Dr Claire Fuller's stocktake on integrated systems and primary care sends an important signal about how national NHS bodies and local leaders must co-produce reform in the NHS. Considerable energy has gone into engagement with health and care leaders – crucially bringing together trusts, local authority, and primary care leaders. What happens next will go a long way to either validate that contributory model, or to undermine it. As key figures in their systems, trust leaders tell us that they want to seize this opportunity.
The stocktake aims to tackle real challenges, and recommends changing care models for two distinct groups of patients. These changes are not add-ons but instead tackle the real operational challenges that are driving such pressure in systems across the country.
The first group is people who need to access primary care urgently: a same day urgent care solution including at the level of primary care networks (PCNs) has been recommended. This is not simply extended access – it will require the alignment of those leading mental health crisis response, community response teams, federated and at scale general practice – among others. If it succeeds it will improve on the status quo and should replace the heart-sinking experience of those seeking an urgent appointment outside of core hours. It will also change the early morning phone call queue at practice level.
The second group of patients that the stocktake emphasises are those who need continuity of care and a more holistic approach. These are the patients who are most likely to benefit from an anticipatory care model focusing on people with multiple co-morbidities. Such services rely on proactive case-finding and coordination between primary care and other parts of the system. The benefits of managing these patients effectively will be felt by the whole local system: it should therefore be the fulcrum of an integrated care model within an integrated care system (ICS) and it cannot therefore fall solely to general practice to make this change.
While the clarity of Dr Fuller's recent publication is new, the ideas within it are not.
System leaders, and trust boards, must now focus on making tangible improvements for patients in these two groups. The former is envisaged by Dr Fuller to release capacity for the latter. While the clarity of Dr Fuller's recent publication is new, the ideas within it are not. Implementation will be key and providers will want to take a central role within that. The publication does illustrate very many examples of good practice and in most ICSs there will be examplars from which to learn. The challenge posed by the stocktake is how to make these and other examples the consistent experience in each neighbourhood.
As they look to bring about improvements, ICS investment plans will need to reflect the scale and importance of primary care: over 30m appointments happen monthly in primary care settings, and that data takes no account of the contribution made by community pharmacy. The stocktake's terms of reference excluded explicit reflections on different methods of vertical integration and contract change. However, Dr Fuller does imply that aligning incentives and supporting improvement is a locally-led activity. Neighbourhood-based models of care – operating below the scale of "place" within ICSs – will thrive if the assumption of national uniformity is relaxed. Rather than waiting for a contractual change, ICSs are being invited to get on and do.
That said, local leadership will require the right policy framework and national support, and the stocktake has specific asks for forthcoming national workforce strategies, estate plans and digital infrastructure priorities. Adapting the most successful Additional Roles Reimbursement Scheme arrangements and making them more locally determined over time is one of the recommendations that stands out. It's clear that a delicate balance to be struck between the national and the local: between programmes and funding which are ringfenced for primary care and ensuring that all investment and development within places and systems gives due weight to primary care. Both are essential.
We now have a nationally endorsed vision that signifies an important shift by defining integrated primary care services, with a vision that stretches far beyond general practice.
We now have a nationally endorsed vision that signifies an important shift by defining integrated primary care services, with a vision that stretches far beyond general practice. It encompasses the roles of ambulance providers, health visitors, social prescribers, and open access diagnostics among many others. A rapid consensus is needed within ICSs about what is to be done in what sequence, and how those changes will be evaluated.
While those debates take place, one idea within the publication needs to seize the imagination. The neighbourhood teams that lie at the heart of the stocktake need to be visible to patients. Trust boards, and those leading ICSs, must ensure that their services form part of those teams and that their resources do move towards earlier intervention in a caseload of at-risk patients.
NHS Providers and our membership has been part of many conversations over recent months in which trust chief executives, chief nurses and medical directors, set out that intention and describe examples of this in action. The stocktake takes us all at our word. And asks for that to become the new normal.
This blog was first published by HSJ.