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Primary care collaborative: The Black Country

Primary care collaborative: The Black Country
By Kathy Oxtoby
30 May 2023

Black Country Primary Care Collaborative aims to sit ‘right at the heart’ of designing what primary care needs to look like in the future, reports Kathy Oxtoby, in the third article in Healthcare Leader’s series on this topic. 

Black Country Primary Care Collaborative has set itself a huge task. Along with the Black Country Integrated Care Board (ICB), it aims to co-design a five-year strategy to transform primary care in the region.  

‘One of the things we want the collaborative to do is to sit right at the heart of designing what primary care, from a provider perspective, needs to look like in the future,’ says Sarb Basi, director of primary care for the Black Country ICB.  

Together, the ICB and the collaborative will produce a transformation strategy for primary care. The collaborative will provide clinical leadership to design what that looks like and how it will be delivered.  

‘It’s a massive opportunity,’ says Mr Basi. And rather than seeing some of the challenges with ‘a lens of doom and gloom, we see them through a lens of opportunity’.

Three clear priorities

Mr Basi says the collaborative is at ‘the very first stage’ of an organisational development journey with primary care. However, already the collaborative has ‘three clear priorities’. He says the collaborative wants to ‘get a grip’ on access and to set a clear intention for the planned care of people with long-term conditions. It also seeks to ‘reduce unwarranted variation’ such as differences in how providers operate, their outcomes, and patient experience.  

Working on something that describes what ‘good primary care looks like’ and getting an agreed and collective view across the Black Country is a ‘massive achievement’, says Mr Basi. It is ‘something that primary care, particularly the GPs, are committed to’.

Even though it’s early days for the collaborative – it was formally established in May 2022 – it draws on the combined knowledge and experience of health and care professionals who have worked in primary care for many years.

The collaborative began as the clinical commissioning groups (CCGs) were ‘winding down and we were transitioning over to ICBs’, says Dr Salma Reehana, chair of the Black Country Primary Care Collaborative and a GP partner at Health and Beyond, a multi-partner and multi-site practice in Wolverhampton.

‘As things were evolving, we knew that primary care needed a space where we could come together, have clinical discussions about what is right for primary care and for our patients, and also look at how we could influence the working of the ICB, and do what is right for the system,’ she says.

Creating the primary care collaborative

She explains that there were originally four different CCGs in the Black Country. They merged just under a year ago, before the transition to the ICB, ‘so we had four different ways of working and four different systems that people were used to’.  

‘The more we integrated and talked to the four different systems within the Black Country, we realised that our problems and our challenges were very common. And there were things we could learn from each other.

‘Initially, that’s what led to us forming a group together, and then we developed into what is now Black Country Primary Care Collaborative,’ says Dr Reehana. ‘Our main reason to form the collaboration was to develop that single strong voice for primary care.’

The drive to form the collaborative was also about ‘how do we create an appropriate at-scale provider environment in which we can harness the skills, expertise, and experience of GPs’, says Mr Basi.

 ‘Unprecedented demand across the whole system’

Covid and the post-pandemic growing demand on services also fuelled the need for a collaborative approach. ‘We’ve provided an increase in primary care capacity since Covid across the Black Country. We’ve outstripped capacity since 2019-2020. We’re providing more virtual consultations and we’ve increased face-to-face consultations – and we’re still not meeting demand,’ says Mr Basi.

‘We’re seeing unprecedented demand across the whole system. What Covid did was to throw the system into a disequilibrium position, and we’re still recovering from that. But what it’s allowed us to do is to think differently. And in terms of restoring the equilibrium, things need to look different,’ he says.

The Black Country Collaborative represents and provides for 181 practices. And with ICBs taking on delegated responsibility for commissioning pharmacy, optometry, and dentistry services, this means ‘we now have responsibility for 749 independent contractors’, says Mr Basi. The collaborative serves a population of 1.2 million, and ‘we are in the process of recruiting programme management support for the collaborative’, he says.

There’s a ‘bottom-up approach’, starting with the practices, which have formed 27 PCNs working across four places – Dudley, Sandwell, Walsall, and Wolverhampton. Each of these places has its own primary care place collaborative, which is essentially ‘a clinical leadership group that takes the view on all things primary care in that place’, explains Mr Basi. ‘They are part of a Black Country ICS wide, primary care collaborative that looks to do things at scale, to deal with our key priorities, and to develop the provider landscape at scale across each of our places,’ he says.   

Primary care collaborative is an expert group

The collaborative is where ‘providers can come together and work on the problems that matter to them, help solve them, and also work with the ICS in designing the future of an operating model for primary care,’ says Dr Reehana.

