Measuring What Matters in Primary Care

Primary Care activity, demand and need is poorly understood. The GPAD (GP Appointments Data Dashboard) hasn’t helped.

The main problem with GPAD is the assumptions that seem to underpin the approach.

Assumption 1: More appointments = better healthcare

Data is always built from assumptions and hypothesis. This data set looks like the hypothesis is that some GPs are not offering enough appointments, and that more appointments = better public satisfaction with general practice (on the basis that the public say that they are dissatisfied with access to their GP). Neither of these are borne out by NHSE data.

If more appointments = better satisfaction you would expect there to be a correlation between the number of appointments and better patient satisfaction with appointments. But there isn’t. We compared the two sets of NHSE data and this is what is shows:

There is no relationship between number of appointments and patient satisfaction with appointments, in fact you may as well compare satisfaction with the length of a practices name!

The GPAD data on access has no correlation with quality of care, and health outcomes. The assumption that there is a correlation is unhelpful as in fact a volume approach to appointments can lead to poor quality of care.

Complex patients need longer appointments and continuity of care. It is the quality of the consultation NOT the number of consultations that improves health outcomes (Health Foundation). We ask practices to do a ‘deep dive’ case review into one or two complex patients. What we mostly find is that patients are bouncing between short appointments, costing thousands in time (one young person had over 30 appointments, often very short, in 3 months costing circa 2K none of which had met the person’s health needs), without meeting their needs or improving their condition. Spending more time with people who have complex needs, over less appointments where you can focus on need, will improve the patients health and reduce costs. So for some people longer and less appointments = better quality.

Assumption 2: Variation in appointments is at PCN level

the GPAD data shows there is no variation that is meaningful between PCNS – the variation is all at a practice level. Here are two PCNs in the same place as a small illustration. These are neighbouring PCNS with similar demographics. Practices in PCN 1 offering according to GPAD data between 400 and 600 appointments, with a satisfaction variation between 40-90% with both the lowest and the highest satisfaction offering the same number of appointments. PCN 2 has one practice apparently offering nearly 1K appointments but with only 45% satisfaction with appointments.

When PCNs were established, founded on the experience of the Primary Care Home, one critical part of thier work as networks (not hierarchies or organisations) was to do what networks do best – learn together. The persistent requirements of PCNs to deliver and manage services has undermined the key function of PCNs which is to support their member practices to be the best they can be – to reduce unwarranted variation between practices. The GP patient satisfaction data shows that this still needs to be a major focus for PCNs.

Assumption 3: Naming will shame GPs into doing more (they are not all working hard)

Publishing this data is causing exactly the consequences you would expect if your assumption is some GPs are not offering enough appointments, and you think the way to change that is to stoke public opinion with local newspapers ‘naming and shaming’ practices for lack of access. But the data is flawed as are the assumptions behind the data and this is misleading the public. Stoking the flames of public unrest and pointing it at general practice makes everyone’s lives worse, from the receptionist dealing with massive demand and constant anger, to the clinician putting in long hours to try and care for local people, to the population who are fearful they wont be seen. The latter itself will increase demand – fear of scarcity drives up a requirement for access at a lower level of need.

Once Practices start scrutinising their own data, it may well be that we find practices are over performing – doing much more than they are paid to do. The approach of naming and shaming will shed goodwill and eat into practice’s resilience and willingness to go above and beyond. Changing the assumption to one where most GP practice and PC teams are working harder and faster than they can sustain, with local people’s needs at the heart of their work, changes how you approach performance data and how you interpret it. The headlines from GPAD could easily have been very different. As it stands the data doesn’t help understand the public feedback about their experience, or find a solution that addresses the cause of the problem.

What Now?

The NHS should do better than this in being responsible with data. We find when we work with practices the data on appointments needs cleaning up, as between 20-30% of it is wrong (double counting, mis counting, we have even found appointments lasting days…). It is highly unlikely that the data presented is accurate.

The best way to support practices to be the best they can be is to get fully behind the Fuller Stocktake to:

(a) Provide data support to practices so they can understand and differentiate their list, providing an appointment system that meets needs. This is intensive but important work. Until practices can understand the needs of people who turn up at their door they can’t provide an appointment system, or a care system that works, or even know which roles they need in their MDT.

(b) Stop pushing PCNs into being performance management organisations, and reignite the intent of these networks to be learning communities sharing good practice and solving problems together, and developing collaborative models of care. The demands on PCNs leave little room for the lifeblood that keeps practices connected – learning and sharing.

