Solving the Problems in Primary Care.

The solutions the DES was looking for….

After the push back on the draft DES what should PCNs be doing themselves to secure better quality primary care, reduce demand and improve population health?

I’ve written plenty of blogs on PC so this one is an update on key issues where you can make a difference without centrally prescribed solutions.

Purpose

Whilst there are endless contributions about PCNs having to find their own purpose and NHSE not prescribing a sole purpose, the draft DES demonstrated the disconnect between what PCN CDs thought PCNs were for and how to deliver that, and NHSE’s approach.

To find out what PCNs think they are for I set up a survey which you can fill in here sharing your Purpose with colleague PCNs (and where you can see theirs) which will give you access to the emerging picture of how PCNs describe their raison d’etre and what they are focusing on.

The survey shows the following direction in terms of purpose:

“To develop integrated working and sharing across practices to provide resilience and allow for innovation and excellent community based care for patients.”

“Strengthened practices, empowered community, support of the vulnerable”

“Joined up working to address issues one at a time across the PCN to improve care”

The responses so far focus on working collaboratively to:

  • Meet complex needs through integration, and secure access for marginalised people
  • Improve the quality of care for the whole population,
  • Support sustainable general practice and a resilient workforce
  • Empower communities

On the whole these mirror my proposal in terms of domains of work with reference to other health systems internationally:

  • Complex Integrated Care
  • Reducing unwarranted variation
  • Collaborating with Communities

Any purpose must be described in a way that you would know if you’d achieved it – these PCN ones signal direction but they are not quite there yet in terms of specificity along the lines of some famous ones (e.g. RNLI – a charity that saves lives at sea).

Without purpose PCNs will, like the rest of the system, be reactive rather than proactive. And it’s being reactive that has generated the crisis in PC.

So NHSE should be heartened from those that have participated so far, that the direction of travel they describe will secure quality primary care. But the next year is crucial – the same PCNs have been wise in where they are focusing their efforts, getting member practices on board, collaborating on complex needs, securing a workforce to meet needs. Disrupting the formation of these collaborative networks will mean these PCNs will not achieve their purpose (that and unsophisticated metrics for monitoring see below on averages). And this was the push back on the Draft DES – PCNs need space to understand the problems they face and build the relationships to collaborate.

Step one is to get a clear purpose and determine your focus for the coming year. Then direct your development money at achieving that. Assuming yours will be along the lines of those above here are some updates:

Meeting Complex Needs – Acuity

I’ve talked before about ‘know your list’ – if you know the patterns of people using your services (and other services e.g.A&E) you can start to be proactive in meeting needs. This means you have to differentiate your list. In the blogs on Frequent Attenders here and here we identified that people who turn up frequently are not all the same sort of people. We share how you might differentiate the ‘type’ of FA. Our proposition is that in all practices there are varying degrees of ‘acuity’. Here is an example of the range of complexity for the whole system and how to differentiate within a practice

One Surgery devised a project to improve how they triage, care for, and provide continuity to patients who attend their surgery the most (>30 attendances in last year), using an Emis code within our Care Plan template to trigger a “Patient Access Contract”. Over a 12 week period for 25 people with the Access Contract, the data shows a reduction in all appointments of 43% (67 less appointments for 25 patients), a reduction in the number of clinicians involved by 45%, and a reduction in OOH contacts by 56%, suggesting that improved continuity can reduce demand on appointments and improve care. This is the first iteration of their innovation in reducing the number of people who attend frequently. They are going on to explore even better ways of identifying and proactively securing continuity.

The only health warning on this is the regression to the mean –  we know that a % of people who attend frequently do just stop attending frequently in the subsequent year, so this is a great start and its good to look even deeper for the patterns over time.

Care Homes

There was a fair degree of uproar at the care home requirement in the draft spec. However the direction of travel was supported. You can find an overview of ‘what works in care homes’ here and I’ve popped a googledrive with evidence summaries here (if you have more do send and I’ll add). It triggered the sharing of multiple examples of dedicated teams of nurses, ward rounds, paramedic hot lines, GP alignment, and concerns that the DES would disband the best practice that has emerged.

