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How is primary and secondary care integration impacting trusts?

How is primary and secondary care integration impacting trusts?
By Carolyn Wickware
22 June 2017

A wave of integration between primary and secondary care is sweeping across England from north to south as four trusts in Northumberland, Somerset, Wolverhampton and Gosport have taken over multiple GP practices in the interests of integration.

A wave of integration between primary and secondary care is sweeping across England from north to south as four trusts in Northumberland, Somerset, Wolverhampton and Gosport have taken over multiple GP practices in the interests of integration.

Healthcare Leader reported this week that The Royal Wolverhampton NHS Trust will be taking over five more GP practices in the next three months to bring the total number of practices under its wing as part of its vertical integration pilot scheme up to 12.

This new way of providing care is in answer to the Five Year Forward View’s proposition to ‘dissolve’ the boundaries between primary, secondary and community care.

But as Dr Gurmit Mahay, a GP and medical secretary for Wolverhampton LMC, pointed out, the trust is taking on a significant amount of responsibility, having to secure staffing, financing and meeting regulatory standards – so what’s in it for the trust?

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Why are trusts taking on GP practice contracts?

It’s designed to improve the quality of care while delivering ‘better value for money’ in ‘communities where local general practice is under strain and GP recruitment is proving hard’, according to NHS England’s Five Year Forward View.

Dr Julian Parkes, a clinical director for the Wolverhampton trust’s integration programme, told Healthcare Leader the trust took on the practices as part of its commitment to finding new ways of working.

‘We all recognise that we cannot continue to work with the system as it exists now, as all areas are under a lot of pressure with rising healthcare needs,’ he said. ‘The programme provides a way of taking resources in terms of money and staff and deploying them in a better way across the health community for the benefit of patient care.’

While this decision to share the burden of patient care was also true for the other trusts, Dr Jane Weatherstone, associate medical director primary and community care at Northumbria Healthcare,describes the formation of Northumbria Primary Care at the Northumbria NHS Foundation Trust as a ‘natural progression’ of the trust’s involvement with care in the community.

But she added that beyond the benefits for primary care, integration allowed doctors at the trust to experience a different way of working.

She said: ‘People in this neck of the woods stay working for the trust forever, and they’ve only seen one side of healthcare provision so it allows managers to work out in primary care and get a really good understanding of how it works, which then they can bring that knowledge back to the trust.’

Where are the integration plans taking place?

Aside from the integration programme in Wolverhampton, four practices in South Somerset joined Yeovil Hospital Healthcare to form Symphony Healthcare Services, a primary and acute care systems vanguard, after significant recruitment and financial difficulties were reported.

Another four practices in Gosport, near Portsmouth, decided to surrender their contracts to Southern Health NHS Foundation Trust as part of the Better Local Care multispecialty community provider vanguard.

Dr Donal Collins, GP lead for the vanguard, said the practices ‘had to do something’ to avoid closure, highlighting that the four practices have 'taken the risk out of general practice' by merging and joining the hospital.

He said: 'They've got a stable platform to work from and they can concentrate on doing the job, in terms of delivering outcomes to the patients, rather than worrying about their financial future.'

But this type of project isn’t always seen as the primary care life raft as intended.

In Northumberland, where five practices are run by Northumbria Primary Care Ltd, a wholly-owned subsidiary of Northumbria NHS Foundation Trust, most practices in the area refused to join the trust – despite a push from the CCG.

The local medical committee said at the time that GPs weren’t given enough opportunity to consider alternatives; with the CCG looking to set up a new care model simply to attract funding that would be used to close a financial deficit of approximately £17m.

How are these integration schemes impacting trust budgets?

Every trust has said GP practices have had to undergo a period of ‘due diligence’ before joining the trust.

Kerry Cooper, the general manager for the MCP at Southern Health NHS Foundation Trust, said its more than just assessing the practices’ performance as it also gives the trust a change to ‘get to know the practices so we can understand what the strains are for the future’.

But she admitted that the trust did take a financial hit when it took on its first standalone GP practice.

She said: ‘That's really because the ability to recruit locums at the time was expensive and I think we ended up using more locums while we brought in more substantive GPs to provide the workforce.’

Back in Wolverhampton, to avoid shortfalls the trust has given each practice a budget based on their past income and expected them to spend against that budget.

But Dr Parkes added that, far from creating debt, practices even have the potential to make money for the local health economy.

He explained that the trust is ‘exploring ways of a developing a system of fair-share funding allocations’ allowing money that was received under payment-by-results can be used across the local health system ‘to provide patient care in a more integrated way within the community’.

How can other trusts follow suit?

Ms Cooper from Southern Health NHS Foundation Trust advised trusts going forward with a similar integration scheme not to ‘underestimate the consideration’ that is required to bring primary and secondary care together.

She said: ‘The trust has to be prepared to understand primary care. I think within whichever area of healthcare we're in, that's how we view the world sometimes. And I think that we have had to take some time to really understand the differences and the benefits of primary care.’

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