(c) Recognise and reward primary care for managing to increase its provision creatively by incorporating a range of new roles to meet need, all this whilst coping with a considerable GP vacancy rate. Thank primary care and share excellence.

(d) Build confidence in the population that primary care is open and providing a service and help people to use those services sensibly. Help primary care share how it is changing to meet increasing demand, so that there is the best chance everyone gets access. Fear is driving more demand.

(e) It is known where practices are not performing. This is more than a PCN can solve on its own, but PCNs can be the bedrock for developing collaboratives at place for primary care. Places need to dive into those practices and work out how to ensure that the practice population gets the same quality of care as their neighbours. We know that if your practice isn’t providing good care, you don’t need to move a million miles away, a great practice could be just round the corner. This level of variation needs addressing but no amount of poor data and public shaming will solve this.

(f) Take responsibility at system level for the systemic issues that are increasing demand in primary care including poverty, waiting lists (and deterioration whilst waiting), Long COVID and the Children and Young people pandemic mental health crisis. The whole system needs to get behind primary care and collaborate to meet need.

With thanks to Tony Hufflett for data visualisation

Universal Healthcare – a coalition of the willing

We are going to make visible the reality of inequalities in service provision, and work through how best to secure services that are designed around health needs.

Two ICSs (Sussex and West Yorkshire) and two places (Bradford and Hastings) have stepped up to work out what we can do if we work together across health, local authorities, voluntary services, and communities.

This week, after a summer of building relationships and using data to understand whats happening, we start getting underneath the issues in a whole system process to see what it is we can do together. You can find out more about how we are making a difference by following this blog, and twitter #UniversalHealthcare #nooneleftbehind and you can find out more about the process here

If you want to join the National Inquiry, helping us mobilise people to take outrage into action please do contact us from this blog.

Who are we?

The Universal Healthcare Network is a network of NHS leaders, community leaders, and thought leaders, who have mobilised because we are so concerned that NHS’s reliance on a ‘flat offer’ increases inequalities. We want to address the difficult issues of rationing, unequal provision, the model of primary care to design healthcare services that are truly Universal.

Shameless Sharing

Guest Blog: Alex Fox on taking a strengths based approach to social prescribing

I met Alex Fox many years ago when he was running Shared Lives Plus a fantastic model of ‘homeshare’ where people open their homes and lives to support others. He has always seen the talents, assets and aspirations in others. Alex is now leading the Mayday Trust supporting people in tough times. If you are involved in long term conditions services you must read his book A New Health and Care System: Escaping the Invisible Asylum . So this is Alex’s blog and a shameless sharing of the fantastic work he does.

The Health System Innovation Lab at LSBU asks the question, What is social prescribing for? As its recent Asset-Based Health Inquiry into how best to develop social prescribing charts, social prescribing is a contested term: intended to socialise the medical, but too often at risk of medicalising the social, as some in the health sector look for a quick fix for their ‘difficult patients’.

‘Asset-based’ social prescribing, as outlined in the Inquiry’s findings, can tackle a longstanding problem: some people who visit their GP, particularly people who do so regularly, do so for non-medical reasons, which can include mental distress, loneliness, housing issues, lack of social care, and a wide range of issues related to the health and wellbeing impacts of poverty. Altogether Better’s pioneering work with GP practices consistently identifies a group of people visiting the practice regularly for non-medical reasons which do not improve, often with 80% of the resources being used by 20% of the practice’s patients. So if social prescribing link workers can build a rapport with an individual, find out what matters to them and link them to social and community activities, they have the opportunity to help those individuals in ways that GPs cannot.

However, some link workers having high caseloads, short timeframes, and rely heavily on ‘signposting’ to local charities at a time when they may have high demand and shrinking resources. Some ‘health coaching’ is provided by people with little training and with no obvious change model underpinning the work. This can mean that some social prescribing works best for people with less complex needs, in areas with lots of community activity and less poverty and inequality. This has the potential to exacerbate health inequalities and reinforce unconscious bias among health practitioners about who can be helped. Social prescribing was also not designed to engage with deep-rooted issues like poverty and institutional racism within the NHS.

So in order for social prescribing to fulfil its goals, it needs to offer support which:

• is personalised to the individual, with the flexibility and ethos to form deeper and longer lasting relationships where needed, with an evidence-based approach to coaching
• links people to existing community resources, but also has a community development remit to help people build new community connections and activities where none exist
• can help people and services to recognise and tackle systems that don’t work, or that work unequally for different groups.

