Kathy Oxtoby reports on how primary care provider collaboratives are evolving in response to increasing demands on health and care. Click to read the other features in this series on collaboratives in Herefordshire and the Black Country
Across the country, a quiet revolution in primary care is taking place – and it is being driven by collaboration between providers.
The work of provider collaboratives in acute care and mental health is well documented and their remit clearly defined. NHS England describes provider collaboratives as partnership arrangements that bring together two or more trusts to maximise economies of scale and improve care for their local populations.
Less well known, however, is the work of provider collaboratives in primary care, which are evolving in response to increasing demands on health and care. According to the NHS Confederation, ‘many local primary care providers are beginning to come together to build provider collaboratives that deliver a strong and united voice for primary care in their local areas’.
Ruth Rankine, director of the Primary Care Network at the NHS Confederation, says that around the country, formally and informally, ‘collaborators are emerging within systems’. ‘Some of that has been expedited by Covid, but also the realisation that actually some things are better done at scale in terms of efficiency, sustainability, access and improving the quality of care,’ she says.
The individual nature of their development makes it hard to pin down exactly how many primary care provider collaboratives there are, what they are doing, who is involved, and the scale of their achievements.
Developing a national picture
To better understand what is happening with primary care collaboratives, Ms Rankine says the NHS Confederation’s Primary Care Network is undertaking a piece of work to develop a national picture, due for publication later this year.
‘We were finding a lot of our members were starting conversations locally about primary care provider collaboratives. We wanted to look at where they are developing, what they are setting themselves up to do, who they involve, and what links they have with integrated care boards (ICBs) – as well as the rest of the system and potentially other provider collaboratives – and what are the conditions for their success,’ says Ms Rankine.
‘This work is a way of shining a light on how these collaboratives are working, and also to help people who are in the process of setting them up, or who are looking to continue to evolve them – sharing ideas on how they are operating and their potential,’ she says.
Ms Rankine says the work the Confederation has done so far has found there are different types of primary care provider collaboratives. Some have been established purely to provide a space where primary care can come together and have a collective voice, which could be at the level of place or system.
Within this model, she says some are the collective voice of general practice while others have the ‘full spread of primary care representation’, including optometry, dentistry, and pharmacy.
Delivering services at scale
In other areas of the country, she says primary care provider collaboratives are trying to establish themselves to deliver services at scale, most likely at place level. ‘Some of these services may be patient facing – such as the vaccination programmes delivered on behalf of PCNs and practices in the past year – or they may be “back office” services, such as finance and human resources,’ says Ms Rankine.
The origins of these collaboratives began nearly a decade ago when GP federations were formed as a response to the Five Year Forward View to carry out at scale – and so more cost effectively – some of the services individual practices would not have the time or space to deliver, says Ms Rankine.
Over time, primary healthcare has seen the benefits of delivering services at scale from a workload and a patient perspective. For example, this was evident during the pandemic when PCNs or groups delivered the vaccination programme of PCNs, and GP Federations, she says.
With the abolition of CCGs and the advent of ICBs, ‘primary care has been trying to recreate a space where it can bring primary care providers together to have a collective voice’, says Ms Rankine.
Since Integrated Care Systems (ICSs) became Statutory in July 2022, there has also been ‘an increasing focus on the unique roles of neighbourhood, place and system’, says the NHS Confederation. ‘Primary care is at the heart of neighbourhoods but across most systems, more needs to be done to create a primary care infrastructure fit for the future,’ the healthcare membership body says.
An appetite for primary care collaboratives
With The Next Steps for Primary Care: Fuller Stocktake report, “there has never been more appetite for provider collaboratives within primary care’, the NHS Confederation says.
The report suggests that ‘integrated neighbourhood “teams of teams” need to evolve from Primary Care Networks (PCNs) and be rooted in a sense of shared ownership for improving the health and wellbeing of the population’.
‘They should promote a culture of collaboration and pride, create the time and space within these teams to problem solve together, and build relationships and trust between primary care and other system partners and communities,’ the report says.
As to where primary care provider collaboratives fit in with the report’s suggested integrated neighbourhood teams, Ms Rankine says they ‘tend to be delivering services at scale, above neighbourhood level (or PCN level)’. For example, a collaborative could be providing an enhanced access service on behalf of its PCNs, where patients can access general practice services outside of core hours.
The scale of primary care provider collaboratives across the country is unknown. ‘If you asked ICBs: “Have you got a forum where you connect and engage with primary care?”, I think the majority would say yes’, says Ms Rankine.
