Too many patients are frustrated. They are unable to get an appointment with their GP, experience long waits in the emergency department, and get pushed around from pillar to post in the health system. What’s more, the finances are woefully insufficient, the staff are demoralised and exhausted, and we’ve got an entirely reactive overridden health service. Nothing will change until we embrace a proactive population health focus to prevent the crisis we are witnessing year on year to meet the growing health and care needs of the people we serve.
If we look at the most sustainable systems in the world, including Denmark and Singapore, their investment and focus is on delivering strong, integrated, community-based primary healthcare services working in partnership with the local community, the voluntary sector and other public services.
Integrated working requires brave, agile leadership and a bottom-up approach in addition to clear strategic direction. The biggest issue we see as we travel around the country speaking to chief executives and frontline teams is siloed, fragmented services that have been created over the past decade in the out-of-hospital sector. We have established a number of services, all doing the same role albeit with a different name – ‘virtual ward’, ’hospital at home’ and ‘frailty service’ – and we create a whole new team rather than investing in the current one sitting in primary and community care where the core skills are already honed.
A GP recently expressed frustration at the number of health and social care teams aimed at complex and frail individuals and families – 26 in total, working independently of one another within the geography covered by the practice. The biggest issue, he explained, is that no one knows each other, and no one takes responsibility for addressing the underlying problems, the complexity and the mess of multiple teams. Patients are passed from one team to another, rarely receiving the right care in the right place at the right time. It is case of ‘hand offs’ and results in poor patient experience and patient outcomes.
At the National Association of Primary Care (NAPC), we see the delivery of timely, high-quality care when the staff working across the whole community come together to deliver integrated care, to deliver a holistic service addressing the needs of the community that they serve. The model does not require an increase in staff numbers. The evidence in the model that we have developed shows that you get better returns by investing in the existing staff so long as the teams have time to find the headspace to fully integrate, come together and think about how they can cut out the waste and the unproductive steps in their part of the system.
This is not another sticking plaster. This is about investing in current teams supported by robust operational and improvement processes that are augmented by digital estates and wider infrastructure strategies. It requires significant team development and brave agile leadership to re-engineer and redesign the process in which staff work, and people flow through the health service.
The right teams need to be shaped around the communities they serve, and we have to shift our mindset and move away from the obsession with economies of scale. This is working well in mid-Dorset where the fully integrated team covers a population of 5,000 in a small town. Equally, there are opportunities in other areas with a very similar population to do things at scale – for example, in Fulham, where there is a very high turnover of people in their twenties and thirties who want a largely digital-based service. In this circumstance, it is cost-effective to cover a wider population.
The fundamental improvements in health happen when we address the wider social determinants. It’s when we work with the acute sector, local authorities, the wider public and voluntary sector to provide a holistic service that is aimed at enabling people to be partners in their care. This proactive population health approach is how we improve the wellbeing of the community.
We can also improve patient outcomes when we align members of a specialist team to join the integrated community team. A consultant in respiratory medicine can prevent serious and debilitating respiratory disease by working with existing teams to get upstream and see patients in a community setting at early onset rather than waiting for them to arrive in an outpatient clinic via an outdated referral system. Similarly, when a patient does need a hospital stay, it is more efficient and better for the patient to be discharged home with services to support them to receive continuing care in their community rather than being stuck in a hospital bed.
But this isn’t a quick fix. It is a five to 10-year journey. However, there will be quick wins along the way. For example, the evidence suggests that a patient with type 2 diabetes can be in remission in less than six months. This reduces hypertension and the musculoskeletal burden and improves mental health, thus reducing demand for both primary and secondary care.
The joint statement on the need for reform of urgent and emergency care to prevent the perennial winter crisis – Our urgent and emergency care improvement proposals – National Association of Primary Care – clearly demonstrates that the system needs a radical shift to a proactive population health approach. It has to be about a fully integrated neighbourhood team taking care of our patients’ health and wellbeing needs in the community.