Mayday Trust has adapted its strengths-based coaching and system model, the PTS Response, to achieving these goals within the Spring social prescribing contract, with local partners in Northamptonshire and Bridges Outcomes Partnership. This model forms a good example of the ‘asset-based social prescribing’ which the Inquiry calls for.

The three principles of PTS coaching are:

1. Seeing the whole person, their strengths and potential: avoiding forms, assumptions, eligibility criteria or targets. The coach’s primary goal is to build a trusting relationship.
2. Being led by the person without ‘fixing’: tough times shouldn’t be permanent, but coaches stick with people for as long as they want, and offer personal budgets where needed.
3. Engaged with the world outside of services: building connection and community, helping people to access resources and to challenge systems which are harming them.

Two of Mayday’s PTS coaches, Lilly Broujerdi and Shauna Hemphill offer coaching to people with long term conditions. They say, “A diagnosis becomes an identity. People will introduce themselves as their long-term health condition and their deficits, thinking that’s what we are there to talk about. They are used to clinical and formal environments which focuses on things they cannot do, or things that ‘other’ them such as groups for people with certain long-term health conditions”. A common comment heard by coaches is that they are first person who “actually listens to me,” and “makes me feel like a ‘normal’ person”. On a practical level, this can mean that rather than automatically signposting someone who has a stroke to a stroke group, the coach might support them to find and join a group based around one of their interests, and work with the group to make it accessible, or attend with the individual to begin with until they gain confidence. Personal budgets can be used to overcome barriers. For instance, a man in his 40s who is ashamed of his long-term condition was unwilling to use a mobility scooter, but purchasing an electric bike meant that he could ride around the park with his children, and he is now excited to experience increased mobility and aiming to progress in other ways.

The PTS Response has been developed over ten years and evaluated by the new economics foundation (nef), which found that people tracked over 18 months reported huge improvements in self-esteem, sense of purpose, and optimism, as well as better mental health including feeling happier, and a reduction in anxiety. The most radical part of the model – helping people to challenge services and systems which didn’t work for them – is also the most challenging to deliver, with the model’s success impacted where people were accessing multiple services with misaligned values. This points to the need and opportunity for ICSs to align health and other agencies around shared goals. Mayday Trust is part of a group of organisations aiming to drive this kind of system change as part of the New System Alliance.

The PTS Response is delivered by eight organisations who are supported by Mayday with resources, learning materials and a national community of practice. It is one of an emerging field of strengths-based or asset-based models which have the potential to enable social prescribing to achieve its ambitions for support which is not just community-located, but which builds individual assets and community capacity, reshaping the NHS’s community relationships at a time when statutory resources are ever more stretched, and inequalities in health and in access to healthcare are becoming ever more apparent.

Area of work	Traditional support work	The PTS response
Initial meeting	Appointment to attend at an office or centre Eligibility & Risk assessment Support planning based on little knowledge	Meet somewhere safe & known for person & coach Get to know each other Build a trusting relationship​
​Offering support	Support only looks at service’s priorities Timetable and time limits set by service	Person defines and can change their goals Broker opportunities​ & personal budgets  Build community connections
When services don’t work	Focus on engagement and compliance Manage ‘challenging’ behaviour	Identify what would work better Support the individual to challenge and identify changes to services
​Ending support	Signposting to other services Goal is to close case Few other relationships when support ends	Person can pause and vary level of support Person chooses how to end support Support feels less important in busier life

Alex Fox OBE is chief executive of Mayday Trust. For more on how to develop the PTS Response in your area, or to build strengths-based thinking into primary care work: www.maydaytrust.org.uk. 

Integrated Primary Care (isn’t that just Primary Care?) PART 3

Final part of our submission to NHSE Stocktake

Our Response 4: The Potential of PCNs

We have already identified the benefits for young people of practices collaborating through their PCNs to meet young people’s needs in collaboration with other services.

This is exactly what PCNs should be doing. PCNs are best placed for practices to work together to develop health care service solutions for people whose needs are more complex than can be met by any practice on their own.

However, because the purpose of PCNs was never well determined, there is a drift into PCNs becoming the providers of services on behalf of practices (in effect becoming a business), rather than a network of practices collaborating to meet complex needs. The former is better placed in a Federation model.