People who live in Care Homes have increasingly complex needs and need continuity. Staff working in Care Homes are in the lowest 10% of the pay scale, are often on zero hours contracts, and there is a high turnover of staff (Roy Lilley, Gimme Strength 15th January 2020). It’s tough working in care homes, and even tougher if you are trying to navigate the different requirements and care plans of practices where the residents are registered. We know aligning care homes to practices improves the quality of care for people who live there – and they spend less time in hospital. As above in the section on acuity – having continuity makes a real difference as does valuing and supporting people who care for these folk. So given this is known, why isn’t primary care doing this everywhere? My experience is that many Practices have found ways of working with their CCG and Local Council to solve the problem. But there are examples where this is not happening – often a mix of a lack of imagination about funding and Practices being intransigent. It doesn’t require a DES, it requires learning from those who have worked it out, and for a collaborative approach to funding. Proactive management improves people’s lives, reduces overall costs and reduces demands on general practice overall, but it does need the CCGs to find ways to fund it. My sense is that PCNs can solve this one without a DES – and should.

Here are a couple of amazing examples:

“For several years we have a LES for GP care home rounds and one care home per Practice. It works, our practice does weekly rounds and we have the lowest rate of unplanned admissions for dementia patients in the county.”

“We have GP weekly ward round. GPs are supported by community nurse practitioners from community services. We were one of the care home vanguards. Secondary care geriatricians support weekly MDT. We have case management and pharmacist support. We have developed fantastic relationships with care home staff we support & help each other. It reduces overall demand for GPs.”

Social Prescribing

To help people struggling with life you need to recognise their assets, and make the most of the assets in your community to generate a network of local people (volunteers) who can help each other, lead by practice/patient/community champions who will nurture and value and grow the volunteers. See this blog.

Social prescribers can help that happen if they have skills in community building, and they should have. Without that SPs will be inundated with the need for appointments with people who need ‘connecting’ – and they will never meet the need. As we are seeing, SPs are finding that their appointments are filled quickly. Sucking up what should be the role of community building into the NHS won’t work. You can see more in my blog on this here.

SP came out of fantastic examples of success. These had at their essence, community building; face to face appointments for people who need help navigating the system; support to be able to make personal choices; help with their coping strategies; and leadership of this combined system. Those transactional models that are emerging will increase demand and will not reduce workload. Just a reminder from my SP blog

Metrics that relate to the transactional model (number of appointments) mirrors the problems in general practice. We provided a set of metrics for SP based on models that have worked and have demonstrable impact in terms of people living well and reducing their demand on the NHS. This is what we found in The Asset Based Health Inquiry. How best to develop social prescribing? (page 17)

“We suggest metrics along these lines that get to the heart of the intent of a primary care model of social prescribing:

  1. Increase in numbers of friends
  2. Proliferation of citizen-led not sector-led lifestyle support.
  3. Primary care ‘coverage’ to touch the whole population in a way that is more fairly and equally distributed.
  4. Reduced demand on general practice, meeting people’s needs and better overall health.”

Reducing Unwarranted Variation – Understanding Primary Care

Underneath all of this is a fundamental difficulty in understanding Primary Care. This blog isn’t long enough to go into the details – I’ll ask Nick Downham to help us out here – but one thing is for sure, getting all practices to the ‘average’ of them all is not securing quality nor will it solve the problems in PC.

I had a rather odd experience recently where a practice was below average on out patient referrals one year and above (a bit) in the next year and the CCG wanted to know what the problem was. The average had gone up because all the PCN practices had improved!!! It wasn’t a problem, the average had changed. Somehow getting to average will solve A&E admits, referrals etc. etc? Of course it doesn’t. There needs to be a fundamental change in understanding at CCG level about what they are commissioning for (it seems to be reduced A&E admits rather than people living healthy lives, and there is a belief that will reduce secondary care costs), how the metrics they use relate to what they are commissioning for (A&E admits are not just about PC nor are all A&E Admits bad, AND you need to understand what sort of A&E admits you need to reduce and by how much – i.e. what’s good practice and what’s possible). Another GP practice challenged this narrative to find that the A&E admits their CCG wanted to reduce wasn’t anything to do with their practice.

So another blog to follow on how you reduce unwarranted variation in primary care but the starting place has to be:

  • What is the need for PC that we are trying to meet?
  • How much of that is best provided by health?
  • What is all the evidence about how best to meet that need?
  • Are we using that evidence to develop our own responses to need?
  • Are we doing all we can to not make our own work?
  • Have we got metrics in place that help us understand what we are doing and whether its’ working?
  • Are we peer reviewing our work and learning together about how best to delivery primary care?

At the heart of all of this is data. PCNs are getting a range of support to meet needs, but they need help understanding population need, understanding variation and acuity, differentiating their list, understanding if what they are doing is making a difference. As yet there is no additional provision for data support to understand all these key factors. If there is one thing that will help PCNs get off the ground its data.