Primary care collaborative Herefordshire General Practice is improving patient access, providing integrated primary care, and giving general practice a unified voice, reports Kathy Oxtoby as part of Healthcare Leader’s series on this topic. You can read part one here.
‘Capacity, workforce, and resilience’ lie at the heart of what primary care provider collaborative Herefordshire General Practice is all about. Dr Mike Hearne, a GP, and managing director of Herefordshire General Practice says: ‘It’s about supporting the capacity of general practice, supporting the workforce to deliver good quality care, and ensuring that general practice is resilient, with effective representation, and a peer level relationship with other parts of the system.’
The collaborative supports the partnership model, ‘which has small, motivated, efficient teams at practice level’, says Dr Nigel Fraser, a GP, and chairman of Herefordshire General Practice. ‘But then at scale, either at network or place, we have the additional services that can provide that resilience, capacity and overspill if necessary.’
As well as providing integrated primary care, the collaborative also brings ‘stability for our practices, and a unified voice for general practice to the wider system’, says Dr Fraser who is also co-chair of the Herefordshire and Worcestershire General Practice Provider Board. ‘There is enormous value in integrated working, of having general practice with a single voice, and as a peer in place based integration,’ he says.
The collaborative started out in 2012 as a GP federation known as Taurus Healthcare, which was owned by the then 24 practices in Herefordshire. ‘At its inception it was about all the practices coming together to procure as a jointly owned body,’ says Dr Fraser.
The federation carried out some 20 pilot schemes which included looking at access, musculoskeletal services, and a variety of digital innovations, and in 2018 became the out of hours provider for Herefordshire.
The federation then integrated with the LMC and clinical directors to become a single primary care provider collaborative, which provides all general practice services outside those delivered within a practice. ‘We’ve been doing development work over the last year and that has produced, with effect from 1 April this year, the coming together more formally of Herefordshire General Practice,’ says Dr Fraser.
How the primary care provider collaborative works
The collaborative represents and provides for 20 practices with a combined total of 200,000 patients – some living in rurally dispersed areas – and has more than 300 employees in the collaborative.
The collaborative works at practice, PCN – of which there are five – and place level. ‘Our structures are all geared to delivering care in a more integrated way than previously,’ says Dr Fraser.
Its leadership team, or executive board, includes PCN clinical directors, GP federation leaders, and the LMC secretary. ICS representatives (director of primary care and deputy) attend the collaborative’s leadership team meeting, and Dr Fraser is the nominated individual to sit on NHS Herefordshire and Worcestershire ICB, ‘so there’s an executive ICS two way channel at that level’, he says.
At place level, there is One Herefordshire Partnership, which has all providers, including general practice as peer, in that partnership. It features a number of subcommittees, which work to deliver activities such as the Clinical Practitioner Forum where clinical and social care leaders come together. There is also a learning forum called ‘Safety in Sync’ which involves collaboration on any cross organisational learning. And there is a regular discussion across the system called ‘Transformation Tuesday’, which highlights and celebrates different activities and updates on projects across the system.
One of the collaborative’s achievements has been to increase capacity by developing an additional workforce through a locally owned remote hub – Herefordshire Remote Health Service (HRH) – which delivers 190 appointments per day across all 20 GP practices.
The hub aims to address recruitment challenges by attracting a workforce beyond Herefordshire with a team that can ‘helicopter’ between practices. It has brought in 22 additional clinicians from outside the county, including nurses, GPs, and physician associates ‘as you can live and work anywhere within that model’, says Dr Fraser.
The model has evolved over 18 months, and now almost all (97%) of patients who have opted for the hub service have been able to have their care managed remotely. ‘One of the challenges that general practice faces is capacity, so the hub makes a huge difference,’ says Dr Fraser.
He explains that all the practices have use of the hub. Some purchase additional capacity from within the remote hub if, for example, they lose a member of staff. The hub is helping to tackle workforce shortages, he says. ‘It appeals to very experienced people at the end of their career who want to work in a portfolio way. It’s very much an integrated service, so people are not working in isolation, but feel supported, and some prefer to do this rather than take on the full commitment of working in a practice.’
Dr Hearne says the collaborative is looking to expand the hub’s support of practices in other ways ‘so we can ensure we get the best use of remote access to patients who need it, and make the best use of our clinicians at the front line’.
The collaboration also provides an out of hours service across Herefordshire, which developed under the federation. ‘It is always difficult providing continuity of care across 24 hours, but this is as close as we can get to doing that. This is because clinicians have access to the same patient records, and it provides the continuum of their healthcare, so we can look to manage patients’ conditions whenever they are seen, working to the ethos of making every contact count’ says Dr Hearne.
