Analysis: Pointing the way to change in primary care

A new drive is about to begin to bring about the personalised, proactive, holistic and coordinated care, which offers both flexible access and is embedded in communities, that has been long sought in primary care.

General practice is at the heart of the ongoing review of care for “vulnerable older people”, launched by health secretary Jeremy Hunt in June, and which he has devoted part of his summer to considering. Its scope includes management of and accountability for patients, self-care, changing workforce, and service integration. Meanwhile, NHS England has said it will draw up a primary care strategy as part of its Call to Action work on making the NHS sustainable despite a £30bn funding gap.

For much of general practice, it would be a major step to comprehensively meet the aspirations which many believe are the future of primary care.

However, with NHS and professional leaders asserting the sector is at a tipping point, it is increasingly being accepted that lessons have to be learned from those already experimenting with extended and specialised primary care.

One such service is the York Street Health Practice, which provides services in the centre of Leeds for people who are homeless, temporarily housed or seeking asylum.

Many of its patients have long term mental and physical health and social problems, and serious alcohol and drug addiction. They fail to access conventional services, which often do not meet their needs.

The centre’s core workforce is very mixed: There are around two whole time equivalent GPs among some 25 staff. They work closely alongside practice nurses, nurse practitioners, mental health nurses, nurse drug therapists, alcohol specialist nurses, support workers, managers and administrators.

Extended services

Critically, the centre hosts a number of peripheral services provided by others. There is a regular presence at the centre from physiotherapy, social services, housing, welfare rights, and solicitors, whose services are often important to those in the asylum system.

While many of York Street’s quickly growing 1,200 patient list will visit several times a week, they often struggle to access other services directly, whether because of chaotic lifestyles, conflicting priorities, or difficulty interacting.

John Walsh, a senior mental health support worker and long-time leader in Leeds homeless services, says if services were not in one place, many clients would not reach what they need, and a miss the chance of recovery. “There is a need for people to be able to come to one place,” he says. “If we’re asking them to knock on five doors the likelihood is they are not going to make it. If there is one door they are more likely to take up those services.”

The practice is also managing its population proactively, attempting to ensure people get help rather than deteriorating. This extends to holding informal outreach clinics in McDonalds; maintaining extremely strong links with relevant voluntary sector services; and identifying those with serious problems, whether through street work at 5am, or those regularly attending accident and emergency units.

York Street patients’ chaotic or difficult lives, and tendency not to prioritise their health, mean the practice cannot afford to be difficult to access. In some cases, if clients could not get seen, or were ignored and left waiting, they would walk away from the services they need.

Catherine Hall, the practice’s head of service, says: “We run an incredibly flexible appointment system. If our partner organisations have people they are worried about we will work outside the box to make sure they get access.

“We also tolerate a lot of behaviour [from patients] that others wouldn’t tolerate, while balancing that with protecting staff.”

Perhaps most importantly, though, the centre’s staff work to a service model – drawn up by Mr Walsh – which delivers highly personalised care, focussing on each individual’s general wellbeing.

Relationships

The model prioritises inclusion and developing “therapeutic relationships” with patients. Mr Walsh says: “We know from our experience that if we can build this relationship we can accomplish effective work based on respect and trust – without it the work is very difficult.”

If patients’ non-health needs are not addressed, and they do not develop their own “positive vision and hope”, they are highly unlikely to see long term change in their lives and health, Mr Walsh says. York Street staff therefore aim to address wellbeing in every contact, and prioritise “work to support clients connect with what they identify as important”.

In practical terms, as well as ensuring they reach wider support services, this can mean helping them begin education or training and careers; connect with faith based communities; or set up bank accounts, which is difficult for homeless people.

It is a specialist service, in specific circumstances, and those working in general practice will quickly identify why in many ways its approach cannot or should not be transferred.

That said, part of the requirement for future general practice is to better provide for the type of people who currently rely on York Street and the handful of similar centres in cities nationally.

More generally, many of the key characteristics seen in York Street’s services will run through the high profile discussions about the future of primary care which are set to take place in coming months.

Jeremy Hunt is expected to announce findings from his review in the autumn, and is eyeing changes linked to the GP contract for 2014-15. Specific ideas which appear to be under consideration include giving named GPs more specific responsibility for their cohort of frail older people; and ensuring those patients can get urgent appointments more easily.

Primary care strategy

Meanwhile, NHS England is working to develop a strategic framework aimed at moving primary care to meet modern requirements, encompassing but not limited to timely access; extended availability of diagnostics and other services; proactive management; patient centred care;  and multidisciplinary workforce.

Clinical commissioning groups are being encouraged to work with their NHS England area teams to experiment with new models of general practice, and develop their own plans.

A national-level consultation document is expected imminently, with conclusions and a framework to follow late in the year or early next. It will aim to shape policy for the next few years.

We will see, as part of these discussions, new attempts to grapple with difficult organisational and contracting questions. How dramatically do GP practices need to change, and how quickly?

Should extended community services be provided through general practice-based organisations, or by other providers – for example NHS trusts – wrapped around practices?

More radically, there could be a growth of primary care provider organisations which are not necessarily led by GPs, but simply employ some alongside a much more mixed workforce.

These could be run by NHS providers – for example York Street is operated by Leeds Community Healthcare Trust – or independent providers, whether small or large. Some at NHS England are enthusiastic about such models.

Organisationally they represent a step away from today’s list-based general practice, and ideas on the table include creating providers for specific cohorts of patients – whether those with long term conditions, or the frail elderly.

Funding and contracting

Barriers to meeting the widely held aspirations for future primary care include funding, premises, contracting, and availability of workforce.

Services such as York Street – and other extended primary care – require additional investment, and are already stretching existing contracts.

Creating larger models of general practice will be cited as part of the answer to paying for staffing and expansion, without dramatically greater investment. National officials will return to the question of how to incentivise practices to group or merge.

Meanwhile, the contracts currently used in primary care and community services can make it difficult to create and support extended, integrated models.

York Street has no complaints about its current funding but, like many other providers of specialised primary care, it has faced intermittent uncertainty about its income, including from the current NHS England review of primary medical services contracts.

It is now safe from this particular review, but those hoping to develop specialist primary care nationally are suggesting a new tailored type of contract is needed to support them in the future.

York Street has had early stage discussions with NHS England about finding a way to commission it to be the lead contractor of the set of related services which it is at the heart of.

This could prove to be a starting point for a future contract model to be applied widely elsewhere.

The government may not rush into creating a new type of contract for general practice, which requires legislation. But NHS England is likely, at least, to endorse further experimentation with existing models, including a new approach to establishing enhanced and extended services in practices.

It is recognised there is a problem commissioning services combining both general practice, commissioned by NHS England, and community services, which are the responsibility of CCGs.

NHS England is likely to explore the potential for pooling budgets between its area teams and CCGs, opening the way to purchasing various forms of integrated service.

There appears to be a belief among leaders at national level, and in some CCGs, that change in general practice must now gather pace. They will be expecting practical challenges, along with intransigence, and services such as York Street, where elements of radical new models are already operating despite the system, may help show the way.