Embracing different partnership models
It is important to remember that there are many different forms and functions of primary and community care collaboration that pre-date and co-exist with PCNs, ranging from informal collaborative relationships to shared pathways, collaboration at scale and structural integration. The drivers behind this collaboration also vary, including the financial unsustainability of the local primary care system and implementation of population health management approaches.
Structural integration of primary and secondary care
Some trusts, such as Northumbria Healthcare NHS Foundation Trust, have set up wholly owned subsidiaries and now run several GP practices alongside their acute and community health services. This approach is often taken in partnership between primary and secondary care to prevent financially unsustainable GP practices handing back contracts. Trusts have the scale required to absorb the financial risk, standardise workforce models to tackle recruitment and retention issues, and use technology to support back office functions. While this fully integrated model of delivery is sometimes unhelpfully framed as a takeover, trust leaders are clear that their drivers are support and sustainability.
Integrated patient pathways
In other areas, primary care providers now deliver parts of acute and community care pathways. For example, in Birmingham, the at-scale primary care provider Modality has been subcontracted to deliver parts of speciality pathways in secondary care. Modality has successfully reduced waiting times – for example, from over nine months to less than two weeks in cardiology – and costs to the system. This model also aids recruitment as placements can be offered across general practice and secondary care specialties, which has proven essential given the serious shortages of GPs.
Collaborative working relationships and joint projects
Where relationships between primary and community care are less mature, joint projects and enablers can foster collaboration on a more informal basis. Developing shared patient records, such as the Hampshire Care and Health Information Exchange, and collaborating on digital care pathways can improve mutual understanding and facilitate further collaboration. Enablers include good analytics, financial sustainability, simplified pathways and workforce collaboration. The case study of primary and community care collaboration in Bexley shows how digital technology can enable joined-up working across different services.
Primary care at scale
Prior to PCNs, many GP practices were already operating at scale within GP federations, super-partnerships or the Primary Care Home model developed by the National Association of Primary Care. These arrangements are also at varying levels of maturity and some still harbour elements of local competition. PCNs were not designed to replace these pre-existing models and NHS England and Improvement has confirmed that PCNs and GP federations can co-exist to deliver a broader set of integrated out of hospital services for their local communities. Our case studies in Leeds and Bexley show how this coexistence works in practice.
Neighbourhood integration: the building blocks of system working
As PCNs embed their new multidisciplinary teams and develop population health management approaches, sustainability and transformation partnerships (STPs) / integrated care systems (ICSs) are connecting innovative work at neighbourhood level up to provider partnerships at place level (defined by NHS England and Improvement as a patient population of 250,000-500,000 although this varies between systems). Neighbourhood integration between primary, community and local partners provides the building blocks of meeting local health and care needs and addressing the wider determinants of health. The scale of this transformation at neighbourhood level will be highlighted in the Community Network’s upcoming Neighbourhood Integration Project.
Overcoming barriers to primary and community care collaboration
There are several challenges that providers of primary and community care often need to overcome to work together collaboratively, including:
- a history of poor relationships, different cultures and lack of mutual understanding between secondary and primary care providers
- procurement processes, contract structures and commissioning are still tailored to the GP partnership model rather than facilitating collaboration
- PCNs are still embryonic in some areas. Even with PCNs, navigating the primary care landscape within an STP/ICS footprint can be challenging for secondary care providers given the sheer numbers of GP practices in their patch.
- primary and secondary care clinicians need to be brought along with the integration agenda, often by workforce or technological incentives rather than financial incentives
- the lack of tangible deliverables for integrated health and care services can also be a barrier to collaboration, although increasingly systems are taking the initiative to do this locally
Despite these challenges, community providers have adapted and reconfigured their existing multidisciplinary structures and workforce arrangements within the new PCN footprints. Given it takes time to develop relationships and an aligned vision for health and care services for the local population, there is a mixed picture of engagement and progress across the country. The case study of integration between primary and community care in Derbyshire shows how investing time and energy in building good working relationships is essential.
The impact of COVID-19 on primary and community care collaboration
Both primary and community services have played an essential role in the NHS' response to COVID-19. Community providers used their years of experience and expertise to rapidly adapt services, including redeploying staff to new discharge to assess teams and priority services. This ensured the community sector was able to safely discharge thousands of medically fit patients to free up hospital beds for the initial peak of COVID-19, as well as support patients with more complex needs (both COVID-19 and otherwise) in the community.
Many community providers also played a key role in supporting care homes during the pandemic. They built on existing relationships developed during flu outbreaks and winter pressures, to provide similar support with staffing and resilience issues, training on good infection prevention and control practices, and early identification of deterioration.
Primary care services have been similarly essential, continuing to support patients via remote consultations and using virtual triage to ensure people received the care they needed. Innovative super-partnerships like Modality report that productivity and staff morale remained high, as the increased use of digital technology and drop in referrals meant that clinical time could be redeployed for care planning and proactive case management.
Community providers' experiences of collaborating with primary care colleagues during the pandemic are variable. In some areas, COVID-19 has accelerated PCNs' development and cemented nascent integrated care initiatives at neighbourhood level. Shielded patient lists have given renewed impetus for primary, community and social care colleagues to support the most vulnerable. Community providers have also been able to support PCNs with their expertise in infection prevention and control, such as advising how to operationalise red and green GP sites for COVID and non-COVID patients.
The case study of primary and community care collaboration in Leeds shows how the foundations of neighbourhood-level partnership working facilitated an effective response to COVID-19.
In other areas, community services report gaps in primary care capacity, which they have sought to support. For example, some providers saw an increase in referrals into community nursing because general practices were not able to offer home visiting services. This is demonstrated by referrals to take blood for shielded patients or develop care plans for people not previously on community services' caseloads. Where PCNs were embryonic prior to COVID-19, it has been more challenging to collaborate a coherent primary care service offer.