In our view PCNs are best placed to:

• As a network of practice members learn and develop general practice to secure better quality across all member practices
• Collaborate to address complex health needs that are beyond the capability of general practice on its own
• Collaborate with communities to help support the social determinants of health

It is very early days in the life of PCNs. With the underinvestment in the development of General Practice members, the lack of support for PCN administration, and PCN work being on top of a really challenging workload, the time PCN leaders have had to bring disparate practices together to secure new models of care has been limited. Our research shows that PCN leaders are navigating their way through striking a balance between the ‘top down’ mandate and meeting local health needs. They need time to develop their practices to secure equity of provision for complex health needs (reducing variation between practices).[1]

Our Response 5: The Need for Robust and Adaptive General Practice

The foundation for integrated PC is that all ‘parts’ work to the top of their license, working together only when acuity drives the need for collaboration. However General Practice has been consistently under supported in terms of both data and organisational development support to enable General Practice to be the best it can be. In addition, the focus on appointments versus General Practice being the provider of primary care to meet population needs is now a significant disabler. If General Practice understood who was needing what on its list it could then proactively put in place a range of appointments and other services that would reduce daily telephone demand, this would include:

1. Continuity and regular appointments for complex needs
2. Group consultations for those that would benefit from a peer-based collective health consultation
3. Reaching out to people and communities that are being left behind (Ethnic minorities, young people)
4. Determining who would best benefit from social prescribing.

This in turn would release capacity in General Practice.

Prof Malby, Health Systems Innovation Lab, LSBU

Supported by Nick Downham, and Tony Hufflett LSBU Associates

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[1] Kordowicz, M., Malby, B. and Mervyn, K., (2021). Primary care networks: navigating new organisational forms. BJGP open.

Integrated Primary Care (isn’t that just Primary Care?) PART 2

More from our submission to NHSE Stocktake

Stocktake Qn 2: What practical enablers are needed to realise this vision, and how should these best be put into practice?

Our Response No 2 : Take an Evidence Based, Data informed Approach to Problems

No matter where you start the approach to integrated must be evidence based and data informed.

Overall, the NHS appears to operate on a set of assumptions and prejudices rather than taking a data driven evidence based approach to understanding the ‘causes’ of the problems being faced. These assumptions drive behaviours both in terms of finding solutions, and in catalysing public behaviour. For instance, the narrative that GPs are not seeing patients face to face despite the evidence to the contrary, drove a wedge between local people and their GPs. But even more importantly there are narratives that are driving investment and policy decisions that are based on stories and assumptions not on evidence and data.

High performing health systems have information (including real-time activity data) at the heart of team decision-making (Baker & Denis 2011[1]). Data Scientists support decisions by helping clinicians and managers understand the problem’s causes and making the patterns behaviour and decisions and the impact of those, visible. This is very different from the dashboard large data sets that look at prevalence rather than seek to understand the issues teams are facing. With Primary Care having so little access to data to help it both understand and respond to local demand and need, it cannot organise effectively to meet that need. In order to collaborate to meet complex needs, PC along with partners in the system need to better understand needs, the impact of the current pattern of organising, and what works in terms of collaborating to meet needs.

For Example there is a longstanding narrative that A&E is full because General Practice doesn’t have enough appointments available. However, there is alternative evidence that is not being considered when trying to understand the problem of A&E capacity. Wyatt (2019)[2] found that A&E breaches are related to

• increasing acuity/ complexity,
• increased length of stay,
• staffing and facilities out of pace with the changes in need in A&E, (ie staffing focused on trauma expertise not complex chronic disease management)
• increase in case management within A&E, (i.e. significant increase in diagnostics ordered from A&E)

not as the dominant narrative suggests, as a result of increased numbers and poor primary care.

I described another example of how Young People are not getting access to General Practice here

Stocktake Qn 3: What type of leadership, engagement and decision-making structures are needed?

Our Response No 3: The Crisis in Primary Care Management

General Practice and Primary Care is undermanaged. GPs spend too much time doing the work of general managers and administrators. Private sector businesses typically have 9% management costs. NHS Trusts are at around 2% and Primary Care is even less (under 1%) (Kirkpatrick et al., 2017a; 2022[3]). Additional roles funding for PCNs focuses extensively on health care professional roles with no infrastructure funding for data scientists, administrators, and project management. General practice needs people who can do data searches to inform the best way of offering primary care services, administrators and receptionists that can reach out to people, or contact them with straightforward test results. It is hard to recruit clinicians, there is a workforce crisis, but the work that is needed is not all clinical work.

Primary Care Networks are equally under-resourced with PCN leaders working long hours to do essentially management and administrative roles particularly in relation to the DES. 

