Delivering primary care without boundaries

Delivering primary care without boundaries

Dr Karen Kirkham is GP, National Clinical Advisor for Primary Care for NHS England and Clinical Lead for Dorset ICS. She will be speaking in NAPC’s Primary Care Zone at Confed19 on Thursday 20 June at 915am in the session:Team-based working – breaking down the barriers, new roles and MDTs

Delivery of care across traditional boundaries in primary care requires shared vision, resilient leadership, creative follower-ship, cultural change and the relinquishing of organisational sovereignty – it’s not easy, and requires a real focus on nurturing new and trusting relationships.

If we get it right, it brings rewards for the patient, to the workforce within those teams, to the local community and for the wider system – through improved outcomes, quality and efficiency and a happier and motivated workforce.

Team-based working at its best devolves decision making to the front line, not only in terms of direct patient care, but in redesign of service delivery with clear lines of support from senior clinicians and managers to ensure that problems are solved quickly and teams guided and supported to deliver best practice.

These principles empower multi-professional teams to get back to what they do best – delivery of patient care in a seamless and holistic way which enhances workforce satisfaction and patient and carer experience.

Delivering integrated care in my local area, Weymouth and Portland – a population of around 76,000 began with the frailty agenda and a need to look after the most complex patients in our community in a powerfully different way. Investment in creating a shared vision for the care model took time and commitment from multiple partners across general practice, community services and the local authority and secondary care- truly care across boundaries, delivered by multi-professional teams with intricate knowledge of their patients, their families/carers, and detailed knowledge of the local system, including the voluntary sector.

We didn’t decommission or recommission a new service. We used what we had to redesign the service offer, and then evaluated and filled any gaps in care, with a clear and communicated vision and plan and a focus on reducing unwarranted variation and improved outcomes. Constant communication is needed for best effect, and we are now spreading this way of working to long term condition management and urgent care delivery with plans for much more.

The increasing use of linked data sets across health and care will allow us to ensure that we are targeting more proactively those patients with rising risk using the principles of population health management and is a key enabler to ensure we use resources wisely. But we don’t have to wait for this – we are already data-rich so use whatever data and local intelligence you have to select patients for MDT working at its best.

Shared patient records are absolutely essential for team-based working, and without waiting for grand and expensive solutions, we can do this by using the records we have, shared within defined information governance (IG) rules and finding local solutions. Patients expect that we do this and it is paramount for high quality and safe care.

Our greatest challenge is our workforce. The NHS is fragmented and silos of care exist everywhere, but despite this we have a hugely committed and talented workforce dedicated to care, and always giving much more that their contracts demand.

Learning together, working together, respecting each other and understanding each other’s talents and professionalism – all the time sharing our successes as well as our problems is a powerful driver for change and the development of high functioning multi-professional teams.

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