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Integrated working: Leading together

4 March 2014

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Integrated working between different practices and their communities will be key in transforming and maintaining sustainable primary care

Transformation of primary care feels like the holy grail at the moment, but few would doubt that if the reality of out-of-hospital care is to be realised, this is a fundamental issue we all need to grapple with. I have had many fascinating debates with my colleagues in the NHS Alliance about the breadth of people and providers who constitute primary care, and the importance of far more integrated working around – and with – patients and communities. There are huge benefits to be gained through better understanding of local issues and the assets already existing within a community. However, there is wide recognition of the importance of the registered list to the continuity of care and the essential gatekeeper and care manager role of the general practitioner. Jeremy Hunt’s commitment to a named GP for every patient over 75 demonstrates what we all know that the relationship between the patient and ‘their’ doctor is the cornerstone of good care and wellbeing, especially for patients living with long-term conditions or who are vulnerable in some way. 

So what are the reasons for general practices to engage with redesigning their future? What will general practice look like in 5, 10 or 20 years? We have to find answers fairly rapidly if we are to attract and retain the brightest and the best clinicians in primary care to replace the exodus of experienced GPs over the next few years. The NHS Alliance general practice network have worked closely with a number of leading practice managers, GPs and professionals such as Justin Cumberlege of Carter Lemon Camerons who has a keen interest in the legal aspects of how practices can benefit from working at scale. 

There are two very clear reasons that practices quote:

Protection. Many practices of varying sizes voice their feelings on the onslaught they are experiencing from various levels of regulation and contractual uncertainty. With threats to income, rising expenditure and greater competition for work there is real business sense in collaborating to minimise threats and improve quality in a cost effective manner. The lack of support for practices inherent in the new restructured NHS where providers have to stand on their own feet has been a challenge to many practices, not least because of the lack of information and chaos in the system. The excellent Kings Fund and Nuffield Trust report on the future of general practice summarised the pressures on practices:

 – Rising patient expectation.

 – Competition and procurement law.

 – New medical technologies.

 – IT developments.

 – Constrained funding growth.

 – Workforce pressures.

 – Rising prevalence of chronic disease.

 – Undertaking clinical commissioning.

Many practice teams are crying out for stability and an opportunity to concentrate on their core function of caring for patients rather than feeding the information beast. There is quoted to be a 12% vacancy rate for practice managers, and at recent meeting of the national Practice Manager Network all seven organisations reported concerns from front-line practice managers who were burning out under the strain now being exerted on general practice and its teams.

Business opportunity. With the demise of local enhanced services from April 2014, many practices are considering the pros and cons of being an ‘any qualified provider’ (AQP) provider. As any practice who has been involved in any form of procurement will tell you, this can be both time consuming and costly if unsuccessful in obtaining new work. For a group of practices working together it is far more feasible to scan the horizon for opportunities, and manage the business risks of competing delivering quality-driven contracts. The overheads of procurement are far more affordable at scale, and so are expenses such as corporate indemnity and legal representation.

Over the years I have worked in practice management, the small business agility of general practice has been able to deliver on many performance-driven targets, often seen as having over-performed. There is long proud history of how general practice has been the jewel in the crown of the NHS. The challenge is whether can we retain the agility of the small personal organisation whilst gaining the benefits of the larger more corporate organisation and the Partnership Act versus the Companies Act. The ability to collaborate at scale providers opportunities to offer a wider range of services closer to patients homes and utilising and developing clinical skills and expertise. 

There are various examples up and down the country of practices beginning to talk about how they can collaborate and develop networks of care expanding the level of current service available to patients and ensuring equity of access across populations. One example is a network in South Barnet where Jacqui Tonge, a lead practice manager, is working with practices who are coming together to improve current access to mental health services for their patients.  First for Health in Newham have done a considerable amount of work in developing technology and workforce led by Karen Stubbs-Vincent, finding solutions with member practices to reduce variation, improve quality and build the clinical expertise they know will be needed to develop primary care services. In Bradford, Nick Nurden is closely involved in a city-wide integration project involving his 25,000-list practice with a wide range of partners to join up and improve local services. I have been privileged to work closely with Harness Care who are a well-established network of 17 general practices in North West London caring for 90,000 patients since 2008. The practices now have a shared quality management system and have done substantial work around improving access both within each practice but also at above practice level to bring good quality care closer to the community. 

The key feature of all four examples is the strong practice management leadership working in partnership with practice teams and GPs who intend to find the holy grail and transform primary care in their patch for the good of patients and the future of their practice. All four have looked at the local situation and are working through how this will look and feel here. The hardest step is the first one in opening up to change – the next one in reaching out to others with a shared problem. It was Ghandi who observed that all change starts with you. The majority of practice managers I speak to now recognise that not doing anything is no long an option. As a profession, practice management needs to be a key partner in leading transformation.