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Transforming primary care: let's start with the basics

As part of the King’s Fund’s Time to Think Differently programme, a new series of articles will explore how the funding and delivery of healthcare must change to meet the challenges of the future. Hugh Reeve, clinical chair of Cumbria CCG, highlights the fundamental reforms he believes are needed in primary care

It seems as if the world has woken up to the fact that we must transform primary care, and that unless this happens the NHS will struggle to deliver the patient-centred, joined up services and the financial efficiencies that patients − and the public purse − demand.

‘Most practices are already running flat out, exhorting them to work harder will cause more cracks to appear’

I have argued for some time that the key challenge for clinical commissioning groups is to deliver a transformed primary care system, and to do this in a way that preserves the relationship between a patient and their primary care clinician.

In her Time to Think Differently blog, Christina Patterson argued that patients with ongoing ill health need a relationship with their doctor or nurse at their local health centre that focuses on keeping them well.

She also called for routine access to clinicians at weekends and in the evenings, and online access to her records and to book appointments. These perfectly reasonable expectations clash with a primary care service model that hasn’t really changed in the past 40 years.

I would add that in addition to transforming the way we interact with individuals, general practice must take seriously the health of its registered population. This means going much further than the Quality and Outcomes Framework: it involves working in partnership with statutory and non-traditional providers to improve the well-being of the population.

Front line pressure

What would be the impact if practices measured their success by the number of patients who exercised regularly, ate their five a day, didn’t smoke, drank alcohol responsibly, were not overweight and were happy?

GPs and their teams are the NHS front line when it comes to dealing with the increasing pressure resulting from our ageing population (such as the rising number of people with long-term conditions, increasing frailty, dementia and the number of people now living with cancer).

Add rising expectations from patients, downward pressure on finances and the shift of activity from hospital to community settings, and my colleagues feel as prepared as Dad’s Army facing a German invasion.

So what needs to change? Most practices are running flat out already, so exhorting them or incentivising them to work harder will simply cause more cracks to appear. Sadly the NHS has an appalling track record of supporting system change in primary care, which is in stark contrast to the resources and energy directed at improving secondary care services.

Getting reform right

In Cumbria, our approach is to start with the foundations and develop a common platform across the county on which to build. The first element is an integrated clinical information system that allows the patient record to be shared across primary care (in and out-of-hours), between health and social care and between primary and specialist care. This also supports the sharing of significant back office functions across practices and allows clinicians to work across teams.

The second element is supporting redevelopment of the primary care workforce: GPs, nurses, healthcare assistants and administrative staff. This needs to be done in a structured way across the whole system, ensuring consistency of standards between practices. Communication skills in particular will need to move to another level.

‘Clinicians need the space to reflect on what must change and then they need support from experts’

A third element is helping practices change the way they work − reducing waste and inefficiency, and moving from reactive to far more anticipatory care. This is fundamental stuff and at the moment there seems to be an expectation nationally that practices will somehow achieve this while getting on with the day job.

I believe considerable investment is needed to support practices in doing this. Clinicians need the space to reflect on what must change and then they need support from expert “change agents” working with them in their practices to implement these changes.

As I began writing this article, I expected to wax lyrical about practices working in federations, integrating with community and specialist services, and the need for CCGs to have greater influence over the GP contract − all potentially controversial and sexy stuff. 

On reflection, I think the challenge is to support system change at scale − getting the infrastructure right, raising standards across the whole primary care workforce to reduce unwarranted variation, and helping practices change the way they work. If we get this right, the federations, the integration and the contractual stuff will follow.

Time to Think Differently is the King’s Fund’s major new programme exploring how the funding and delivery of health and social care must be transformed to meet the challenges of the future. This requires new thinking and radical change. Join the debate at www.kingsfund.org.uk/think.

Hugh Reeve is a GP in Grange-over-Sands and clinical chair of Cumbria CCG. This article was first published on the Time to Think Differently blog.

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