‘Having an integrated out of hours service means we can be more proactive – booking in patients for review who we are concerned about,’ says Dr Fraser. ‘There’s close working between that service and the practices, so they feel a sense of ownership. And we get very positive feedback for our out of hours service,’ he says.
There has also been investment in a primary care analytics team, which is helping to identify where there are pressures in general practice. ‘We’ve created dashboards looking at data in general practice, because traditionally in the NHS most of the data was very much secondary care based,’ says Dr Fraser. ‘So when problems occurred all the information was coming out of secondary care, and all the solutions were based on secondary care because primary care was a complete void,’ he says.
Dr Fraser says the collaborative’s primary care data has been ‘instrumental in driving new ways of working or new understanding with partners’. This includes data that highlighted how there has been a significant increase in the amount of phlebotomy primary care was being asked to do, which led to the collaborative negotiating a shared budget for this work between the hospital and primary care.
‘If you look at a dashboard it can instantly tell you how many routine appointments happened in the last week across all of our practices, and how many were done on the day, and you can compare that with, say, winter time. This helps us to form a picture when we’re at meetings about system pressures,’ says Dr Hearne.
Key to the collaborative’s approach is ‘to make sure things are done at practice level wherever possible, because we believe they can do the job that delivers continuity and good quality patient care’, says Dr Hearne.
‘What we do at scale is only when it makes sense to do so. We try to provide the support and infrastructure to allow general practice to do what it does best,’ he says.
An important part of the collaborative’s work – which it does at scale – is providing expertise in areas such as human resources and finance. ‘These areas are necessary to ensure that practices can still be effective businesses, and that we can take an effective peer approach with other parts of the system.
‘This is about relationships – so where practices need support we provide it,’ says Dr Hearne.
‘We can also oversee management and finance for PCNs, and again that is led by the PCNs – we facilitate where required rather than dictating their structure,’ he says.
When working at scale, maintaining relationships and good communication becomes even more vital. ‘We do a weekly podcast for example, to try and ensure all of our colleagues understand what’s happening at system meetings, and we also give regular educational updates,’ says Dr Hearne.
‘Safety in Sync’ – regular integrated safety meetings – are attended by all partners within the place – including local authority, the acute trust and community services. ‘At those meetings we’ve talked about end of life documentation, end of life drugs, and about the things that are a real bugbear for general practice. Having a more integrated response enables us to improve quality of care,’ says Dr Fraser.
There has been a lot of positive feedback about the collaborative says Dr Fraser. ‘Practices are very proud of working within this structure.’
Services like the out of hours and the Herefordshire Remote Hub are providing ‘real benefits to practices’, he says. ‘And the collaborative is a way of keeping small, efficient teams practising general practice without burdening them with some of the wider system responsibilities.’
Making this approach work is not without its challenges. ‘There’s the challenge of change, of moving to different ways of working. So it’s about relationships. It’s very difficult for things to happen overnight. You need to build up strong relationships and trust, and sometimes you have to take “baby steps” first,’ says Dr Fraser. ‘We’ve been fortunate that we’ve been around for a period of time and have built up a portfolio of things we can deliver.
‘However, the challenge is always to keep on double checking with practices, and you have to move at the speed that they’re comfortable with. You also have to keep on double checking and reinventing yourself. It’s a continual process that’s quite hard work, but it does pay dividends.’
Next steps for the collaborative include looking at localising the 111 service ‘particularly with regards to clinical support, so that we can aim for patients to be triaged once in the system, rather than multiple times’, says Dr Hearne.
‘There’s also integrating neighbourhood teams. We want to support the left shift of activity into the community, but we want to make sure that it is not only understood from a business intelligence point of view, but that it is also resourced appropriately,’ he says.
‘We would also like to see general practice becoming more joined up with its approach to quality and risk. This is so that we can build on what we’ve been doing already, but with regards to things like incident reporting, make sure that we are much clearer about what’s happening between practice, PCN, and place, so we can really fly the flag for effective, safe but also resilient general practice,’ he says.
Dr Fraser would also like to see ‘some national recognition’ for primary care provider collaboratives, ‘and that actually this is a model that could be supported that builds on the GP partnership’. ‘This would go a huge way towards allowing others to do something similar. If it’s not talked about, and not condoned nationally, then you do sometimes feel you’re pushing the ball up the hill.’