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Primary care homes: A new way of working

Primary care homes: A new way of working

The journey towards fully integrated health and social care has been a long one with many false dawns and some successes, Dr Nav Chana explains
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For the last two years in primary care, we have been witnessing a change of gear in the drive towards collaborative working that is fast gaining momentum.

The walls that once divided the health, social, community and voluntary sectors are being replaced by bridges as teams from all these disciplines come together with a view to improve health outcomes for their local population.

There’s a renewal of passion in the principles of primary care. I’m seeing staff who are suddenly energised and enthusiastic about new ways of working that are producing rapid early results, both in terms of improving morale and producing clear benefits for patients.

The primary care home (PCH) programme was launched in October 2015 with a remit to bridge the gap between primary and secondary care and provide a better-quality, more personalised and integrated service in appropriate settings.

Developed by the National Association of Primary Care (NAPC), the PCH model brings together a range of health and social care professionals to improve the health of their local community. The model is featured in the NHS Five-Year Forward View Next Steps and forms part of the practical delivery plans to transform primary care over the next two years.

Following the programme launch, the NAPC received 67 applications, from which it chose 15 rapid test sites in December 2015 to pilot the model.

Each site received investment of £40k in 2016/17 from NHS England and the NAPC to help cover the costs of establishing a new, integrated way of working.

They were given the freedom to decide which health priorities they needed to focus on, based on their population health needs, and were charged with devising new ways of working to improve outcomes in those areas. The key aim was to identify groups or communities of people with similar needs – for example, the frail elderly and those with mental health issues – and develop a workforce response around that common cause rather than the traditional model of silo working. By working in this way, we are beginning to show an impact on the need for developing new roles and modifying our view of where we need extra capacity. More than 70 new sites joined the programme in December 2016 and another 70 successfully applied in the last few months – evidence of the current appetite for change.

In the PCH model, plans and new systems are developed at the coalface, with the proviso that each must have, in time, the following four defining characteristics:

• A combined focus on personalisation of care with improvements in population health outcomes.

• An integrated workforce with a strong focus on partnerships spanning primary, secondary and social care.

• Aligned clinical and financial goals drivers through a unified, capitated budget with appropriate shared risks and rewards.

• Provision of care to a defined, registered population of between 30,000 and 50,000.

The reason for this population size is that the NAPC believes this is optimal for developing the best results. It’s the right size for developing highly effective, unified, multi-professional teams, for providing high-quality care and for taking budgetary responsibility together.

Within a matter of months, we started to see significant and measurable results among our 15 rapid test sites. Key findings from an early analysis of three of these sites showed significant reductions in A&E attendances, emergency hospital admissions and GP referrals to hospital.

A report commissioned by the NAPC and published in March 2017 (Does the Primary Care Home Make a Difference?) looked at the impact of the three sites, covering a population of more than 110,000 patients, and assessed how PCH could support the delivery of the 44 sustainability and transformation plans (STPs) across England.

Benefits

For GP practices and other providers involved, the report showed that benefits of the PCH model included reduced prescribing costs and a rise in staff satisfaction and retention. Patients experienced a drop in the average waiting time to see their GPs and reduced stays in hospital.

Of course it’s still early days and there will be much more detailed evaluation of the initial PCH projects over the coming months. But I believe there is reason for cautious optimism. Take, for example, the Larwood and Bawtry PCH, which consists of two practices in Nottinghamshire and South Yorkshire including areas of high deprivation and disease.

The appointment of an in-house practice pharmacist led to a 5% reduction in prescribing costs following a review of medications being taken by care home residents. Analysis over a seven-month period found a significant reduction in prescribing costs and projected annual savings of £229,000, as well as reducing the risk of side-effects for patients. Emergency hospital admissions dropped by 8% over the same period with the clinical commissioning group (CCG) estimating savings of £277,000.

Both surgeries are now running citizens’ advice clinics with community advisers, funded by the voluntary sector, who signpost patients to voluntary and non-medical services in the area. They provide a vital link to services that can address some of the underlying causes of anxiety and depression, including debt and unemployment.

In Kent and Medway, where three practices have come together to form the Thanet Health Community Interest Company, the frail elderly are now receiving better care out of hospital and being admitted less frequently. An integrated nursing team was established to provide an enhanced frailty pathway and an acute response team was created to provide a range of treatment and personal care support to keep people out of hospital. Over a 10-week trial period in 2016/17, non-elective admissions fell by 155 compared with the same period in the previous year, suggesting potential annual savings of almost £300,000.

