20
nov
0

5 Actions to Prepare for Neighbourhoods

Posted by Blogs, The General Practice BlogNo Comments

All the signs point to “neighbourhoods” as the next priority area of focus for the NHS.  The new government has spoken repeatedly about creating a “neighbourhood health service”, and at the recent NHS providers conference Secretary of State Wes Streeting stated that the role of ICBs should no longer be performance management but instead he said,

“I want ICBs to focus on their job as strategic commissioners and be responsible for one big thing: the development of a new neighbourhood health service.”

So while we await whatever is to be included in the promised 10 year plan, one thing we can be relatively certain of is that neighbourhoods are going to feature front and centre.  At the same time PCNs are getting less and less of a mention, so it also pretty reasonable to assume that while practices operating together at a PCN level will continue, primacy will shift from PCNs to neighbourhoods.

The question, then, is what does this mean for PCNs and practices, and what (if anything) should they be doing now to prepare for this shift?

Here are 5 actions I would recommend:

  1. Strengthen PCN working. General practice will still hold a pivotal role in neighbourhood working.  PCNs as group of GP practices within a neighbourhood will be very important and will need to be strong together to be able to shape how the neighbourhood functions.  While there is a temptation right now for practices to retreat into core service delivery and away from PCN working, doing so would fracture the unity of local general practice and reduce its influence within the new neighbourhoods.

 

  1. Match PCNs to neighbourhood boundaries. In recent years the pressure has been on community teams and others to match to PCN boundaries, but the nature of neighbourhoods mapping to both local communities and existing community and social care teams means that the pressure will most likely now come for PCNs to change rather than vice versa.  We have seen this already in the NW London Integrated Neighbourhood Team  It would be sensible where there is not an existing alignment for PCNs to start to think about how they could make this happen in the least disruptive way, before the system imposes its own inevitably heavy-handed approach.

 

  1. Focus on building strong relationships across the local area. Neighbourhood working ultimately relies on local relationships.  Just as effective PCN working requires strong relationships and trust across the practices, the same is true for all the different organisations working across a neighbourhood.  Relationships take time to build, so early investment in them now will pay big dividends in the future.

 

  1. CDs take on a leadership role for cross-organisation working initiatives. Lots of pilots and MDTs are already springing up in local areas, as systems start to gear themselves up for neighbourhoods.  PCNs playing an active role not only within these initiatives but in leading them is extremely sensible preparation for the future, as it will position primary care as the natural leader for these emerging neighbourhoods.

 

  1. Support local at-scale general practice to prepare to become an “integrator”. GP federations have been in and out of favour over the last 10 years, but one important emerging theme in all the publications about neighbourhoods (going right back to the Fuller report) is that there will need to be some form of at-scale support for them.  This could be from general practice (i.e. a federation) or from an NHS or local authority organisation.  If general practice is keen to both be able to influence the way neighbourhoods develop and is keen to protect its on ongoing independent contractor status then there would be a lot of value in the local federation taking on this integrator function.  To do this, however, local PCNs and practices will need to actively support it now so that when the time comes it is in a position to be able to take on this role.
13
nov
0

Why Deliver More Care in the Community?

Posted by Blogs, The General Practice BlogNo Comments

One of the questions that is often not explicitly answered is that of why care needs to be delivered outside of hospital, and why we are trying to effect with this so-called “left shift” from secondary to primary and community care.  In the past, lack of clarity as to what constitutes success has caused huge problems with sustaining any efforts to make this happen.

The challenge is essentially an expectation from some that success is achieved when system savings are made.  This is based on the assumption that it is cheaper to deliver care in community settings rather than in hospitals, and therefore shifting care will result in lower levels of system expenditure.

The big problem with this in practice is that whatever care is delivered in the community is always in addition to the work carried out in hospitals.  The size of the waiting lists and (necessary) tolerances for admission based on bed availability means there is no way that carrying out work in the community will actually reduce hospital activity.  Hospital activity is more a function of hospital capacity than of demand, because the demand exceeds the available capacity.

As a result, initiatives that have been put in place get stuck in analyses of individual patients or cohorts of patients to prove lower hospital utilisation to demonstrate the value of the work.  This is ultimately futile because even demonstrating a reduction in expenditure at a patient cohort level does not produce an overall saving as there is no commensurate reduction in acute activity.  If the measure of success is short term system savings then shifting care out of hospital will inevitably fail.

Sometimes the aim (explicit or implicit) is not financial but to reduce the strain on hospitals by shifting routine work to local providers so that they can focus on the acute and complex cases.  Unfortunately, taking away the relatively straightforward work and leaving only the more acute and complex cases actually increases the strain on acutes.  It increases the pressure on staff as there is no balance between routine and complex work, and at the same time can create financial difficulties as often income generating procedures are replaced by loss-making ones.

