Dr Claire Fuller’s review into how to improve access for patients to primary care, ‘Next steps for integrating primary care: Fuller stocktake report’, has been published.
The review was commissioned by NHS England and NHS Improvement, with an aim to review what is working well in integrated primary care, why it is working, and how implementation of integrated primary care can be accelerated. Dr Fuller engaged with around 1000 people across the health sector for the purpose of the review, forming recommendations which the NHS will now work to implement across the system.
Here we will take a look at some of the key points raised.
The report begins by setting out a new vision for integrating primary care with improved access, experience and outcomes for communities. The vision is built around three main offers: to streamline access for people who get ill but use health services infrequently, providing them with more choice and ensuring care is always available when needed; to provide proactive and personalised care from multidisciplinary teams for people with complex needs; and to help people stay well for longer with an ambitious and joined-up approach to prevention.
The role of ICSs
“At the heart of the new vision for integrating primary care is bringing together previously siloed teams and professionals to do things differently,” the report states.
Sharing examples of this in practice, the report goes on to say that integrated teams within a neighbourhood need to be “rooted in a sense of shared ownership for improving the health and wellbeing of the population. They should promote a culture of collaboration and pride… and build relationships and trust between primary care and other system partners and communities.”
Fuller notes that this requires two significant shifts in working culture, towards “a more psychosocial model of care that takes a more holistic approach to supporting the health and wellbeing of a community” and realigning the wider health and care system to a population-based approach.
Systematic cross-sector realignment will be required to form multi-organisational and sector teams working within a given neighbourhood, which the report says will “not only unlock improvements in patient care but also help individual PCNs and teams better manage demand and capacity, building resilience and sustainability.”
Working with communities
“Throughout the stocktake, we heard that the PCNs that were most effective in improving population health and tackling health inequalities, were those that worked in partnership with their people and communities and local authority colleagues,” the report states, with the ideal partnership focusing “on genuine co-production and personalisation of care, bringing local people into the workforce so that it reflects the diversity of local communities, and proactively reaching out to marginalised groups breaking down barriers to accessing healthcare.”
Fuller comments that the COVID-19 vaccination programme has provided a “fantastic opportunity” to build on its outreach model by developing relationships within communities and using expertise and resources by the NHS, local government, community groups and more to understand local social, demographic and cultural factors.
The report points out that ICSs have an opportunity to use their scale and combined power to develop relationships between sectors. This integrated working “offers the NHS a real opportunity to deliver more effective and sustainable change and paves the way for a much bigger prize: creating the space and opportunity to do far more on the most pressing challenge for health and social care systems, tackling the determinants of ill health and helping people to live happier and healthier lifestyles.”
Improving same-day access
“We are going to need to look beyond a traditional definition of primary care and understand that NHS urgent care is what patients access first in their community – typically from their home or high street and without needing a GP referral,” the report says. “As part of accessing urgent care, a patient may then get immediate referral into emergency care or go online to talk to somebody before walking into a hospital emergency department.”
The report comments on the need to work together to make better use of capacity and workforce, in order to make managing access for multiple services at practice level achievable and scalable.
Recommendations include enabling primary care in every neighbourhood to create single urgent care teams and to offer patients the care pathway appropriate to them, highlighting the importance of improvement support, data and leadership which is central to making this work.
“Critically, we need to create the conditions by which they can connect up the wider urgent care system, supporting them to take currently separate and siloed services… and organise them as a single integrated urgent care pathway in the community that is reliable, streamlined and easier for patients to navigate.”
Personalised care
Another key issue rising from the stocktake is that of continuity of care, and meeting patients’ preferences for this. The report describes how determining which patients benefit most from more personalised continuity of care can depend on a range of medical, psychological or social reasons which should be determined through conversations with patients, clinical judgement and by data analysis.
“By managing urgent care differently and supporting the growth and development of integrated neighbourhood teams, we can create the capacity for team-based continuity,” the report states.
Shared decision-making with patients and carers, improving availability and usability of patient records and expanding the role of social prescribing in primary care teams should all play a role in developing personalised care.
The report comments: “This reorientation of our existing workforce to support our most vulnerable and complex patients to stay at home and access care in the community will, over time, contribute significantly to efforts to reduce growth in hospital demand and signal a shift away from a hospital-centric model of care that is no longer suited to the population we serve.”