‘It works as an expert group with people who really understand how things operate currently and what the challenges are,’ she says. The dialogue between the ICS and the providers on the collaborative means that when looking at, say, a problem with access, ‘this leads to a better plan than could ever have been achieved by one party on their own’, she says.

Director of primary care for the ICB, Mr Basi also has a seat on the collaborative board. ‘This means that I can go to the collaborative and with, say, winter pressures, talk about how we are going to work together to co-design a solution.’  

The collaborative also allows primary care to have ‘much more influential discussions with acute and mental health providers, and to have a collective voice for primary care when we start to have discussions around clinical care pathway design’, says Mr Basi.

For example, across the Black Country, there is a single acute and a single mental health provider collaborative, ‘and we have agreed to have cross-collaborative summits in the Autumn to start that process of having joined-up discussions around what integrated care should look like’, he says.  

Early achievements

One of the collaborative’s early achievements has been to drive a winter access programme, which included setting up children’s respiratory hubs that provided additional capacity across the winter period.  

‘We set out a winter access programme, gave £1m across the four places, and asked each place to design what they would like to deliver,’ says Mr Basi.

As a result, two places – Sandwell and Dudley – set up a respiratory hub for children known as an Acute Respiratory Infection (ARI) hub, and Wolverhampton and Walsall set up general access hubs. The programme has provided ‘much more capacity, increased traffic to face-to-face and virtual appointments, and alleviated pressure on emergency services during the winter period’, says Mr Basi.   

Sandwell’s ARI hub, for example, increased its capacity by 40% to help support urgent and emergency care during the busy winter period. The hub offers same-day, face-to-face GP appointments for children aged 12 and under with respiratory issues such as coughs or chest infections. It enables children to be seen within the community if their usual GP practice is fully booked. The hub provides earlier diagnoses for patients through quicker access at a location close to home. And it reduces the number of children presenting to out-of-hours services and emergency departments due to not getting a same-day GP appointment. All GP practices in Sandwell have direct access to the hub and can book an appointment for their patient online.

The hub has seen more than 13,000 children, and data shows that less than 1% of these patients required an onward referral to A&E or a paediatrics assessment unit, significantly reducing the burden that would otherwise be on A&E or walk-in centres. The model is now being rolled out across the Black Country.

Patient input

Another achievement is the recruitment of four mental health ARRS providers specifically for children. Dr Arun Saini, a GP at Portway Family Practice and a clinical director at Citrus Health PCN, Sandwell, worked with the collaborative in using about £100k from NHS England to arrange match funding by PCNs in Sandwell and Dudley. 

Then there’s the ongoing work to design the Black Country’s primary care delivery model for the future. The collaborative wants to involve the public and patients in its design. ‘That’s important because it deals with some of the misconceptions about what you should and shouldn’t expect from primary care,’ says Mr Basi. It also allows the system to understand what primary care does well in terms of acting as the health service’s gatekeeper.   

The ICB and the collaborative are also working together to design a primary care transformation workforce development and delivery unit. ‘It’s a tremendous example of partnership working and collaboration,’ says Mr Basi.  

‘We’re pulling all of this together as we speak and are going to get some external support to help us produce the strategy in the next six to nine months,’ he says.  

Changing GP mindsets

One of the challenges has been creating an awareness and understanding of why there is a need for the collaborative in the first place.

‘It’s taken a while to change some GPs’ mindsets, and we’ve done this through two summits involving GPs from all areas,’ says Dr Reehana. ‘Our initial intention was to have sign-up at practice level. However, we found this hard to do with all 181 practices, so we’ve had an interim sign-up through PCNs. Every PCN has signed up to the collaborative, which is an achievement in itself,’ she says. 

Another challenge has been that the Black Country has ‘every conceivable model of provision – from super partnerships to single handers – and every kind of contract. So, where we’ve got to in 12 months is remarkable’, says Mr Basi.

With the collaborative only in the first year of its organisational development journey, ‘where we’ll be in a year or two is going to be very different’, says Mr Basi.

In the future, ‘I hope that we’ll be a primary care led integrated care system, with a clear primary care at scale provider environment’, he says. ‘I also hope we’ll have delivered on the value of integrating with pharmacists, optometrists, dentists, as well as community services, so we can have a better offer for patients – keeping them out of hospital and managing their care in the community as the default position.’

For now, ‘It’s very early on, and we’re nowhere near to bringing all the systems together under one umbrella’, says Dr Reehana. ‘But the will is there, the conditions are being set up, and we’re on the right journey. It’s going to take us a while – but we’re in a good place.’

This is the third article in Healthcare Leader’s series on primary care collaboratives. Read the first on Primary Care Collabovatives: A Quiet Revolution and the second on Primary Care Collaborative: Herefordshire.

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