General practice has real-time data but does not have the tools time or expertise to use the data to help them understand who is accessing their surgeries, when and why. The lack of data capability in general practice means that practices work tends to be generated by (a) who rings, (b) DES requirements to offer services to (e.g., health checks) and (c) incentivised activities such as QOF. Practices need data support within practices, and time to use it as part of their everyday business. They do not need more and more external dashboards/ pop health which is more “stuff” that will be ignored as they don’t know how to use it

Primary Care needs professionally trained, business mindset, resource management focused staff. 

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[1] Baker, R., Denis, JL (2011) A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Canadian Health Services Research Foundation. Accessible at https://www.cfhi-fcass.ca/sf-docs/default-source/commissioned-research-reports/Baker-Denis-EN.pdf?sfvrsn=0

[2]Wyatt, S. (2019) Waiting Times and Attendance Durations at English Accident and Emergency Departments. The Strategy Unit

[3] Kirkpatrick, I., Veronesi, G., and Altanlar, A. (2022) ‘Hybrid professional managers in healthcare: An expanding or thwarted occupational interest?’ Public Management Review – forthcoming.

Kirkpatrick, I., Veronesi, G. and Altanlar, A. (2017a) ‘Corporatisation and the emergence of (under managed) managed organizations: the case of English public hospitals’, Organization Studies, 38, 12, 1687-1708.

Integrated Primary Care (isn’t that just Primary Care?) PART 1

Theres an NHSE stocktake going on on Integrated Primary Care. Here is our (shortened) response

Stocktake Qn 1. What are the key priorities for ensuring a more integrated and effective NHS primary care service in future? (and then there are a list of really important services all of which need ‘integrated’ responses…)

Response No 1. Start with Acuity not Services

The stocktake assumes that priorities for integrated care are a choice between services. In our view the priority is to develop an integrated approach in order to address health needs which require collaboration. If the approach is right then it becomes obvious where to integrate.

The current stocktake approach is in effect rationing at the outset. In our view the starting place should be understanding what acuity requires integration. High performing health systems understand the ‘acuity tip’ between levels of service collaboration. In fact Primary Care Leaders also understand this. As complexity increases so does the need for an integrated approach. (Intermountain gets it as do all high preforming health systems – the NHS resolutely sticks to levels being associated with power not acuity)

The Primary Care leaders in South East London working with us, have provided these ‘personas’ that describe the work of each scale of the current Health system in relation to providing integrated primary care:

You can find what sort of integration is needed at each scale in my previous blog here

In developing an Integrated Primary Care Approach the first step is to map what scale of integration for what work. For instance taking a service based approach e.g. Long Covid needs to understand what are communities best placed to support and enable (and therefore you need to work at the level of the community); where you need to collaborate across providers (an acuity approach); where you need to locate the leadership of that integrated service (based on critical mass of provision as per the care home model above); where you need to integrate back-office support and where you need to collaborate to learn how best to deliver those services.

With thanks to Brenda Donnelly, Monica Pathak, Sarah-Elizabeth Odogwu, Therese Fletcher, George Verghese, Andrew Parker, Simon Parton, Sabah Salman, Kat Warren, Clive Anggiansah, Juwairia Hashmi – Primary Care Leaders from SE London.

Response to misleading FT article by Camilla Cavendish on General Practice

This is my comment posted on the FT page to “Its Time to Stand Back and Ask What GPs are For’ Camilla Cavendish.

“This has subtly misrepresented our work. People who are ‘struggling with life’ are primarily poor. This is not about delegating that work to someone else. Poverty cannot be fixed with an NHS appointment – but it can be fixed with a universal credit system that does not leave people struggling to cope. The issue we raise is that the NHS providing a sticking plaster to poverty is much more expensive than ensuring we are not leaving people in poverty. In addition this is something communities can help with, supporting people who have no social connections. Where people have friends they use health services less. Overall delegating poverty driven health problems to other workers is not the solution. This is not something it is within the gift of general practice to solve and it is misleading to say it is. 

Linking this to the face to face appointment issue is also misleading. We have been working pre-pandemic on a much better mixed model of telephone, video and face to face appointments. This means more people can be seen, and for many many people video consultations are both effective and meet their needs. In fact patient satisfaction with video consultations is really high. There are face to face appointments available with GPs but they are triaged ie only those that need it – and that means General Practice can see many many more people.  You can’t advocate for delegating work on the one-hand and then saying there must be more f2f on the other – its a contradiction. We understand that general practice is now running at at least 110% from pre-pandemic. The demand from Long Covid, people waiting for hospital care, people who have waited with their concerns until they felt safe to see the NHS front door, anxiety and mental health issues from the pandemic, alongside the regular GP workload means if General Practice is to manage and see those that really need their services they must ‘filter’ early (so they can delegate as you suggest where relevant) and then work out who to see f2f and who virtually, providing information so patients can make a choice as they do so.  

