The scale of things to come...primary care: from individual patients to larger populations

The scale of things to come...primary care: from individual patients to larger populations

Dr Andy Hilton is a GP at Carterknowle and Dore Medical Practice in Sheffield and Chief Executive Officer at Primary Care Sheffield

International evidence suggests greater investment in primary care results in better quality and more efficient health care.

Our future NHS needs to be built on strong, consistent, high quality primary care. That’s why the strategic development of primary care is at the heart of the NHS Long Term Plan. Primary care should be viewed as the foundation on which to build what I see as a pyramid of sustainable, integrated health care.

In building this pyramid, it’s important not to lose sight of the core principles of first class primary care – equal access for all, continuity of care, comprehensive care and co-ordination with other organisations when needed.

There needs to be a measurable, year-on-year increase in the proportion of NHS money spent on care outside hospital where we know this care is best provided in out of hospital settings. We must have a fundamental shift of both power and resources out of hospitals and into primary and community care with more focus on preventative health care, where the evidence for this is strong. And we need to have a strategic vision for primary care, not just at the base level of the pyramid – consisting of individual practices and primary care networks (PCNs) covering populations of 30,000 to 50,000 – but also at the higher levels where transformational change takes place across much larger populations.

If primary care providers are to influence system transformation and offer a credible alternative to hospital-based services, they must be able to demonstrate that they have the scale, infrastructure and robust governance to justify that shift of resources. A resilient primary care system for the future will be built upon the foundations of consistency, co-ordinated care and the harnessing of economies of scale while remaining focused on the needs of individual patients.

Evidence from the primary care home (PCH) model – the original and validated form of PCN – shows that team-based care and population health management is best delivered to a population of around 30,000. But as integrated care systems evolve, it’s likely that PCNs will also need to consider how they work together at a larger scale. This will enable them to present a unified voice to bring about transformational change and jointly deliver services to much larger populations.

Across the country there are existing, larger scale primary care provider organisations (often called federations) that are already at the forefront of this system transformation. They work with local partners to transform health care both in terms of system change and the way services are provided within their geographical areas.

In many cases these organisations have a track record of both delivering services at scale and of responding to the challenges within the health and social care systems as they reform. Where such organisations do not currently exist or are ineffective, PCNs will ultimately need to join forces to form the foundations of their integrated care systems (ICSs).

This pyramid of scale creates an opportunity for primary care providers to have a greater say in the design and delivery of care than is feasible when separate practices or networks work alone. It enables primary care to stand shoulder to shoulder with NHS trusts, local authorities and other system partners driving the transformational change needed for sustainable care and population health management.

Through greater scale, these larger primary care providers are better able to innovate, develop the strategic vision for primary care, co-ordinate services, provide governance and assurance and share learning and best practice. At the same time they’re able to reduce duplication, enabling member practices to focus on patient outcomes.

The future primary care workforce strategy needs to tackle this issue of scale. It must acknowledge the benefits of individual practices as the smallest units of primary care provision, able to retain continuity of care and respond to the particular needs of the local population.

We know from the PCH model that collaborative working across populations of 30,000 to 50,000 produces significant benefits for staff, patients and the wider health system. These include a rise in staff satisfaction and retention, a drop in waiting times for GP appointments and reduced prescribing costs and hospital stays. But the strategy must also recognise the need to be linked into networks delivering care on a much larger scale with partner organisations where it makes sense to do so. It must support the development of much larger, more strategic GP federations and the connection of PCNs without losing the sense of belonging for the workforce and local populations at the network level

These larger primary care units have the ability to co-ordinate and deliver 24/7 services which are fully integrated with wider system partners and therefore support primary care networks to deliver what they need to.

They are already demonstrating their effectiveness in making more efficient use of resources, for example through a reduction in unwarranted hospital attendances and admissions. They are growing and diversifying their workforce, testing new employment models and redesigning the nature and scope of their services. Because of their size, they’re able to employ a diverse range of staff who can work at the level of a practice, neighbourhood or locality – or in some cases across citywide populations.

At a more strategic level, these large scale organisations are contributing directly to the successful implementation of local sustainability and transformation partnerships, ICSs, the GP Five Year Forward View and the Long Term Plan. From their experience of understanding and overcoming the barriers to change and because of their size and capacity, they can make change happen quickly and efficiently.

If the primary care strategy is a jigsaw then PCNs are clearly a major piece of it. But if we are to see the whole picture we must ensure we don’t perpetuate the fragmentation of general practice and wider primary care. We must also look at the levels of scale both below and above populations of 30,000 and 50,000 and recognise the advantages of each level of the entire pyramid.


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