Let's learn from what works: Letting local leaders break down barriers between secondary and primary care

There is a really good case for bringing together high-quality general practice and some secondary providers as a merger with mutual, two-way benefit. But this is no quick fix.

Ideas about how to best support and integrate general practice are a growing feature of the health policy landscape. The creation of an NHS England and NHS Improvement stock-take about primary care, led by Dr Claire Fuller, follows hot on the heels of the integration white paper and a parliamentary inquiry into primary care. One suggestion is that the health and social care secretary is considering creating a permissive approach to practices being run by NHS trusts.

Many in general practice have made clear their scepticism at this prospect. Yet all accept that the status quo cannot hold. As small enterprises workforce gaps hit hard. Taking on lifetime partnership property commitments may not be attractive to some entering the profession.

If doing nothing is not an option, doing something has to be thought-through. The breach of trust from past governmental promises of thousands of new GPs lingers.

The unacknowledged reality is that many trusts are already employing or taking contracting responsibility for general practice. Northumbria Healthcare NHS Foundation Trust, Yeovil District Hospital NHS Foundation Trust, Sandwell and West Birmingham NHS Trust, Royal Wolverhampton NHS Trust and East London NHS Foundation Trust are examples of the former.  Others have partnership arrangements which seek to galvanise real change in how services are delivered, with the Hurley, Modality and Operose among those who have taken on services offered by hospitals. Quietly, these steps have been going on over several years. Guy's and St Thomas' Hospital employed GPs before the start of this century: I helped set it up!

So if this is being done now, the question becomes how-best: a discussion about scaling it up. This could get clouded by three missteps:

  1. Scaling up often implies one size fits all. There are not infinite ways to gain benefit from integration, but it is improbable that a single approach will help all settings or patient populations. Primary care networks (PCNs) themselves serve to illustrate the potential achieved by some, but the poor-fit for others. Different collaborative models, like federations on Teeside, or incorporation in Leicester, may be better placed to work. It is to be hoped that the Fuller stocktake is explicit about local flexibility – what counts is what works.

  2. What problem are we trying to solve? Pressure on primary care is longstanding yet data on appointment backlogs is not published, so the legitimate concerns of those unable to get an appointment are an unsized iceberg. The typical media narrative reverts to how to take pressure off emergency departments.  It is implied that more capacity in general practice would reduce A&E demand. But there is little evidence that primary care access alone is a material driver of attendance to hospital. We certainly do need a new anticipatory relationship in urgent care – one with continuity for complex patients. But if the aim was to turn GPs off the idea of trust employment, then being deployed as a make-weight in an acute hospital salvage deal is a poor sell.

  3. And finally do trusts have the skills to collaborate well? A competency question and one of trust.  Trusts can bring estate management skills, IT deployment expertise, HR and finance skills that will be difficult to replicate in less operational bodies that might succeed Clinical Commissioning Groups (CCG). But the key skill is making transactions work but without losing purpose. The risk right now is that horizontal standardization has the system's attention when vertical coordination is where the gains lie.

Why this matters, and how could it happen?

The focus needs to be on shaping services around those with multiple long term conditions: less a discussion about the front door or back door of hospitals, more a revolving door based around needs within the community. Recovery demands exactly this if outpatient care is to be reformed and duplication removed, as in West Birmingham. Repeat attenders at emergency departments need a joined-up approach between local professionals, as well as the skills of the third sector, as Wolverhampton have shown. All types of trusts offer many of the gains required; in some places mental health integration may offer more than a hospital.

Listening to the trusts who have been down the path of primary care collaboration what comes across is the time these relationships take to build. With a backdrop of lingering suspicion, clinical collaboration has to be genuine and strong to overcome concerns. Boards are still faced with distinct sectoral regulatory regimes within the CQC, separated funding streams from top to bottom, and the consequent duplication of separate operating functions. If the policy is to now scale up it needs a recognition that those inhibitors have to be changed.

Categorically this is about mutual gain. Primary care has leaders used to changing working practices and with insight in holding risk at home. Trusts have financial muscle and management bandwidth, with research and educational infrastructure to make careers more rewarding. Blending these talents has much appeal. The devil will be in the detail of local conversations about how to make the idea work. Yet this renewed attention on how to deliver models of at-scale primary care may break down barriers.

Done well then, this should be an option for some. Asking 'what would help', rather than an institutional takeover. Practices and PCNs opting in should not be viewed as undermining primary care, but as innovators wanting to fulfil the overdue promise of population health. Sufficient sites are doing this now that a national longitudinal evaluation is needed before dismissing the chance to enable more.

This blog was first published by Pulse.