This article mixes the issues and contradicts itself. GPs know they need to develop a new model of primary care,  and they need to do this based on local people’s health needs not a whole set of assumptions about what they are and are not doing. Given the huge increase in workload across the NHS, GPs need support to (a) understand the needs coming through the door (b) to work with community leaders to help communities help themselves (c) time and space to redesign general practice and (d) the causes of poor peoples health needs to be properly addressed (see Marmots work which sets all this out – https://www.instituteofhealthequity.org/home). 

We work with GPs in the evenings on how better to deliver care; they are doing this at the end of the day after 6pm having had a full day in surgery. They are having these evening conversations because they care, even though they are absolutely exhausted. GPs are not immune to peoples needs, they are highly tuned to them. Why are journalists making out GPs are turning their back on people when they are working non-stop to see them. One GP was telling me she had 200 calls to make in 2 hours last week. Thats the level of demand. 

If you look at management in the UK business sector it runs at 9% of total costs; in general practice its less than 1%. We have one of the lowest doctor to person ratios in the western world. General practice management and development has been underinvested in for years. The new roles coming into general practice really help but they are not the whole solution. Tackling poverty would really really help. As would a more managed approach to the community spread of Covid. 

Alongside all the issues I have covered General Practice is also coping with Covid running rife through its staff now there is so much community prevalence – no-one talks about that. Once practice I worked with last week had 7 staff members off, and one GP suffering long covid not able to work for 2 months. Given the crisis in recruitment of GPs thats work that has to be managed by the rest of the staff in that practice.  GPs are coping with a pandemic response that has no plan for General Practice, a hugely increased workload, and is trying hard to adapt to do everything it can to meet needs effectively. Relentlessly criticising GPs in this context is really unhelpful, as is grasping for simple political solutions. Its hard to understand why the media is not helping general practice by sharing the real story of whats going on in surgeries across the country. General Practice needs the community to help, fuelling the fire of disenchantment will not solve the problem. Neither will a simple fix reorganisation of how General practice is structured. Right now communities need to help general practice look after those that really need it and get through this winter. “

Prof Becky Malby

Network Case Studies : Podcast Series

https://www.buzzsprout.com/1767967/episodes/8414820

Farzana shares an example of how she is sustaining the PCN in Newham, with a story of their work on knife crime. This story illustrates the key areas you need to pay attention to to sustain your network:

•Making progress on Purpose

•Members Being Engaged 

•Securing Impact 

•Resources

•Capacity

Forgive the amateur start!

Universal Healthcare

“I sit on a man’s back, choking him and making him carry me, and yet assure others that I am very sorry for him and wish to ease his lot by all possible means-except by getting off his back” 

(Tolstoy, 1991)

The NHS is Contributing to Health Inequalities

Covid made visible that people’s health is directly linked to their wealth (Marmot et al, 2020), and that the NHS is providing unequal healthcare, an issue identified in the Kings Fund’s evidence to the Joseph Rowntree Foundation (Buck and Jabbal, 2014)[1]

The NHS Constitution requires the NHS to provide comprehensive healthcare for all based on need. It starts with the words ‘The NHS belongs to the people.’ In fact it belongs to some of the people. Charlotte Augst from National Voices (2021) reminded us that the Pandemic has shown that the NHS is not providing universal healthcare.

Of course we know from the Marmot Review (2020) that poverty has had, and is having a disgraceful impact on health. But there is more the NHS can do to address the lack of universality of healthcare, it has been complicit in three ways:

1. Medicalising poverty and providing ‘sticking plaster’ approaches, with the best intentions, that make the problem invisible. That means that those accountable are not held to account.
2. Not being frank and open about the reality of the rationing of services, in effect creating a fantasy that the NHS is actually providing universal services when its not. The latter is depicted in one of the National Voices ‘I’ statements.(National Voices 2020)
3. Providing services that are not accessible to all.

‘I statement’ National Voices (2020) p7 .