So in the NHS world of increasing financial and workload pressure it is easy to understand why shifting care out of hospital has never actually happened.  But that is not to say it should not.

There are real benefits that this left shift of activity can realise.  Outcomes for patients can be improved by delivering care outside of hospitals, through offering greater continuity of care in community settings, through enhanced or proactive chronic disease management.  Care delivered in local communities is more accessible, convenient and personalised, which all contribute to improved outcomes for an important cohort of patients who otherwise will place increasing demands on the NHS in the future as their conditions worsen.

Ultimately, delivering care outside of hospital now can prevent the health needs of patients becoming greater in future, creating a more sustainable NHS.

But to have a chance of success, we need to be clear that this is the aim of shifting care from hospitals to the community.  It won’t save money within the financial year.  It won’t reduce short term pressure in hospitals.  It will require additional community capacity and it is a medium to long term investment in improving outcomes.  The explicit (and implicit) measures of success need to reflect this, so that expectations are managed accordingly.  If they are not, we will stay in the same cycle of failure that we have been in for at least the last 20 years.

6
nov
0

Does the Budget Show Where this Government’s NHS Priorities Really Lie?

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On the podcast recently Joe McManners highlighted that the more government and policy makers talk about shifting resources out of hospital and into primary and community care the less it happens.  Well, we have had the talk in the form of the Darzi report, and now does the budget simply prove his point?

On the bright side, the Chancellor did at least announce new money for the NHS.  £22.6bn was announced over 2 years, but the narrative that she used to go with it was painfully familiar, “Because of this record injection of funding, because of the thousands of additional beds that we have secured, and because of the reforms that we are delivering in our NHS, we can now begin to bring waiting lists down more quickly and move towards our target for waiting times to be no longer than 18 weeks by delivering on our manifesto commitment for 40,000 extra hospital appointments a week.”

It seems the chancellor didn’t get the memo from Darzi.  When we look at the detail of what the money is for (although the Kings Fund have indicated the majority of it will be needed to fund the already published workforce plan) there are specific capital projects identified:

  • 40,000 extra operations and acute sector appointments a week
  • £1.5 billion for capital for new surgical hubs and scanners and new beds
  • £70 million for radiotherapy machines
  • Fixing RAAC (reinforced aerated autoclaved concrete) hospitals
  • £2 billion to invest in NHS technology and digital – contingent on 2 per cent productivity next year
  • A dedicated fund to deliver around 200 upgrades to GP surgeries (£100M “earmarked”)
  • £26 million to open new mental health crisis centres

 

The majority of these are secondary care focussed.  The primary care and mental health items at the end look very much like someone noticed this and added them on at the last minute.  Anyone who has been involved in the development of new GP surgeries will know that half a million does not get you very far, and even 200 developments isn’t going to touch the sides of the need across the 6000+ practices out there.  And of course no one is going to be surprised if even that money comes with caveats about “neighbourhood working”, or if it gets forgotten when NHSE decide they need the money for something else.

In fact general practice does not even get a single mention in the budget.  This does not inspire hope that the service will then be at the front of the queue for investment when the much touted 10 year plan arrives in Spring.

The new government has talked about shifting care from hospital to the community and shifting from treatment to prevention, and has raised our hopes via the Darzi report which called for a “hardwiring of financial flows” to lock in the shift of care closer to home.  So it is somewhat depressing to then receive a budget which ignores this altogether and goes back to funding more activity in hospitals.

But the Prime Minister has continued to insist that the government will focus on reforming public services rather than simply spending more on what we currently have.  It may be that this budget is what is needed as a short-term fix to prevent the NHS deteriorating further, before the promised reform plan is published next year.

Let’s hope that what it is.  If we are being honest we are seeing an early gap develop between the rhetoric and the action, but it feels too early to give up just yet, and hope still remains that this government will provide the investment for primary and community care in future that is needed to prevent the NHS becoming even more hospital-centric.

30
oct
2

The Neighbourhoods are Coming

Posted by Blogs, The General Practice Blog2 Comments

The new government is a fan of “neighbourhoods”.  They continually talk about how the NHS will become a “neighbourhood health service”.  A few weeks ago I considered the potential impact on practices and PCNs of neighbourhoods, based on the NHS Confederation’s report on the same.  But now some more concrete proposals have emerged.

North West London ICB have published a Board Paper entitled “Development of Integrated Neighbourhood Teams in North West London”, which outlines its plan to put these teams in place over the next few years.  This is the first of its type that we have seen, and so what can we learn about the potential impact of these teams on general practice and PCNs?

Before we get into that we should bear in mind that this is the same ICB that wanted to mandate the introduction of same-day access hubs for urgent primary care appointments separate from GP practices, and only backtracked in the face of significant pubic and professional resistance to the plan.  So this is not an ICB that has the needs of general practice anywhere near the forefront of its thinking.

