The new secretary of state for health and social care has rightly focussed on the scale of challenge facing the NHS if we are to successfully tackle the growing backlog of elective care.
Central to meeting that challenge will be transforming the relationship between patients, their GPs and their hospitals and linked community services. We know that, in the past, the boundary between primary and secondary care has been far too rigid and the gap, from the patient perspective, far too great.
This has meant that, too often, patients have bounced back and forth between GP and hospital or community service, with no clear pathway for treatment. Patients have felt they lack the information they need about their treatment and therefore, rightly, have regularly chased progress, bringing extra work and worry.
If the NHS is to work smarter, faster and differently to tackle the backlog, transforming the relationship between primary and secondary care will be key.
If the NHS is to work smarter, faster and differently to tackle the backlog, transforming the relationship between primary and secondary care will be key.
Over the last 18 months, NHS Providers and a group of large, at scale primary care providers have been working together to identify how these two parts of the NHS family, divided at birth in 1948, can work together more effectively. Our first report is published this week.
It highlights the new partnerships that are now being created across the country to move services out of hospital and create more primary care led services in community settings. We know that delivering as much care as possible in local settings adds convenience for patients, reduces anxiety and improves communication. We believe that scaling up this transformation, at pace, could be a key weapon in tackling elective backlogs at the speed required.
The report is clear that it is relationships, rather than structures or contracts, which underpin these changes. It sets out a range of different examples of concrete changes to individual pathways, recognising that there is no one-size-fits-all model. Systems and places will need to work with the most appropriate 'unit' for their local footprint and in the way that suits their local context and relationships. The report highlights the fact that COVID-19 has seen new collaborations, deepening relationships between sectors, creating more hybrid roles for clinical staff and providing a leap forward on which we can now build.
The case studies show the potential for digital approaches to blur the boundary between care sectors. New technologies allow faster and shared triage, co-consulting by video or telephone, and more rapid segmentation of referrals to get faster to the right skilled professional.
Our case study from Northumbria demonstrates the benefits of consultant advice provided to a general practitioner remotely. It shows that we can rapidly reach the point where the traditional hospital-based face to face outpatient consultation can cease to become the default setting.
Much of the innovation we have identified focuses on re-design of diagnostic pathways.
Much of the innovation we have identified focuses on re-design of diagnostic pathways. This is important because long waiting times generate anxiety for patients. Local places and systems need to look not just at the location of diagnostic provision, with the creation of new community hubs, but at the steps in the pathway and which really do add value to the patient's care.
As an integrated care provider, Croydon is well placed to illustrate the potential for joint working. Their hospital waiting lists are fully visible to general practice and joint decisions are made about priorities. Their case study also highlights two essential enablers. First, a shared focus on the inequalities sitting within waiting lists is best supported by local community knowledge. Secondly, data sharing has been transformed during the pandemic and these improvements can now be embedded permanently.
Our report also raises interesting national policy questions.
The example of Modality, and their long-term partnership with Sandwell and West Birmingham NHS Trust, shows the advantages that at scale primary care providers can bring across, and between, practices given their ability to drive bold, at scale, change. Whole waiting lists or specialties are now being managed together across a significant size of population.
That sharing of skills and the adaptation of traditional list-based practice is crucial to innovation at the primary and secondary care interface. Larger groupings of primary care – primary care networks, federations, at scale provider groups, whichever works locally – offer the opportunity to create new models across whole populations at real speed. Inefficiency and inequality will remain if we try to drive change incrementally, individual practice by individual practice.
Our report also shows that national approaches to policy and incentives need to catch up with innovation on the ground.
Our report also shows that national approaches to policy and incentives need to catch up with innovation on the ground. Support such as the elective recovery fund needs to be available to a broader range of providers, including primary care, to enable them to play their full part in addressing backlogs. A more co-ordinated national response is also needed to avoid a competition to recruit and retain talent between sectors, for example in the paramedic workforce.
Both of our sectors are under huge day to day operational pressure. General practice colleagues are delivering over 30 million patient consultations each month, changing the way they work. They have successfully delivered the bulk of the vaccination programme. Trusts are facing a difficult combination of record urgent care demand, reduced capacity due to infection control and a very uncertain, fluctuating, COVID-19 workload.
But the last 15 months have shown that we can deliver huge change, at pace, alongside huge operational pressure. That is the task now ahead of us.
This blog was first published by HSJ.
About the author
