Why Primary Care Needs Serious Collaboration
Being a GP is not what it used to be.
By our Chief Executive Dr Henry Kippin and Dr Ben Gatenby of the South & East Leeds GP Federation
Not, at least, according to the Royal College of General Practitioners Chairwoman Professor Maureen Baker, who was quoted recently arguing that careers in general practice are becoming “more intellectually and medically challenging, diverse and fulfilling” than ever.
This is a positive slant on an undeniable trend. GPs are experiencing rising patient demand, increasingly complex caseloads, and must strike an increasingly difficult balance between sustaining access, quality and keeping their businesses going as the world changes rapidly around them. A raft of policy reforms since 2010 — think Lansley Act, Five-Year Forward View, its GP Forward View counterpart, Sustainability and Transformation Plans (STPs) and the more recent Multispecialty Community Provider (MCP) Framework — not only rely on the foundation of viable list-based primary care, but also demand its transformation in quite profound terms.
Scale, agility and multi-disciplinarity are core requirements of this emerging primary care model — whether the local bias is for a MCP or any other type of accountable care model. No more stand-alone practices responding to need as it presents; far fewer cracks between different out of hospital services; and much more emphasis on understanding demand and better managing it through creative resourcing and preventative practice. At the radical end, GPs could be acting as the locus of a range of services from health to housing to creative arts.
This is a future that inspires mixed reactions from today’s primary care workforce — not least because it will require meaningful changes to its contractual base, practice staffing models and long-held assumptions about what it even means to work in general practice. A big focus now is rightly on addressing a GP shortage estimated to be almost 10,000 by 2020. But there is an equally pressing need to help today’s transformation-weary cadre work through the implications of a set of reforms that will fundamentally change their role within the health system and the localities in which they work.
Building readiness for these changes has been the focus of a year-long collaborative partnership between the South and East Leeds GP Group (SELGP) and Collaborate. SELGP is a federation of 30 practices, formed in 2015 and covering a diverse demographic and epidemiological base in the south and east of one of England’s biggest and fast growing cities. It’s approach from the outset has been open and bottom up, being honest about the need to build relationships whilst the city-wide policy context change has changed quite rapidly around it.
For general practice this is a critical moment in the planning of health and social care reform. The national focus has been — and will continue to be — on the viability of acute trusts, the perilous state of social care, and the political challenges of achieving system sustainability. But we are also seeing different voices emerge as new care models are implemented — many sharing exciting progress; others being increasingly open about the difficulties.
It is clear to us that real change in the way GPs work will need to happen collaboratively — between and across practices, with their system partners, and, most importantly, with the public. All of this can be mandated through policy, targets and transformation plans. But how can we make it feel credible in practice and meaningful to citizens? Three lessons stand out:
1. There is no avoiding the big questions — conversations about role, purpose and values feel like luxuries to practices who are trying to keep their head above water. But long-term collaboration across a federation or partnership is impossible without them, and any changes implemented without this underpinning will inevitably be reactive and driven by others. This ethos needs to drive our engagement with citizens, too. If we are not asking the bigger questions about people’s lives, aspirations and values, how can we ever understand the incentives and expectations of our patients, let alone have permission to change them?
2. Integrated out of hospital care will fail without proper relationship building — we welcome the drive to more accountable and place-based care models, and indeed five of SELGP’s practices are working with our CCG to implement an ambitious pilot programme in two local neighbourhood clusters. What is clear, however, is that this kind of cross-sector and multi-disciplinary working will stress-test local relationships like never before, and if PowerPoint plans are to translate into observable reality, the collaborative process needs to be properly understood and supported.
3. GPs need to better understand their system leadership role — it is impossible for GPs to manage demand without seeing themselves as part of a system and starting to influence on that basis. SELGP members working through this have made progress on community triage, digital engagement and practice collaboration around urgent and out-of-hours care. Yet progress in these areas will inevitably be limited without a parallel system influencing role to ensure that finance, governance (and referral practice) follows purpose, and that STP implementation plans reflect this.
There is no lack of innovation to learn from (From Bromley-by-Bow to Birmingham’s Modality super-practice), emerging models to adapt, and of initiatives like RightCare that demonstrate where the value in reforming might lie. But our over-arching lesson is this: if we don’t try to embed collaboration in the way GPs work within an across practices, we cannot hope to do it effectively with others. And that is the whole nine yards of health and care reform.
Dr Ben Gatenby is chairman of the South & East Leeds GP Federation, and Dr Henry Kippin is chief executive of Collaborate CIC
Read our report on place-based health, Get Well Soon:
