The NHS has had a winter like no other. Pressures that have been building for years – aggravated by a fundamental mismatch between demand and capacity – have been compounded by the rising cost of living and the impact of industrial action. The role primary care plays within the NHS must be a key part of the solution.
Commentators and politicians of all stripes rightly recognise that things cannot stay the same, but their proposed solutions vary – ranging from a focus on improving access to wholesale reform. The model of primary care is strongly debated: the shadow secretary of state for health and social care, Wes Streeting, has called for the phasing out of the partnership model altogether, others support the benefits and buy-in provided by the current partnership model, while Policy Exchange recommends GPs become salaried employees of at-scale providers.
Some of these ideas reflect changes that are already underway in primary care. An increasing number of GPs are salaried employees: NHS data shows that in 2015, 68% of fully qualified GPs were partners and 28% salaried employees, shifting to 53% and 42% respectively in December 2022, suggesting that amid current pressures, alternatives to the partnership model may be increasingly attractive to GPs.
Recently, we've been working to understand trusts' experiences of integrating primary and secondary care through "vertical integration" whereby the trust owns and manages general practices.
Policy Advisor (Primary Care)
We know that trusts value the flexibility offered by a range of different models of partnership with primary care. Recently, we've been working to understand trusts' experiences of integrating primary and secondary care through "vertical integration" whereby the trust owns and manages general practices. Over 10% of our members operate in this way, directly providing GP services for around 680,000 patients – making their contribution to primary care provision roughly equivalent to serving a city the size of Sheffield.
Trusts have taken on management of general practices for a variety of reasons. In some areas, operating as "providers of last resort" – agreeing the ownership of practices that have become financially unviable. In such cases, trusts have recognised the vital role that general practice plays in the system, and the need to support provision even in difficult circumstances.
In other areas, trusts have proactively sought to realise the benefits that can come from directly integrating primary and secondary care. Trusts have told us how some patients presenting in secondary care are best supported in the community, leading them to first deploy staff in general practices before taking the strategic opportunity to fully integrate services through ownership and management.
Others have sought to provide care to specific demographic groups such as people affected by homelessness, or to re-examine pathways of care and focus on population health management for those with long-term conditions such as diabetes or respiratory conditions, reducing admission to hospitals through a preventive approach. In these cases, vertically integrated services have proved able to respond to issues that affect both primary and secondary care.
Building on the examples of good practice highlighted by the Fuller stocktake report, this model of integration has led to improved working relationships between teams, reduced presentation at accident and emergency for those whose care can be better managed in the community, and improved offers around back-office functions, training and development, and IT. Where it works, integration can make a positive difference to service users as well as staff, helping to both improve outcomes and better manage transitions across the health and care pathway to ensure people receive support in the most appropriate setting.
Many trusts report that partnership brings a level of buy-in that is hard to replicate with salaried staff.
Policy Advisor (Primary Care)
However, trusts overseeing GP services have also often encountered significant structural, cultural, and financial challenges. In particular, trusts we have spoken with were conscious of the value the partnership model can bring to general practice by maintaining a sense of investment in the services provided. Many trusts report that partnership brings a level of buy-in that is hard to replicate with salaried staff.
In supporting financially challenged practices, trusts often saw additional costs escalate. Staffing vacancies – common in practices that had become unviable – increase reliance on locums, inflating costs to maintain the expected level of service. Continued reliance on temporary staff, worsened by supply issues in the labour market, makes it difficult to stabilise practices and put them on an even footing financially or clinically.
So, what have we learned? Where trusts have taken over GP practices, it has been in response to local circumstances. As a result, these innovations are not always supported by national policy direction or system architecture, and therefore bring challenges in commissioning and regulation.
Trusts have told us that instead of being able to develop partnership-based relationships with the practices they managed, the pressures imposed by the wider system around the need to improve access and reduce waiting times for appointments have meant that some have instead found themselves taking performance management approaches.
Even where difficulties have arisen, trusts that run GP services say they have developed more collaborative relationships with primary care colleagues as a result.
Policy Advisor (Primary Care)
This has hampered integration by fostering mistrust, rather than cooperation, between primary and secondary care services. It has also led to duplications in reporting and inspection, which adds administrative burden and takes capacity and resource away from the delivery of services.
In a minority of cases, trusts and primary care colleagues have agreed to reinstate the independence of a practice again, having offered the practice the necessary support. This doesn't mean that the lessons are forgotten, however. Even where difficulties have arisen, trusts that run GP services say they have developed more collaborative relationships with primary care colleagues as a result – an important lesson as local systems continue to implement recommendations set out in the Fuller stocktake.
It is clear there are many options for providing GP services – and that the model of delivery alone cannot solve the challenges we face without investment in capital and estates, digital transformation, and the primary care workforce. But within this challenging context, it is vital that we pay due attention to learning more about vertical integration – the limitations, challenges, and benefits it can bring for practitioners and patients alike.
This blog was first published by HSJ.
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