Dr Richard Vautrey, primary care lead at West Yorkshire integrated care board (ICB) – and who has just been announced as the new RCGP president – talks to Healthcare Leader editor Victoria Vaughan about the shift in work from secondary to primary care and the challenges around funding.
Victoria Vaughan: The idea that more will shift into primary care isn’t new, but maybe it’s got more steam behind it now. What is your take on that and how it’s going in West Yorkshire?
Richard Vautrey: If you talk to any GP practice, they will highlight the shift of unfunded work from secondary care to primary care that’s been going on for years, well before the latest changes in commissioning architecture. Drugs we now commonly prescribe in general practice were originally initiated in hospitals. When I started, we had many patients with diabetes going to hospital clinics, and now they come to us and see our teams. It’s the same with other conditions, such as asthma and COPD.
But we haven’t seen the funding being transferred from a secondary or tertiary setting into primary care or community care to support the increased activity. And that’s the fundamental problem. To make the increased activity sustainable, we need a comparable workforce expansion – and the funding to support it – that we’ve seen in secondary care.
VV: Do you think that ICBs are better placed than their forebears to help make this happen?
RV: Not really. Like their predecessors, ICBs are constrained by the funding they receive and national contract arrangements negotiated elsewhere.
The benefit, potentially, is that the ICB can bring together representatives from all parties within a local area – not just the health service, but also local government and social caregivers as well – and that’s helpful. It enables an understanding and discussion across an area. But finding solutions to the problems that all parties face is still very difficult because of the historical underinvestment in the NHS over the last couple of decades.
VV: Do you get a sense from acute trusts in West Yorkshire that they recognise this direction of travel and that funding will need to be moved from them?
RV: Well, I think they see the direction of travel. But secondary and tertiary care have never accepted that funding would need to follow that additional work.
Most recently, we have seen outpatient transformation programmes where there is an expectation that fewer outpatients will take place and more work will be done in a community or general practice setting. But there’s no sense that the funding to secondary care will be reduced to make that change happen. The assumption is that we will just be able to pick it up and deliver on that.
The new additional role reimbursement scheme (ARRS) staff are all welcome members of the primary care team, but they are already fully committed. They’ve not got the capacity to do the work currently being done in a hospital setting.
We haven’t seen a comparable increase in the number of GPs or practice nurses for many years, and that’s what we need to meet the existing need, let alone to do more work.
I’d like to see a much greater blurring of the boundaries between secondary and primary care. Teams with the necessary skills, including hospital specialists, could work in the community.
We need to see that wholesale change of working from hospital-based to where the patient needs them to be. That will take some significant work.
There is also the need to improve our premises in general practice because one of the limiting factors for community-based delivery of services is having the necessary space to do that.
VV: In terms of bringing consultants out to the community, do you see PCNs and integrated neighbourhood teams getting closer to achieving that than others have in the past?
RV: Not yet. Often, the closer working is with community-based teams that already exist. And many district and community nursing teams are struggling with increased workloads and challenges around recruitment. Bringing them closer together helps improve connectivity and gives them a sense of being one team, but it doesn’t expand the capacity. And that’s one of the challenges.
We have seen some good examples where, for instance, there is the creation of dedicated wound management clinics that are supported by nurses who have the necessary skills. Community nursing and general practice nurses can refer patients with complex wound management to it.
But we all recognise that those teams are overstretched.
We need to get a better understanding of the implications of shifted work between primary and secondary care. So that things can be dealt with at the time rather than passing it on to somebody else.
It can be simple things like ensuring the necessary prescription length has been provided to the patient so that we do not have people coming to general practice asking for information they could have obtained from the hospital.
VV: Do you get a sense that this can be fixed? Because none of that is new.
RV: I think it can be fixed, it just takes a lot of energy.
One of the downsides of the split that’s been in place for the last 30 years is that clinicians have separated into silos. I would like to see a bringing together of clinicians more regularly, wherever they happen to be working. And it’s starting to happen.
