Healthcare Leader spoke to Dr Mark Spencer about how a GP recruitment crisis in a Lancashire town proved to be a blessing in disguise – and led to a national award
Seven years ago, the GP surgeries of Fleetwood in Lancashire faced an acute recruitment crisis. The 28,000 residents of the coastal town on the northern tip of the Fylde peninsula, about seven miles north of Blackpool, were served by three practices, but these were woefully understaffed.
Usually, the practices employed 16 full-time-equivalent GPs between them, but the retirement of a number of GPs meant they were down to eight. At the Mount View Practice, which covered 12,000 patients, there were only two.
Needless to say, the practices were struggling to meet the needs of the community at that time, which is less affluent than the county and the country as a whole. Life expectancy was lower than in several areas only a few miles away, while the number of hospital admissions was higher.
In an effort to resolve the situation, Dr Mark Spencer and the rest of the skeleton staff at the Mount View Practice had put much time and effort into hiring new partners – without success.
It was a thankless task, recalls Dr Spencer. ‘Trying to recruit GPs was horrid,’ he says. ‘We couldn’t. Even for a fully staffed practice, the workload is horrendous, but when you’re only half-staffed, it’s even worse.’
At this point, Dr Spencer reached out to the town’s other practices – Broadway Medical Centre and Fleetwood Surgery – to see if they might find a solution by working together. The ultimate result would be the formation of a new primary care network (PCN).
A new dawn for collaboration
‘Our initial purpose was to stabilise general practice,’ says Dr Spencer. ‘Could we work collectively as three practices to address the workload issues, and then could we create a model where general practice was more attractive to work in?’
The surgeries agreed to make general practice available seven days a week by jointly staffing a shared building. Using money initially earmarked to hire GPs, as well as a contribution from the prime minister’s challenge fund, several healthcare practitioners were recruited, including paramedics, mental health nurses and healthcare assistants.
Together, they helped relieve the workload of the overstretched GPs. The practices also adopted time-saving technologies, including video and phone consultations.
‘We agreed that we would staff the building together and put on GP surgeries, nurse clinics and healthcare assistant clinics to take the pressure off Monday to Friday,’ says Dr Spencer. ‘Not only was that really successful, but also we started to build some really good relationships across the three practices. We really got to know each other a lot better and built up that trust.’
However, the most important change was philosophical. For years, as a result of Fleetwood’s significant health needs – particularly around mental health and drug and alcohol abuse – the practices had been focused on treating illness. Having reduced some of the day-to-day workload, they were able to consider a more holistic, preventative approach.
‘The biggest step for us was to involve our residents in this whole process,’ says Dr Spencer. ‘We started to have a big conversation with our residents about how we could create a healthier community. Our thinking was: if we could create a healthier community, that would further reduce the pressure on practices.’
The group that emerged from this conversation was Healthier Fleetwood, which would later be incorporated as Fleetwood PCN. It adopted an approach called health creation – which is predicated on ‘the three Cs’ – connecting, confidence and control.
‘Connecting is literally that – connecting residents together,’ Dr Spencer explains. ‘It doesn’t really matter what residents do when they’re connected; we’re human beings and we thrive in social situations, so overcoming social anxiety and social isolation is good for our health.
‘Regarding confidence, it doesn’t really matter what we do, as long as we do it on a regular basis: the more often we do something, the more confident we get. That might be singing, gardening, arts.’
To support this, Healthier Fleetwood set up a community choir, a gardening group and a ‘non-judgmental’ support group called the Men’s Shed, which were all very active prior to the coronavirus pandemic.
Dr Spencer continues: ‘The third C is control: residents themselves being in control of this process, of their health, of the community and their lives. You put those three things in place and health improves.’
All in the numbers
The results were impressive. In 2017/18, the practices had the three worst rates for A&E attendance in the CCG. Within a year, these had dropped by 21.3% at Broadway Medical Centre, 11.7% at the Mount View Practice and 18.5% at Fleetwood Surgery. In the same year, they also reduced non-elective emergency activity by 3.7%, 6% and 10.4% respectively.
‘[Reducing these figures] wasn’t our purpose; that just happens to be a happy, fortuitous side-effect,’ says Dr Spencer.
As he points out, Healthier Fleetwood had effectively adopted social prescribing – long before it was included in the NHS long-term plan. Indeed, much of the model created by the practices in Fleetwood was replicated in the PCN model, which emerged from the same plan.
While finding the money to hire pharmacists, physiotherapists and other staff has proved challenging for some PCNs, Healthier Fleetwood has had no such trouble. Indeed, as Dr Spencer says, during the recruitment crisis, the team was struggling to use their available resources.
‘Because we had so many GP vacancies, we were flush with cash,’ he says. ‘You lose a partner and you’ve got all that money, but you’ve also got all the workload. We had more money than we could use, because we were working all the time, but it was making us ill.’
The decision to hire alternative healthcare professionals has opened new avenues of funding, too: the mental health team is now funded via the CCG, which also funds lower-acuity mental health interventions; the pharmacists and physiotherapist are paid through the PCN.
Riding the crest of a wave
This put the practices back to full strength, with 16 GPs across the practices leading a skilled, multidisciplinary team.
‘It has made recruitment into our GP vacancies a whole lot easier,’ says Dr Spencer. ‘I’ve got GPs contacting me, saying: ‘Have you got any jobs going in Fleetwood? It sounds great.’ We’ve got five full-time-equivalent mental health nurses, five clinical pharmacists, a paramedic, a physiotherapist and two social prescribing link workers. And that’s just a community of 28,000.’
His experience in the past few years has made Dr Spencer evangelical about the benefits of collaborating with patients.
‘We used to think, arrogantly, that we were so busy because patients were the problem. But working with residents to deliver what’s important to them is absolutely, 100%, the solution,’ he says.
‘Now, within the singing group, the gardening group and the Men’s Shed, we’ve got residents who care for residents. We’re still there to treat illness, but because those social connections are much more in place, we are finding that we’re less involved in social crises. There’s a real community spirit.’
The turnaround in Fleetwood saw the network named PCN of the year at December’s General Practice Awards, which are run by Healthcare Leader and its sister publications, Pulse, Management in Practice, Nursing in Practice and The Pharmacist.
The judges were won over by the ‘impressive track record of integration between healthcare professionals as well as local authorities and significant reduction of hospital visits’.
Naturally, Dr Spencer is keen to promote the Fleetwood model to other PCNs. However, he warns that its success cannot be replicated overnight.
‘The hard thing is it takes time,’ he says. ‘So many people come to me and say: ‘Mark, what’s going on in Fleetwood is brilliant, but it’s taken you six years. How can we speed that up and get it going in six months?’ And I say: ‘You can’t.’ This is not something that can be rushed.’
Nonetheless, the investment in time and resources is worth it, he says.
‘You know what? It’s 4 o’clock on a Monday and I’ve finished. I’m at home. That’s the reality of it.
‘The reason that GPs are retiring early across the country is we aren’t in control of our workload and it is piling up and up. We are much more in control in Fleetwood, which is why we’re not struggling to recruit.
‘People like this way of working. I suppose that’s why somebody said: ‘Here, have the PCN of the year award.’ Because this is how it should be everywhere.’