‘However, if you asked ICBs: ‘Have you got a primary care provider collaborative?” I’m not sure the majority would say yes. This comes back to the terminology, and how organisations are describing themselves,’ she says.
What is clear is that there are different models across different parts of the country – there is no one-size-fits-all approach. ‘How primary care provider collaboratives are emerging is very much in response to local circumstances and local need,’ says Ms Rankine.
A snapshot survey by the NHS Confederation found there was ‘significant variation’ in terms of who is involved in primary care provider collaboratives, says Ms Rankine. For example, these collaboratives could be a general practice voice, a service delivery vehicle, part of wider primary care, or be seen as a formal part of ICB governance. Or they could sit to one side of the ICB and feed into it.
‘We would also like to see primary care involved in other collaboratives within the system, for example, acute or mental health collaboratives,’ says Ms Rankine. ‘If we want to see strong integration of services and redesign of services to deliver better outcomes, then we need to involve all providers involved in the delivery of patient care. As we found in our recent survey of provider collaboratives, relationships with primary care were still in their infancy,’ she says.
As for who could get involved with these collaboratives, Ms Rankine says there are ‘lots of opportunities’ for different primary care professions to work together, such as community pharmacy where they can work alongside general practice to support the management of long-term conditions.
Ms Rankine says these collaboratives can also be a space that brings different professionals together to discuss how to improve services for patients and the integration of those services between providers. ‘For example, some services could involve local government or the voluntary sector,’ she says.
What primary care provider collaboratives are doing is ‘really variable’, says Ms Rankine. She says some collaboratives are having conversations about strategic healthcare issues or acting as a sounding board for the ICB. Others are looking at how they can support general practice and patients getting the care they need, such as through delivery of care at scale at place level. And some are looking at how they support primary care through training and development or managing some of the bureaucracy that general practice has to deal with.
In Herefordshire, for example, primary care collaborative provider Herefordshire General Practice has increased 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 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 Nigel Fraser, co-chair of the Herefordshire and Worcestershire General Practice Provider Board and chairman of Herefordshire General Practice.
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.
In the West Midlands, the Black Country Primary Care Collaborative has been responsible for driving a winter access programme. This included setting up children’s respiratory hubs that provided additional capacity in winter. Dr Salma Reehana, chair of the Black Country Primary Care Collaborative and a GP partner at Health and Beyond, a multi partner practice in Wolverhampton, with multiple sites, says this approach ‘alleviated pressure on emergency services and provided better access for children with respiratory problems, closer to home.’
The potential of primary care collaboratives
Given the benefits these collaboratives can bring, it is likely that more will be established in future. Ian Holmes, director for strategy and partnerships at NHS West Yorkshire Integrated Care Board, says the ICB is ‘considering what a primary care collaborative would look like across our area’.
‘In taking this forward we will be working with our local medical committees, local pharmacy committees, local ophthalmology committees, and local dental committees to discuss what support is needed for the wellbeing and sustainability of primary care services. This will be another way of ensuring colleagues’ views are heard in all decision-making,’ he says.
Those setting up primary care provider collaboratives could learn from trusts about their experiences, says Nicky O’Connor, a healthcare management consultant who has conducted research into provider collaboratives.
‘Primary care practitioners could discuss with their acute, mental health, and community colleagues about how they set up their provider collaboratives, what challenges they faced, and what resources they needed,’ she says.
An important role
Dr Clare Gerada, president of the Royal College of General Practitioners, describes it as ‘a good idea’ for primary care organisations to work with each other at scale.
‘It makes sense,’ she says. ‘But as ever, it’s not about primary care changing; it’s about the rest of the system changing. We have to fundamentally change the way the NHS is organised to meet the needs of our patients, who have chronic, complex co-morbidities.
That means there needs to be more care delivered out of hospital, says Dr Gerada. ‘And with that, we need to move the staff and the resources out of hospital. We’ve got to start having multidisciplinary teams working across diseases, such as diabetes. So, it’s about GPs working together to redesign how services are delivered.’
While, as yet, there is no clear national picture of what primary care provider collaboratives are achieving, signs are that they have the potential to play an important role in shaping the future of health and care. As Ms Rankine says: ‘These collaboratives give an opportunity to build a strong primary care voice, to bring primary care together, and at the same time, take pressure off other parts of the system by delivering services at scale.’