Besides improving patient care and making substantial savings, the Thanet PCH model has also been a huge boost to staff morale – more than 20 whole-time-equivalent community nurse posts have been filled at a time when there is a widely recognised recruitment crisis for this role.

In Plymouth, the Beacon Medical Group PCH has cut the average waiting times for GP appointments by six days by expanding its urgent care teams across its five sites. Frustrated by the fragmentation and dilution of local services and increasingly distant relationships with other health and care agents, the PCH set up teams – comprising one or two GPs, a paramedic, nurse practitioners and pharmacists – who screen all patients seeking on-the-day appointments on the phone. Only those with the most pressing need are invited in. Over six months, the average waiting time for a GP appointment fell from 14 to eight days.

Frail elderly

For the single practice St Austell Healthcare PCH in Cornwall, the biggest challenge has been finding new ways to provide a better service for its frail elderly patients, many of whom are physically inactive, often socially isolated and lonely. Poverty and unemployment in the area are also major factors influencing the physical and mental wellbeing of the local population.

The practice joined forces with local community providers and employed a social prescribing facilitator who sees patients and refers them to resources ranging from walking groups and canoeing to Zumba and Pilates to increase their physical activity, improve their diet and reduce isolation. The pilot resulted in 52 out of 150 patients completing 12 weeks of the programme. Of those, 94% saw an increase in their wellbeing score and 62% had lost weight.

The South Durham Health Community Interest Company identified mental illness as one of its key priority areas. To address the high levels of adult male suicides and reduce the delays in accessing treatment, community psychiatric nurses (CPNs) are now based in GP practices so patients with mental health needs can be directed to them immediately. The CPNs are treated as a shared resource and patients can be referred to whichever practice’s CPN can see them first. The move has generated positive feedback both from patients
and GPs.

These are just a few examples of the ways in which shifts in care can take place in a short space of time with minimal investment and, in many cases, with existing resources. They demonstrate that projects don’t have to be large in scale to make a big difference. I see these relatively small changes as the building blocks for massive cultural shift across the whole of primary care.

Those of us who work in general practice have been talking for decades about the need for better integration and out-of-hospital care. I’ve witnessed how the lack of progress has worn down dedicated colleagues, damaged morale and at worst driven people out of the healthcare professions altogether.

Those who have been involved in the rapid test sites report a renewed sense of optimism and enthusiasm. They’ve regained the sense of purpose that led them into their profession in the first place. One district nurse told me she was seriously reconsidering her retirement plans because she was so excited by the changes she was seeing under the new PCH model.

I firmly believe the key to the programme’s success is the fact that the shift is taking place at the grass roots level of health and social care rather than being imposed from the top. It’s shown that we need to stop fixating on staff numbers and start changing the model of care, making better use of the staff we already have – and that means listening to them and always involving them in change.

As we know that healthcare interventions alone may only contribute up to 15% of health outcomes, it’s clear that the way to improve those outcomes must be to integrate the services that tackle the broader determinants of health and wellbeing – factors such as social isolation, poor housing and unemployment.

Now people from many sectors in primary care are finally working together at a local level to solve problems they understand better than anyone else. They’re enjoying the satisfaction of seeing rapid results. I also believe the PCH scale – serving a population of no more than 50,000 – is ideal for producing relatively fast results through collaborative working by small, multi-disciplinary teams of people with common goals and local knowledge.

The triple aim

The programme’s successes show how these new models of primary care could act as catalysts to deliver the ambitions of the planning process and contribute to the ‘triple aim’ in the NHS Five-Year Forward View. As the above examples demonstrate, our rapid test sites are already having an impact in:

• Improved health and wellbeing.

• Transformed quality of care – faster access to integrated services closer to home.

• Resource utilisation – by optimising technical aspects of care and making better use of existing staff.

The PCH model is laying the foundations for change to happen at a faster pace and should be viewed as an enabler for primary care transformation.

We now have more than 160 PCH sites across England, covering seven million patients –12% of the population. Applications are continuing to come in as word spreads about this new style of working that may have the hallmarks of a social movement.

It’s a movement I feel confident will continue to gain momentum as it’s being driven by the people who provide primary care – the best people to bring about real and lasting change.

There’s a sense of ownership and pride in these projects and a determination to make them work.

There are benefits for everyone – patients gain from a more integrated, faster service; staff are happier and more motivated; and there is early evidence that it eases pressure on the wider health system.

Dr Nav Chana is chair of the NAPC

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