In Leeds, we have a clinical professional forum that brings together medical directors, clinical directors, and others on a regular basis. It helps develop relationships and mutual understanding.
VV: Regarding the Fuller stocktake, what are you focusing on at West Yorkshire ICB?
RV: I am not a fan of the separation of same-day care from more routine care. It undermines continuity of care and it doesn’t necessarily reduce worker pressures.
What we can do is to have pressure valves within an area – whether the same-day response services or urgent care services – that practices can refer to when they’ve reached capacity.
We’ve had some examples of that where practices have OPEL-type scoring arrangements. When they reach level four, they can access more of the same-day access appointments, so there is additional support.
Respiratory hubs and paediatric hubs across the region have provided that additional capacity. One of the challenges is some of it has been developed on the back of non-recurrent resources. Having these types of services – in addition to the existing practice services – does need continued additional resources.
VV: If practices are overwhelmed, should they seek support from PCNs? What is the ICB role in that situation?
RV: That’s what’s happened with our OPEL scoring. The ICB has provided additional capacity through extra appointments elsewhere in the system, which has been welcomed.
PCNs offer mutual support where possible, but then we know that all practices are under pressure. There’s limited capacity to provide more appointments for one another. Ultimately, it’s the ICB commissioning additional capacity that has been the most helpful.
VV: What would you say you’ve achieved as a primary care representative at West Yorkshire ICB?
RV: One of the key elements of my role is to keep reminding people that we need to continue to empower and support place-based discussion and engagement. That’s where GP practices, local medical committees, pharmacists, dentists and optometrists can get involved much more effectively.
A great strength of West Yorkshire ICB is that we’ve retained a very strong footprint in each of the former CCGs. In Leeds, Bradford, Calderdale, Wakefield, Kirklees, they’re still strong place-based teams.
Within our ICB, we’ve ensured that the resources flow to individual places so that they can make those decisions locally based on the local needs of their population. We’re trying to avoid a sense that some remote body makes decisions. The devolved arrangement means that people know – and hopefully trust – their local ICB colleagues because they meet with them regularly.
Clearly, there are still challenges. GPs would want to see more investment, but they do understand the restrictions and limitations of the ICB based on the national picture and the continued pressure of dealing with secondary care waiting times.
VV: Do you have concerns that services commissioned under CCGs may be discontinued under ICBs?
RV: We’ve not seen it from an ICB perspective, but we have seen it from a local government perspective. We’ve lost the tier two weight management service after Leeds City Council decommissioned that service. So we are concerned that the financial pressures on local government are starting to have an implication on public health services. And that does need to be addressed.
VV: What about access and demand for services in general practice?
RV: We need to better understand why there’s been a big increase in demand for GP appointments. In part, it’s linked to the pressures of secondary care. Reducing the waiting times in hospitals will reduce some of the access problems in general practice.
We need to help patients support their conditions more confidently without the need to access general practice at all. It might be about providing more information online. And it might be about directing patients to pharmacy and other colleagues. We need to help patients see the value of seeing members of the wider workforce team. West Yorkshire ICB has done work to try and address that.
We also need to tackle the abuse that’s directed at those on the frontline. The ICB has done social media campaigns around that to try.
VV: Do you think abuse has increased? And what can the ICB do?
RV: Yes, there’s been a significant increase since the pandemic.
I think there is a post-pandemic lack of tolerance within society as a whole, though the media criticism hasn’t helped. There’s also less tolerance for long waiting times in hospitals.
Clearly, practices will have policies on how to deal with patients who are repeatedly abusing their staff. They’ll remove patients after a warning if they feel it appropriate, and they’d hope the ICB would support them. In our area, in general, we do and, if necessary, allocate the patient to services that the ICB has commissioned for those who cannot receive them in a routine way.
We do need to see a concerted national campaign to make it clear that abusive behaviour is not something that we will accept. It’s an issue that’s faced by many public sector settings – local government and railways, for example.
This interview took place on 8 September, prior to the announcement on 13 September that Dr Richard Vautrey had been elected as new RCGP president.
