Royal College of General Practitioners
Helen Stokes-Lampard is chair of the Royal College of General Practitioners, the UK’s largest medical royal college, representing over 52,000 family doctors across the UK and internationally.
Primary care and community services have always worked collaboratively. We couldn’t do our jobs if we didn’t communicate well with each other. Perhaps we’ve been the part of the NHS that has put the patient at the centre more than other areas of the service traditionally have, because we haven’t been confined by the structures that secondary and tertiary care are confined by.
Structural changes and financial restrictions in the NHS have made it harder for us to collaborate. I think back to 10 years ago when the district nurses, midwives and health visitors were based in the health centre where I worked. We had corridor consultations about our complex comorbid frail patients. We all knew who they were – we talked about them. If a health visitor had a concern about a family that was struggling with a young child, we put together a plan. We were efficient in the care we provided. We didn’t all turn up on the same day by accident – we staggered what we were doing, we coordinated and talked to each other.
Then we lost that connection and the systems that were put in place to help – bits of paper, writing things down – meant things got lost in translation. When you try and repair it, you end up defaulting to more process, which is well intentioned but actually drives deeper wedges. We’re not allowed to send handwritten notes or leave voicemail messages for each other – we have to communicate via electronic forms with 20 mandatory fields - which means people are less likely to even bother and may rely on the patient to pass on an important message to another healthcare professional. You get some real perverse outcomes in the system as an unintended consequence of this evolution.
Structural changes and financial restrictions in the NHS have made it harder for us to collaborate.Chair, Royal College of General Practitioners
The obvious benefit of course has been that the system has been more resilient in providing cross cover to understaffed areas. We can all benefit from that, but what we’ve lost in translation is hard to reclaim. Trust and high-quality communication take a long time to build but minutes to destroy.
Mapping out primary care networks
The aspirations within the long term plan are to move back to better integrated working, using the primary care network (PCN) as the unit of service delivery and as the population health service. If you allow primary care networks to be the unitary building block of future, there are a lot of other structures that are going to have to be mapped onto that which don’t currently work that way. We’re going to have to look at district nursing, midwifery provision, community nursing and dentistry and pharmacy.
The process for forming the primary care networks is already set and in train. Setting the networks up has been totally predicated on groups of GPs getting together and saying “we’ll work together”. It’s hard enough to get GP surgeries in some places to work together, but in other areas we’ve got years of experience of doing this and very effective systems already in place which just need to be mapped across. In areas where this is not the normal way of working, a huge culture shift is having to happen in a short space of time and these wider issues haven’t been factored in yet. There’s not a cause for panic, but there’s probably cause for realism about the timescale in which these new structures are going to be able to realise their ambitions. It’s going to be slower than I think people would like it to be, because building trust takes time. If I were a patient, I’d look at the first pages of the long term plan with hope for the future of the NHS so how do we all get behind that?
If you allow primary care networks to be the unitary building block of future, there are a lot of other structures that are going to have to be mapped onto that which don’t currently work that way.Chair, Royal College of General Practitioners
There’s quite a spectrum of views about the plans. There are some people who are perhaps the visionaries - the people with the energy who see this as common sense. They are already working like this very effectively, delivering care. They are already in this space and they don’t know what the fuss is about. There are a lot of people who are fearful of taking on change, recognising that it’s coming anyway, so what they need is help to overcome their fear. There are lots of people that are cynical about any change because they believe it’s all a conspiracy and that’s because many people are bruised and damaged by the past decade. Those people are often desperately caring, grass roots clinicians who have had the compassion battered out of them by an unrelenting system. When I talk to them what I feel is anger from them and cynicism. They haven’t got any hope left and they are looking to survive and they can’t see the light that others can.
I think there’s something really important for leaders to be honest in our conversations with people so we don’t try to ignore this groundswell, frustration and anger, and we have to reflect it back to the politicians and policymakers in a dignified and professional way – in a way that they can understand without descending into ranting and shouting. It is the lived experience of people who are out there, but it is not the universal truth – not everyone feels like that.
Then there are some people who don’t think there’s a problem and don’t want to change - the ostriches. They are an increasingly small minority but there are – often quite small – practices I’ve visited who don’t think there’s a problem because they’ve had an incredibly stable clinician workforce for a long period of time. The financial levers will be the motivation to get them working in innovative ways, but whether they will be prepared to work at the timescale that others want I’m not sure.
There are workforce shortages right across the board. In the first year, the only additional employees PCNs are looking to take on is more pharmacists and social prescribers. We’d been led to believe that there was an oversupply of pharmacists. For the first time, I’m hearing pushback from people saying we don’t have an oversupply and I don’t know what the truth is.
I think there’s something really important for leaders to be honest in our conversations with people so we don’t try to ignore this groundswell, frustration and anger, and we have to reflect it back to the politicians and policymakers in a dignified and professional way.Chair, Royal College of General Practitioners
Getting to know each other
If we are truly serious about population health management, we’ve all got to start working in more professional ways in terms of trusting one another, getting the financial incentives aligned to motivate us to trust one another and work together, and starting to recognise that what’s right for the population could also be right for our groups. If we get these things right and we are truly working in a population-based way, a lot of these issues will just evaporate.
The first thing we’ve got to do is get to know each other – start building relationships and recognise the new unit of functioning is the PCN. These networks are going to be having conversations with local government, education, lots of other places, recognising that other community services providers are one of a range of other people that are going to be working with the networks and we will all need to establish this new relationship.
PCNs are a complement to community services. The whole point of this is to help us to work better to provide services for our patients. We could find we’re going to focus on particularly frail patients with a wraparound service focusing on a lot of the touch points they have with the service, making sure we’re all communicating, and then do more preventative work for them. There are plenty of really good exemplars of how that works. If PCNs end up in competition with community services that would be a complete waste and a failure of the system.