As with many NHS Board papers, it is not easy to distil exactly what is intended.  The Integrated Neighbourhood Teams are apparently an alignment (whatever that means) of what are termed “core services” around geographical neighbourhoods.  These core services include general practice, along with mental health, community nursing, social care, health visiting and a whole range of other services, with the expectation that there will be over 100 professionals working in each team.

It appears that these teams won’t become organisations in their own right but will have a “dedicated integrator function” that will be a person or small team from one organisation (either a primary care organisation, community health provider or Local Authority) working with all such teams in each place area.  These are expected to be in place by March next year.

I don’t know the at-scale general practice set up in NW London, but it seems there are very few primary care organisations across the country with the capacity to take on this integration function.  This in turn means that ultimately control of neighbourhood teams will lie outside of primary care, which could have huge implications for the future independence of the service, especially if the collaboration of these teams turns into something more formal in future years.

The ambition of the plan is then to have population health management, interoperable IT and an estates plan allowing single neighbourhood hubs to be in place by 2026, joint workforce planning and co-location by 2027, and then shared budgets and integrated funding streams by 2029.

What the plan does not explain is how independent organisations (like GP practices) and their staff will function as a single team.  The responsibility for this seems to lie with the integrator function, and organisations are instructed to create plans to “enact the vision of INTs” and align operational teams to neighbourhoods, but these levers on their own seem insufficient to create what is envisioned.

The document recognises (but does not seem overly concerned by) the fact that PCN boundaries do not align to the INT boundaries.  While in previous national documents the onus has always been on community services to ensure they align with PCN boundaries, the new focus on neighbourhoods makes this much more unlikely. It is hard to envisage a future where PCN boundaries will not have to flex to accommodate recognised local authority/community services neighbourhoods.

The model also appears to lack any significant additional funding.  Dr Joe McManners explained very eloquently in a recent podcast that investing in neighbourhoods will not make the NHS cheaper, but will prevent it from getting worse in the future.  There is no invest to save business case that can fund these teams.  But getting these teams to work does require investment and an element of double running at least in the short term, yet in North West London there is no additional funding provided even for the pivotal integrator function.  The risk, of course, is that funding for this is taken from the core teams themselves, which in turn will simply serve to make these services worse.

The danger is that neighbourhood teams, as the flavour of the day, will be imposed (like in NW London) without the required investment, incentives and support to make them effective.  The government has hinted at additional funding for primary and community care, but we need to see it before embarking on this neighbourhood journey which otherwise seems destined to fail.

23
oct
0

Making the Shift of Resources from Secondary to Primary Care a Reality

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I had a fascinating conversation with Dr Joe McManners on the podcast this week, where he shared some helpful insights into what is required to make the shift of resources from secondary to primary care a reality.

The first point he made is that the more government and policy makers have spoken about shifting investment from secondary care to prevention, primary and community care the less it has happened. What this has made clear is that simply stating this change as a desired direction of travel on its own will not be enough to make it a reality, and that a much more structured approach is required.

For primary care, there needs to be a scaling up of infrastructure – of systems, data, digital capability, physical and workforce capacity – in order to enable this shift to happen.  Even if there was a sudden flow of money into primary care tomorrow, the infrastructure does not currently exist to be able to convert this into more activity.

The point Joe makes is that there needs to be a more sophisticated organisational infrastructure that can provide these things than currently exists across practices and PCNs.  PCNs are an essential part of the infrastructure – if they didn’t exist, we would be looking to invent them – but so far they have only fulfilled a fraction of their potential.  The infrastructure support is what is needed to help them get there.

What this organisational infrastructure will actually look like is something that policy makers will have to decide.  It does not need to replace practices and PCNs, but rather to exist alongside them, maybe as an umbrella organisation, with some nationally-driven development programme to support the implementation of this infrastructure across the country.

There is also the thorny issue of actually making the shift of resources a reality.  Although attempts to do this in past have failed, there can be learning taken from them.  For Joe the starting point is acknowledging not that changing the financial flows will be cheaper (it won’t, and many previous attempts have failed once this has become apparent), but rather that it will avoid a more expensive system in the future.  From this starting point there will need to be some initial double running, and then as evidence of success is developed longer term funding streams put in place.

For general practice this movement in the policy direction represents a huge opportunity.  The available funding for core service delivery is inadequate and needs to be addressed, but the potential for investment in the delivery of core general practice will always be limited.  However taking a leading role in building productive partnerships across local neighbourhoods to deliver better outcomes for specific populations (which may be outside of core contractual work) is not only hugely satisfying but is also the type of work that will ultimately make the shift of resources from secondary to primary care a reality.

You can listen in to everything that Joe said (which I strongly recommend you do!) on the podcast here.

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