There is no doubt that the NHS must change the way it delivers services. Multiple factors mean that the current delivery models are not sustainable, even in the short to medium term.
NHS England is hoping the change will be delivered via sustainability and transformation plans (STPs).
The basic two-pronged strategy being put forward by the majority of STPs appears to be a desire to move care from hospitals into the community, coupled with a renewed focus on prevention and self-care.
Primary care plays a major role in both of these areas. Hence, if transformation is going to move from theory to practice then primary care itself will have to change significantly. Transformation cannot merely be commissioned. It can only be provided.
I hear commissioners using quite confrontational language such as: ‘If GP practices won’t change then we’ll put services out to tender and bring in providers that will’. This really isn’t the basis for transformation; it’s a recipe for conflict and mistrust.
Primary care providers need to be given an equal seat at the STP table alongside hospital and community trusts and local authorities. However, it would appear that the majority of STP boards have little in the way of primary care provider representation. This doesn’t bode well for turning theory into practice.
Primary care providers need to get their act together. Transformation requires delivery at scale. STPs will not want to talk to individual practices about small scale changes. They will want to work with federations, or even networks of federations, covering significant parts of health economies.
Giving federations, or other primary care providers at scale such as out-of-hospital urgent care providers, an equal seat at the STP table will ensure openness and transparency of the planning process, as well as the buy-in of key stakeholders when it comes to the implementation of those plans.
Currently, out-of-hospital provision is fragmented. Disjointed pathways of care have multiple providers, each with their own capacity issues and variable KPIs. There is significant inefficiency with duplication as well as wide gaps, such as exists within mental health.
New contracts may be the answer but little progress seems to have been made to date in bringing together providers who are willing to move to this model of working. Commissioners who think that they can simply go out a tender for an MCP and then expect GP practices to want to work with whoever wins the tenders will end up wondering why transformation hasn’t happened.
Transformation requires both commissioners and providers to develop a new mindset. Commissioners should work with those providers in their patch who are willing to work at scale. Providers need not only to think big but to begin to act big.
The importance of leadership cannot be under estimated.
Leaders of primary care provision at scale need to be brave. They need to listen to those on the front line and then deliver a shared vision. Those leaders need support and I welcome the RCGP ambassador scheme as well as NHS Collaborate.
GP Forward View
Delivery of the GP Forward View is a key element of transformation. This is not just about GPs – practice managers, practice nurses, community pharmacists, and the wider disciplines within primary care all have a key role to play in transformation. Their voices need to be heard and they require support with their own development.
I would therefore encourage STPs to priorities the following:
- Include primary care providers at scale on programme boards
- Support the development GP federations and networks of federations
- Focus on delivering the GP Forward View
Only when primary care is delivering transformed, integrated, multidisciplinary care at scale can we start to safely think about A&E departments closing, hospital wards closing and, ultimately, un-needed hospitals closing.
To try to do this in the reverse order will only lead to primary care collapsing sooner than at the current rate. Transformation cannot merely be commissioned. It can only be provided.
- Dr Mark Spencer is a GP in Lancashire and co-chair New NHS Alliance