Preventative healthcare
Fuller highlights how primary care has an essential role to play in tackling health inequalities and preventing ill health, and must work in partnership with other systems on prevention and management of long-term conditions.
“Through the stocktake, we have identified three areas in which primary care is taking a more active role in creating healthy communities and reducing the incidence of ill health: by working with communities, more effective use of data, and through close working relationships with local authorities.”
The report goes on to discuss how this needs to be matched with positive actions in local communities: “Where used most effectively, [roles such as health coaches and social prescribing link workers] can help form an effective bridge into local communities, building trust, connecting up services and galvanising the wealth of expertise in the VCSE sector.”
It adds: “We heard very clearly through the stocktake that the wider primary care team could also be much more effectively harnessed, specifically the potential to increase the role of community pharmacy, dentistry, optometry and audiology in prevention, working together to hardwire the principles of ‘making every contact count’ into more services.”
The importance of data
When it comes to data, the report stresses that, “Integrated neighbourhood teams can only flourish if we ensure information about patient care can be properly shared.” It adds, “Working across the whole of primary care, PCNs should be given the tools to make routine use of population data to inform how they design care for the people they serve.”
The report commends ICSs already working through plans to improve their data sharing and notes that systems can put in place “a local transformation function which includes joined-up intelligence, improvement and other support functions with a deep understanding of primary care, organised and funded at system or place level, but wholly orientated to provide support for their neighbourhood teams.”
When putting this in place, the report notes that systems will need to consider “how they can develop sufficient expertise in data analytics at the right level level, including retraining existing staff and planning to increase recruitment in key roles.”
Digital underpinning integrated primary care
Fuller comments on the potential of digital technology to transform how people access primary care, how services are delivered and how planning can be improved to meet the needs of communities. She adds that the underlying infrastructure to do this is often lacking, due to factors such as variation in digital maturity and knowledge of digital transformation and procurement.
The report recommends that ICSs support the development of more interoperable IT stems by following the What Good Looks Like principles and GPIT operating model when making decisions about investments and products.
It also emphasises the need to provide digital training for clinical and non-clinical primary care staff, with some ICSs already choosing to appoint a chief information officer (CIO) or similar roles at executive level, along with named leads for primary care digital transformation.
“Digital transformation needs to be embedded as part of a more holistic approach to primary care transformation,” the report says. “Critically, decisions about digital infrastructure in primary care need to be made in partnership with those who will use them… ensuring that potential barriers such as digital exclusion are understood and addressed. Establishment of digitally-enabled primary care hubs on a neighbourhood footprint will be a priority.”
The report moves on to discuss the kind of changes needed to inform the new model of care, and how to make it deliverable. It comes back to the issue of digital and data to outline how NHS England will need to work with ICSs and IT suppliers to ensure “business intelligence tools and timely data are made readily available for practices and neighbourhood teams in an easy-to-use format, supported by the development of real-time data visualisation and standardisation of approaches to data to enable comparability tools.”
NHS England can also support ICSs in improving data sharing by publishing a revised national template data sharing agreement, the report adds, and NHS England and systems should work together to engage staff and patients in why data sharing is so important.
“A growing belief in how we can use digital and technology much better than ever before”
In conclusion, Fuller comments, “We arrive at this moment with an opportunity – through the creation of ICSs – to be brave in embracing new ways of working… that’s why shifting our focus now onto developing integrated neighbourhood teams, places and systems give us such a great opportunity to build a new, more effective health service, designed with our communities to fit their needs.”
The use of digital and technology throughout the pandemic has helped us develop our belief in their role in healthcare, Fuller continues. “More and more people want to use apps and mobile devices to support their healthcare – and this doesn’t have to be at the expense of face-to-face care, indeed as this stocktake shows, providing technology-based services for those who want the can free up more time for face-to-face care for those who need it.”
The report finishes by noting that little of what is outlined in the stocktake is easy to deliver, but “the prize of delivering the ideas outlined in this document is greater than just improving the experience, access and outcomes of primary care: I believe that working this way we can strengthen trust within the NHS and rebuild confidence in the services it provides.”
To read the report in full, please click here.
To read more about this topic, check out Dr Minal Bakhai’s webinar for HTN on transforming the model of general practice here.