Medicalising Poverty

At the RCGP Annual conference in 2019 and 202, I urged General Practice to make visible the impact of poverty by providing details of how many GP appointments directly related to poverty rather than ill health. In our work in the Primary Care Quality Academy we have been finding that circa 40% of people who frequently attend general practice are there because they are struggling with life. Providing access to health because there is nowhere else to go, does not solve the problem. It’s a sticking plaster on the symptom. Whilst clinicians are doing their best to support people with the best intent, and social prescribers are picking up a large caseload from this; tit is not the best use of healthcare resources and hides the extent of the problem. In addition, the NHS does not measure or report where ‘poverty medicalisation’ is occurring. The result is noone knows how much healthcare resource is being directed at needs arising from poverty, and that lack of visibility means that (a) the problem doesn’t get addressed within the NHS and (b) no-one is held properly to account for the impact on people and health services (c) We have no idea of the knock on effects of resources directed to sticking plastering poverty on the ability of the NHS to meet health needs (see rationing below).

The Reality of Rationing

Charlotte Augst calls on the NHS to be frank and open about the extent and nature of rationing as a result of the workforce crisis and pandemic, which has lead to many services closed or postponed. The NHS needs to be clear with communities about what can and cannot be accessed, and open about the causal issues that are creating rationing (Charlotte Augst 2021). Again if the NHS fails to be transparent about the issues faced, then there is no accountability for those who have the power to create the policy to address these issues.

National Voices depicts this in one of their ‘I’ statements ‘I am not forgotten’

Service Design

 “We are not hard to reach but easy to ignore communities”

Fatima Elguenuni 

The Vaccine programme has shown us that when the NHS wants to, and plans to reach the whole population, it really can – from Vaccine Buses to collaborating with faith leaders. The vaccination programme is going to the people. This is a salient lesson. People who are poor are not struggling to be healthy purely because they can’t afford heating, fresh vegetables, and have stressful lives. The NHS doesn’t always help them access services. If the NHS is going to address health inequalities it needs to ensure services are accessible universally no matter what the person’s means.

For example

• Outpatient redesign in its move to digital options must collaborate on digital poverty with local government.
• Primary care provision for a population has to address young people’s needs. Young people do not access GP appointments when they are in need. There is emerging evidence from our PC Academy that they end up in out of hours, or with no services. They are not getting the health care they are entitled to, and that Practices are paid to provide. In fact rarely do practices know if young people are accessing their services. The NHS should be providing primary care to populations in imaginative diverse ways beyond a GP appointments system for those that choose to use it.
• Services have to address people’s life circumstances in terms of their ability to practically access the healthcare they need (considering for instance transport routes, caring responsibilities). Expecting people to come to the NHS when locations may not be easily accessible has been shown by the vaccination programme to leave people behind

Integrated Care Systems will know where communities, populations and people are and are not getting access to the healthcare that they need. Reducing inequalities means people securing the health services they need within their reach. That requires:

• honest inquiry about what people need and what they are and are not getting (who is being left behind)
• data and transparency on the impact of the NHS providing sticking plaster solutions
• commitment to designing service that people can actually access no matter what their means

The NHS is awash with reports on how to reset and recover as a learning system. Something more fundamental is needed. What if the NHS really focused on meeting need not demand, and on ensuring the universality of health services?

You can see a webinar covering these issues here

References

Augst C. (2021) The pandemic has broken the promise of universal healthcare. Health Services Journal online. 13^th January

Buck D. and Jabbal J. (2014) Tackling poverty: making more of the NHS in England. London: King’s Fund.

Department of Health and Social Care (2021) The NHS Constitution for England.

Department of Health and Social Care (2021) Integration and Innovation: working together to improve health and social care for all. Policy White Paper. 11^th February.

Malby B (2020) Young People Need Primary Care Now. Becky Malby Learning Journeys Blog. Available at

Marmot M., Allen J., Goldblatt P., Herd E. and Morrison J., (2020) Build back fairer: The COVID-19 Marmot Review. The pandemic, socioeconomic and health inequalities in England. Then Institute of Health Equity. Available at:

Marmot M., Allen J., Boyce T., Goldblatt P. and Morrison J. (2020) Health Equity in England: the Marmot review 10 years on: The Health Foundation.

National Voices (2020) What We Need Now. What matters to people for health and care, during COVID-19 and beyond – new National Voices I Statements.

Tolstoy L. (1991) What then must we do? Element Books.

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[1] “..there are problems in accessing health care for groups more likely to be in, or at greater risk of, poverty. In the paper we explore three particular areas; namely, families with children with severe disabilities, certain types of care for black and minority ethnic groups, and the impact of long-term conditions on people of working age. We find the NHS could do more to help people in these groups which could reduce the risk of poverty.”

