Seduced by Structure
As we wait for the next round of policy papers on the size and shape of GP practice organisations and primary care teams, I’m struck by how much structure always becomes the answer. Many reshaping documents start with the structures of the institutions rather than the identity and capacity of communities, and yet General Practice has grown out of communities, and practices are deeply embedded in their local place.
I thought it would be useful to offer a view about scale from the place of relationships and needs, rather than institutions and structure. But first of all the practices need to be ready to collaborate.
The Fantasy of the Future
The next seduction is to get into a fantasy about how fast the primary care system can move into these new collaborations. The starting place for the policy is well functioning practices with increasingly complex work, whereas many practices aren’t at the starting blocks yet.
Any development of ‘at scale’ collaboration needs the bedrock of efficient practices working with resilient communities.
We know that practices that are adapting effectively to the context of increase complexity [London Primary Care Quality Academy]:
- Use data to understand presenting needs, review activity and improve the flow through the practice system. Understand their demand and ways of meeting that demand (data capture of patterns of demand and flow in the practice; how they offer appointments and who gets turned away; understanding the profile of their frequent attenders; and their low attenders; number of DNAs.
- Collaborate with communities to coproduce services locally
- Use their skill sets more effectively to meet need (diversify their workforce)
- Use their contact time with patients more effectively (triage, mixed model of appointments)
- Improve their back office functions to work efficiently (managing the paperwork)
- Reach out to partner with other providers to manage complex health (care homes, social care, third sector, mental and acute health).
- Learn fast, looking for examples outside their practice to steal with pride; establishing peer review for their clinical practice across professions. They test and prototype new ideas and check the impact on their demand and capacity using data.
This is the ‘Readiness Stage’, the foundations that practices need before they start collaborating (and merging/ partnering), because this stage exposes the nature of the actual work in practices, and where best the practice teams can intervene, and therefore where they need to collaborate to provide the best option. It also requires practice members to work collaboratively together, beyond the individual roles but as peers to bring all their experience and ideas as a team.
What Scale for What Work?
There are four main resources that secure health and wellbeing in communities –the community itself, the NHS, local government and the third sector. You can’t change General Practice without consideration for the other groups.
In my view there are these ‘scales’ for primary care service development:
Scale 1: The Community: Up to circa 14,000
General Practices grew out of local communities. These communities have natural boundaries, characteristics, relationships and resources. They have stories they can tell about themselves as a community. They recognise people from their community as being one of them. Most communities are at a scale of up to circa 14,000. This is the size of a small town. Go beyond that and people don’t feel like they are part of something they can identify with – it becomes something others ‘own’ and belong too. They don’t feel that its something they can contribute too.
At 30-50K scale that is the current favourite scale, people don’t identify themselves as a community, there are conflicting stories and different cultures. They see people as ‘other’ and its not a size that generates any sense of belonging.
The NHS could be seen as having generated an over dependence on its services borne out of the founding principles of the NHS ‘Can do, Should do’ and medical model ideology. There are many proponents of the assets that communities can and should bring to their health, and examples emerging beyond social prescribing (language that is laden with the intent that power stays in the hands of the prescriber see Corman Russell’s blog on this),to a partnership model with communities that has the potential to reduce demand.
There are masses of assets in communities or perhaps more accessibly – people who want to volunteer and help each other. We need these people to help with the volume of ‘patients’ presenting with ‘trouble with life’. This has to be the bedrock of any further ‘at scale’ working . See my previous blog on Reducing Demand in Primary Care.
Primary care for the future needs to be built out from resilient communities. So this is the first productive scale for primary care.
Scale Two: The Locality: 30-100K
(a) Across General Practices
At this scale you can generate efficiencies in the Practice Business Model:
- Sharing back office functions
- Sharing workforce (particularly non-GP professionals and receptions staff)
At this scale collaborating practices can provide some diagnostics, and more specialised rapid assessment and treatment functions to support GP/ Primary care teams work. See the work of Eastleigh Southern Parishes Locality
Aligning with Care Homes
Care homes provide better care where they are aligned with a practice. Within a borough a practice could specialise in this service for a geographical areas akin to Localities.
(b) As part of Integrated Teams
When you have resilient communities working to support local health and wellbeing, and you have functioning general practices, alongside collaborations for business efficiencies, then the next step is how to collaborate with other service providers to manage complex conditions, to prevent people with complex needs becoming unstable.
At the moment there seems to be a focus on growing these collabortions out of primary care, rather than developing integrated MDTs that bring the best of the skills needed from all service providers locally to bear on the complex needs of specific population groups e.g.
- People who are frail
- Adults who have both mental and physical health needs
- Young people with both mental and physical health needs
- People who have trouble with life which means they can’t cope with their health issues
These different groups require different MDTs with different skills and leadership. The General Practice team are members not neccessarily the leaders. For these teams the GP and practice members are peers in the team. As yet there is some way to go before we have the level of self-organising integrated MDTs that can work collaboratively with devolved authority to support people who have complex needs, preventing them from moving from stable to unstable. The MDT will have different professions taking the lead dependent on the severity of need. So for combined mental and physical health, it could be the community nurse at the lower levels of severity, a GP at a mid level but a Psychiatrist at higher level of severity. People with complex needs do need algorithms that identify the intensity and level of expertise of support required see the Intermountain work (Reiss Brennem at al 2016 ) and Western HealthLinks, Australia.
We at LSBU London Primary Care Quality Academy have the early ideas for the model here:
Scale 3: The Borough : 150K – 350K
At Borough scale there seem to be two main functions:
- Some service delivery potential across a larger population.
- Business Intelligence and Learning : A ‘Collaborative’ where members can work together to spread and share intelligence and to learn. This is in effect a development agency for the NHS in that place. Here Primary Care teams are supported by an Research and Development Team. Every industry needs its R&D function to innovate and adapt. Borough level organisations (e.g. Federations) can partner with AHSNs and CCGs to secure the best business intelligence (data) for quality, and to secure organisational development programmes for member teams, and clinical / professional leadership programmes for leaders.
All of these scales require different relationships:
And therefore different organisational forms:
And therefore different personal development capabilities:
- At the Community and Practice level teams need good management development, team working and coproduction.
- At the partnership level people leading these need good leadership skills for effective organisational collaboration.
- At the locality scale people need peer leadership capabilities.
- For the Borough scale people leading these need good Network Leadership skills.
As you can see a one-size-fits all approach might suit the NHS, but what’s needed is Collaborations borne from an understanding of need, and development to support the nature of that collaboration.
Do get in touch if you are interested in this work.