There’s a buzz in the air of the offices of the National Association of Primary Care (NAPC). Days after moving into rooms somewhere inside the central London HQ of the Royal College of Nursing, the NAPC is preparing to launch its first impact assessment of its flagship primary care home programme.
Meetings in the reception area, meetings in corridors, and last-minute proof readings of the report.
Timed to coincide with NHS England’s Next Steps announcement of the latest package of implementation of the Five Year Forward View, NAPC’s assessment of three of the sites piloting its answer to the new care models programme is in danger of being lost amid talk of waiting times, emergency care, sustainability and transformation plans (STPs) and accountable care.
GP services at scale
Which would be a shame, because NAPC believes it has positive things to report. But even within primary care, much of the day’s focus will be on NHS England’s plans to incentivise every practice to join a new 'local care network' grouping within two years.
Within that Next Steps report, and in GPonline’s interview with NHS England’s director of primary care Dr Arvind Madan, NAPC’s primary care home model gets a mention. Local care networks will cover populations of 30,000 to 50,000. The primary care home sites cover populations of 30,000 to 50,000.
Earlier this month primary care minister David Mowat told MPs general practices would move to hubs serving 35,000 to 40,000. For now, though, as he talks GPonline through his report, hours ahead of publication, NAPC chair and GP Dr Nav Chana is not sure what exactly NHS England is about to announce.
The primary care home model is a kind of pared-down version of NHS England’s own multispecialty community provider (MCP), but without any need for new contracts, or new organisational structures, or even new funding. It is non-prescriptive and each site is designed locally by the providers, not the commissioners. So each of the 92 sites looks different.
But all adhere to four core characteristics: provision of care to defined, registered populations of 30,000 to 50,000; integration of the primary, secondary and social care workforce; a combined focus on personalised care and population health outcomes; and aligned clinical and financial drivers through unified population budgets and shared risks and rewards.
While the new report, Dr Chana is keen to point out, is a ‘moment in time’ look at just three of the programme’s initial 15 rapid test sites launched last year, the findings do suggest positive effects of the model: improved staff satisfaction and retention, reduced prescribing costs, reduced emergency attendances and admissions, reduced appointment waiting times, and reduced stays in hospital.
It’s the effect on the workforce Dr Chana sees as perhaps the strongest message. ‘In many ways, that is what we have built the model around,' he says. Why do almost 70% of staff at the three pilot sites say the primary care home has improved their job satisfaction? The approach, says Dr Chana, is ‘enabling staff who would normally be feeling disempowered to feel much more positive about the way they work just through very simple approaches of integration'.
At one of the sites, in Thanet, Kent, the local health system struggled for some time to recruit community nurses, but since implementing their primary care home all the vacancies have been filled. ‘You need workforce groups to be working in areas they feel they have been trained to work in and feel fulfilled working in,' he says.
It seems like fairly basic stuff. But the point is to find a way of working to create space and time for people to do it, to focus on what they need and want to focus on. For GPs working in primary care homes that means creating the space, through a wider team and better integration, to do more than just respond to the demand that comes through the door. ‘You suddenly got a bit more space to start focussing care in the areas you'd like to feel more professionally fulfilled,’ Dr Chana says.
The whole point of primary care, according to the NAPC, is to address the needs of the individual within the population health context. The primary care home aims to allow GPs and their clinical colleagues to do that, to balance individualised, personalised care with a population health approach.
‘You can't expect very busy GPs to do that on their own,’ says Dr Chana. ‘You have to build a system around GPs, to mobilise voluntary organisations, social care, and mental health services, community services. Bring all that together in a way that starts to work, so that you are focusing intervention in the right areas. Create time and space for GPs to stand back a bit to do the things they need to do in terms of complex patients and do that personalisation stuff.’
Smaller GP teams
Part of the population health management approach, he says, is about being able to do both the big and the small. While the primary care home is about scaling up where necessary, Dr Chana argues they cannot lose sight of everything that must be done at the micro level as well. So some of the sites are developing targeted care home services which could be dealing with populations of just 400 people. ‘It's a question of how you shape your care model around each of those areas. For very complex people you might need smaller teams working more coherently.’
While Dr Chana seems pleased that NHS England appears to have adopted the 30,000 to 50,000 population as its basic unit for organising general practice, he warns against starting from the number. The size, he says, came from what works best. ‘There is some rationale and evidence to the number,' he says.
‘When you take a population health management approach, having a defined population of a certain size is important. We are trying to integrate health, social care, community assets, and helping people live healthier lives, into a manageable unit size that can be sustainable.’ And this size of population allows for a workforce size that does not put at risk the important relationships of support which can be lost in bigger units.
He warns against trying to force practices into these kinds of collaborative arrangements. While he believes every practice in the country would benefit from it - particularly since NHS England has already set this size of collaboration as a minimum to benefit from some of the measures in the GP Forward View - he says top-down mandates are not the way to make it happen. ‘We have to go at the pace and energy people have to do this sort of stuff. And that is very much how it has worked in the primary care home.’
Similarly, the organic approach of the primary care home model means the sites are not all headed to a single destination. While some may use the model as a stepping stone towards full MCP status with all the new contracts and legal entities and larger populations that could entail, others will want to remain in their 30,000-patient grouping.
Rapid GP changes
Either way the primary care home, Dr Chana says, is a mechanism for practices to make almost immediate change. ‘As we have seen in the report, some positive change starts to happen, which then gives confidence that as a result of something like this the health economy in a system could start to benefit and that might encourage other primary care home sites to come forward. And then that becomes in time a bigger MCP-type organisation. But that might take five, 10 years, that journey.’
While new money to support collaboration development would be ‘brilliant’, says Dr Chana, it can happen without. While the 15 initial primary care home pilots were given around £1 patient from NHS England and the NAPC, subsequent sites had nothing centrally. Although some have received local funds, they mostly benefit from learning and experience. NHS England has, however, since announced there would be new financial incentives to support the development of local care networks.
‘What is important is not necessarily, pump a load of money in and something will happen,’ Dr Chana says. ‘That would be great. It's more about the will, the energy, the values, the commitment to doing things differently, which is driving some of this.’
And while money shouldn’t be the focus when planning the primary care homes, Dr Chana also argues it shouldn’t be the only factor considered when evaluating their impact. Value, he says, is more than money. It’s also about ‘doing the right evidence-based interventions at the right time by the right person, and building on decisions individuals make when given the right information.’
Getting decisions about care and treatment right at the right time by spending more time with a patient ‘might yield financial benefit down the line, but it’s quite hard to demonstrate that now’, he argues. ‘Sadly, we only ever focus on the money bit.’
Over 50 new applicants have expressed an interest in joining the existing 400 practices in the programme for the third wave of primary care homes set to bring the number of patients covered to around 6m. ‘We should celebrate getting to this point,’ says Dr Chana. ‘That's quite impressive given the context of where we are at. People are starting to see there is a potential solution here if you can mobilise your resources.’