What Now? This ….

There are 3 priorities now for Integrated Health Systems that will ensure the NHS and the people that work in it can proactively, purposefully and hopefully take the next steps.

Universal Health Care

Do you remember the NHS Constitution? The NHS providing comprehensive healthcare for all based on need. It was Charlotte Augst who first reminded me at least that what the Pandemic has shown is that the NHS is not providing Universal healthcare. Of course we know from Marmot that poverty has had and is having a disgraceful impact on health. But we cant blame the lack of universality just on poverty. The Vaccine programme has shown us that when the NHS wants to and plans to reach the whole population, it really can, from Vaccine Buses to collaborating with faith leaders. The vaccination programme is going to the people. This is a salient lesson. People who are poor are not struggling to be healthy purely because they cant afford heating, fresh vegetables, and have stressful lives, the NHS also doesn’t help them access services. If the NHS is going to address health inequalities it needs to ensure services are accessible universally. For example Outpatient redesign in its move to digital options must collaborate on digital poverty with local government as it does this; primary care provision for a population has to address young people’s needs, recognising that young people do not come to GP appointments. Services have to address people’s life circumstances in terms of their ability to practically access the healthcare they need. As @FElguenuni says “We are not hard to reach but easy to ignore communities” ICS will know where communities, populations, people are not getting access to the healthcare that they need. Reducing inequalities means people securing the health services they need within reach.

Meeting Complex Needs – revisiting the Grand Round

Now PCNs have found their feet they are turning to work on complex needs. The pandemic has generated an escalation in the need for mental health services, and this is causing real concern about the model of care. Previously I have written about the role of PCNs in supporting people whose needs are too complex for one service or one practice. Here is a reminder of the diagram of acuity related to people who turn up frequently. You can do the same for people with mental health needs.

Talking to GPs it is clear that there are a range of needs in terms of people’s mental health that PCNs have to address here are some examples:

• People who are experiencing worklessness – where the PCN needs to ask for help from communities and other agencies. Their social prescribers will be able to provide information on the demand coming from this section of the population, and the PCN can invite others into determining PC and the NHS’s role here. Clearly multiple GP appointments are not the answer. Role: Codesign
• Anxiety particularly in young people – where PCNs need to work with schools, IAPT services, and out of hours providers (where young people often present) to rapidly co-design / collaborate on supporting young people to manage their health, that address these escalating needs. Role: asking for help
• People with severe mental health needs, possible recently hospitalised. Here the PC team need MDT support. Leaving PC to manage this on their own is not going to secure quality healthcare. Do you remember the Grand Round? The MDT needs to get together to review severe MH cases so that the whole system can learn together about how best to provide quality care. Role: Inviting an MDT review

Acuity should trigger a designed response in terms of bringing together expertise and responses. At minimum people with complex needs require MDT reviews across the system.

Preventing the Harm from Moral Injury

I was talking to a Dir of Transformation who reminded me of the legacy of Swine Flu. She was saying that we have to learn the lessons of that time, which was when the NHS expected the ICU team to just go straight back to normal work, the ICU team had really high sickness rates in the following year. I am seeing a range of responses in hospitals trusts to the transition from acute pandemic response to restarting full service as usual. At one end of the spectrum the F1s F2s are moving straight back to their departments and rotas with some support for pastoral care; at the other end, senior clinicians are encouraging the juniors firmly to take at least one weeks AL, are providing emotional and professional support and are then transitioning them back into their rotas over a 3 week period as services open up in a planned way. Clearly there has to be more than individual wellbeing responses, at the scale of the pandemic impact, the NHS needs to take a planned route to enable staff to recover physically and mentally from the exhaustion and shock of the last year.

There are a full range of experiences of NHS staff in the pandemic, but the experience across a whole system has not been accessible to the whole. This means that the moral injury of the rationing, the decisions made nationally that lead to the horror experienced in clinical settings, the inability to take comfort from family and friends, was experienced differentially across the system. Suzanne Shale in the BMJ calls for moral repair. Over the past few months one role we have played here at the Lab is to acknowledge the injury and bear witness to clinicians experience. This needs to happen locally and systemically. It is not the role of the hospital or the GP practice to repair on their own. One way is to use the Schwartz round model bringing people together across the system to listen to accounts from across the system to that the experience and stories can be shared and repaired as a whole.

Shale, S. (2021) Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it. BMJ leader Commentary.