Rewiring primary care

Dr Sian Stanley 
Clinical Director, Bishop Stortford & Valleys Primary Care Network 

Primary care has recently seen a resurgence in its place within the system. The hospital-led model of care is not enough to fulfil the needs of the population, and the ageing nature of the population has created a need for holistic care, which is something that hospitals cannot do well. Primary care is poised to become everything it should always have been. We need to explore the processes and contracts that are working well and build on those, how the contract and partnership model can be used to improve pathways and promote integration, and how this integrated model could be delivered at scale.

Digital

All patient flows into primary care and the emergency department should be streamed to the appropriate healthcare provider, with concomitant patient education so they do not feel ‘short changed’ by not getting a doctor’s appointment. This digital front door should be fully interoperable with existing systems and build on the NHS App to streamline processes. Patients are the constant in their own care and should have the ability to digitally carry their own records. These systems should be safe and user friendly, ensuring secure records that travel with the patient. Any future digital commissioning should ensure that future systems interface with existing primary care systems and work across all the providers involved in that patient’s care. 

Using AI, patients can be streamed to what they need rather than everything going through primary care. Care coordinators should be available to assist patients who are not digitally able to help them navigate the healthcare system. All elements of the system need to share equal responsibility for the patient journey and the concept of the GP reviewing first before other services are involved needs to be a thing of the past.

Traditionally the GP has been asked to review the patient but in the future the GP would only be involved if there was a medical need. We need to stop using the GP as the only trusted assessor: they may hold the record, but they should not be the only ones to act on it.

Alice is 96 years old. She has multiple comorbidities and is worried about a lesion on her leg. She calls the practice and is guided to an AI triage model, helped by the receptionist or the care coordinator. It is immediately noted that she has a dynamic care plan. Her issues are multifactorial, as she comments that she has in fact acquired the lesion due to a fall and this is not the first. Her son, who is usually her carer, has been unwell himself and she confides that she is worried about how they will cope this winter as there is little money coming into the household.

Her call is to the GP as she knows and understands who the GP is and what they do. The reality is that she needs a district nurse to dress her leg, a pharmacist and an occupational therapist to review her medications and see if there is anything in her home that can reduce her risk of falls. She needs a social prescriber to help understand what is going on with her son and finances, and social care to help with care, if needed.

Dynamic care planning

For all patients who are severely frail, a dynamic digital care plan should be implemented and supported, with the whole system taking an equal responsibility for their part of the care. These care plans should be updated after every hospital admission, change in medication and social care change. It should be a single record which sits at the heart of the integrated neighbourhood team and be clear, up to date and travel with the patient. It is not their entire medical record but a precis of their immediate medical and social needs, with an appropriate plan to manage their care closer to home where possible.

Reducing variation

There is a perception that if national and local commissioners centrally control how practices run this will reduce variation. It could be argued that this is part but not the whole solution. A core contract for services is required and parameters set to create a minimum viable product for all primary care. It is not possible to remove all variation across primary care due to local deviation, but there are a few core principles that should be adhered to:

• There should be a set number of appointments per thousand patients and a ratio of 20-minute complex care appointments and ten–15-minute acute appointments. How a practice decides to do this needs to be evidenced and audited based on population health management data in conjunction with the ICB teams.
• Mandate that a practice is offering the appointments that the population needs. Combining population health management data and modelling for deprivation, commissioners should work with the practices to form a structure of their appointment books. Create templates with GPs to maximise the workforce in the context of their population. The Carr Hill formula would be replaced with a formula that reflects not just allocation of funding but how that funding should be used to create the minimum viable product – this would reduce failure demand establishing local systems fit for local need. 

Using digital tools, the ICB should work with practices to ensure appropriate appointments are being offered. The Care Quality Commission should adopt failure demand as a criteria for assessing practices, auditing how many touchpoints a patient needed within the system to get the care they wanted for themselves or a relative, and the outcome of that journey.

Primary care can lean into this variability to create health settings fit for the purposes of that population, for example, in deprived areas co-locating with optometry, dentistry and community pharmacy, creating partnerships that straddle professions. People present to primary care and emergency departments because they are some of the few open access points in the system.

The partnership model should be used to its maximum potential and greater flexibility on who can become partners. For example, frailty consultants could work as partners in primary care to reduce hospital attendances; we could integrate general practice and dentistry through partnerships.

Health inequalities are the biggest variable of all, and we need to use the partnership model to create well-funded partnerships in the most deprived areas with collaborative working, shared risk, and high productivity. These should be more rewarding Alternative Provider Medical Service (APMS) contracts that have clear corporate governance structures, with partnership agreements that are standardised and overseen by regional or local bodies that have the patient and primary care at the centre of their remit. It should be mandated that a partner must work a certain number of sessions in that practice to qualify for this funding and demonstrate leadership and responsibility for the practice.

Access

Access is a perception of patients’ needs at a given time. Some patients will need more access and continuity of care and some less so, preferring a more transactional model of care. It could be argued that this is not a zero-sum game but rather a continuum, and it is often helpful for GPs to see all patients as there is always an opportunity for health education. It is clear, however, that the GP training means that we are moving more towards the model of the medical generalists. This would mean that complex care would need to be the responsibility of GPs, and working with secondary care colleagues, can put in place proactive care plans and reduce referrals.

This takes time. The traditional ten-minute appointment is not fit for this purpose and a minimum of 20 minutes would be needed. Practices need to be given autonomy to create surgeries that meet the population’s needs with minimum standards. If a practice, PCN or federation chooses to create pathways of a higher standard and that is a population need, then they should be funded for that pathway. For example, a diabetic pathway, where minimum standards are met but higher funding is available if insulin is initiated. 

Incorporated PCNs or GP federations should be able to hold contracts on behalf of smaller practices to deliver some services at scale, such as diabetes services and ADHD prescribing. This would create an intermediate tier between primary and secondary care, keeping care closer to home and reducing variability.

The future of primary care could be bright if all left-shift activity is adequately invested in – either through funding or greater sharing of workforce. It is vital to take GPs and patients on the journey too, as top-down structure and reorganisation will only stop innovation.

It is tempting to have top-down integration, with GPs monitored and micromanaged, but the vision would be to see a set of desired outcomes set nationally, a high-trust environment created and reward for excellence at a practice, PCN or alternative neighbourhood provider. This would require clear and precise contracts and collaborative agreements, with the lead provider rooted in primary care. No provider should be allowed to have an INT contract without demonstrating their ability to work with primary care and there should be clear KPIs on how this is achieved and maintained for all parties involved.