is based on extra resource and reduced financial risk, in return for embracing the reforms. 

GP partnerships will continue where working and will be a core part of the NHN. 

To reduce financial pressure, a ‘cap and collar’ approach could be offered to result in less risk, retain a degree of financial incentives for partners within agreed parameters. This should be a win-win situation for the profession and the NHS, helping those GPs struggling with financial sustainability and removing any impression of excessive profiteering.