Primary care holds the key to tackling health inequalities, making early interventions and preventing more costly treatments in the hospital sector. In this report, Healthcare Leader brings together leaders from general practice, pharmacy, dentistry, optometry and nursing to provide an overview of their profession’s challenges and the solutions they’d like to see from integrated care boards.
This winter has been the worst in memory for both NHS leaders and frontline staff across primary and secondary care. The workforce is under enormous pressure and, as demonstrated by recent and ongoing strike action, staff are unhappy.
In February, the Royal College of Emergency Medicine estimated that the number of excess deaths in England that were linked to long delays for emergency treatment sits at 23,000. It also found 1.65 million patients faced 12-hour waits from the time of arrival in A&E last year.
The care backlog is at a record high, with almost 7.21 million people waiting for treatment in England.
While these challenges are most noted in secondary care, all NHS services – including primary, community, and mental health care – are under enormous pressure.
High rates of flu and Covid, the fallout from the pandemic, the Strep A outbreak, along with delayed discharges, which leave more than 14,000 medically fit patients stuck in hospital, are compounding a longer-term issue that lies at the heart of the NHS crisis – the shortage of health and care staff.
The NHS in England hit a peak of 131,000 vacancies last quarter. The latest figures published this month show that it has dropped slightly to 124,000 FTE vacancies, but the rate remains higher than previously seen. And there are shortages in every part of the healthcare system, from general practice and community nursing to pharmacy and dentistry.
The challenges that integrated care boards (ICBs) face are formidable. They need to change the way care is provided in a health and care system at a time when the NHS is stretched to its limits. They need to ensure enough primary care professionals to deliver these services. And they need to do this when morale among healthcare staff is so low that not only are nurses striking for the first time in the history of the profession, but junior doctors have also voted to strike. All at a time when ICBs are still in their infancy. And from 1 April, ICBs will evolve still further – expanding their remit to become responsible for all pharmaceutical, general ophthalmic and dental services.
But when it comes to tackling workforce shortages in primary care, the new and developing nature of ICBs could be to their benefit – allowing them to come up with innovative and creative ways of dealing with recruitment and retention issues, working with and across all the different health and care professions and reaching out to education facilities.
‘The integrated care boards have the opportunity to plan for a workforce that is coordinated and proactive across health and care to support the population health needs of the communities that they serve,’ says Rebecca Smith, director of system and social partnership at NHS Employers, part of the NHS Confederation.
However, with large numbers of the workforce having already left the NHS, and against a backdrop of many thousands of staff vacancies, ‘employers would urge the Government to continue to invest in growing the UK training pipeline to bridge the vacancy gap and ensure that the upcoming workforce plan is fully resourced’, she says.
‘By making more fully funded training places available, this will mean that the NHS will become a more attractive place to work, where people can develop their skills. This includes commissioning extra medical school places, supporting and sustaining the nurse degree apprenticeships route, which has been very successful, as well as undergraduate training courses, especially in mental health, community, primary care and learning disability,’ she says.
Ruth Rankine, director of primary care at the NHS Confederation, says primary care professionals have been seeing ‘vast numbers of patients, delivering more appointments than pre-pandemic levels while facing significant workforce challenges, including a rise in vacancy rates from falling GP numbers, with a quarter of posts set to be vacant by 2030’.
‘The overwhelming majority of GPs and their teams are working longer hours to meet increasing demand, especially now with the knock-on impacts of prolonged industrial action, and primary care has been contending with an extremely difficult operating environment. This has meant that many GPs and primary care staff have felt burnt out, with pressures affecting their mental health, resulting in GPs and health care staff gradually leaving the NHS,’ she says.
The NHS Confederation has seen ‘many innovative examples of new ways of working in primary care, both in terms of use of multi-disciplinary teams as well as digital capabilities, to both address the increasing demand as well as offering a more responsive service to patients’, says Ms Rankine.
To sustain this, the organisation has been calling for greater assurance around the future of PCNs and the Additional Roles Reimbursement Scheme (ARRS), and investment in at-scale delivery where it provides quicker and more effective care for patients.
‘Primary care has much to offer the system in helping to get more care upstream, to address the root causes rather than symptoms and to improve long-term outcomes and decrease healthcare costs overall. But this means greater investment in the community, retaining the workforce we currently have, and a properly funded workforce plan for the future,’ says Ms Rankine.
In the short term, Beccy Baird, senior fellow in health policy at The King’s Fund, says it is ‘very difficult to see what a solution to workforce shortages is going to be, other than overseas recruitment’.
‘But while we’re ‘growing our own’ – which is great in terms of getting new healthcare professionals – ICBs should be working on retaining the staff that they’ve got,’ she says.
A Government solution has been to invest in 26,000 extra roles in general practice under the ARRS scheme to support the primary care team, including pharmacists, physiotherapists, and community link workers. However, research by The King’s Fund on integrating additional roles into PCNs highlights that some thought needs to be given to organisational development and training to support their implementation. Ms Baird says in general practice, ‘this doesn’t happen – the infrastructure isn’t there. One of the problems is that training and supervision is not funded’.
‘ICBs really need to focus on these new roles coming in, and how to make the best of them,’ she says.
ICBs can also ‘help PCNs understand what roles will be helpful to them and how to get the best out of them. And rather than having individual PCNs do their own advertising for people – where a community pharmacist may go into general practice, leaving a vacancy in that pharmacy – it feels very important to do workforce planning at ICB level,’ says Ms Baird.
Having worked out what staff are needed – and recruited them – Ms Baird says ’a bigger issue is how to support and supervise them, and give them career pathways. My research found this is lacking.’
She has key recommendations for ICBs. She says ‘they need to ensure PCNs have access to local skills development. They should think about how they are going to support practices in the necessary redesign of the primary care estate. And ICBs need to think carefully about whether they have got the skills to be able to take on dentistry, pharmacy and optometry’.
To help address the workforce crisis, ICBs have the ability to bring together different partners in the health system, says Nigel Edwards, chief executive of the Nuffield Trust. ‘ICBs could help mobilise hospitals and community providers to think about how they can provide some support,’ he says.
He adds that it is important to remember that ‘ICBs are a collaboration’. ‘But it doesn’t help that some policies [such as ARRS] have led to competition between PCNs and community pharmacists, which is a challenge,’ he says.
As for incentive schemes to recruit healthcare professionals, such as one-off payments for GP trainees to work in deprived rural areas and “new to partnership” payment schemes, ‘little has been done to evaluate whether this is effective’, says Billy Palmer, senior fellow at the Nuffield Trust.
Crucially, ‘we need a good workforce plan,’ he says. ‘It needs to be strategic, to outline the different responsibilities for ICBs and other organisations, and to have clarity in the system.’
Dr Caroline Taylor, National Association of Primary Care (NAPC) chair, says that ‘while we are in dire straits across health and care’, and despite the workforce challenges, ‘there are glimmers of light’. ‘The NAPC has clear evidence from the places and systems we work with that, if you do things differently, it isn’t an insolvable problem.’
A solution, she says, is ‘to look at how to broaden workforce without it always having to be highly qualified, skilled people, because that’s just not possible in the short or medium term because it takes too long to train people’.
The NAPC has established several initiatives to help to address recruitment and retention issues. This includes a Community Health and Wellbeing Worker Programme, where community health and wellbeing workers – recruited from the local community where possible – visit households within defined areas, ensuring they receive tailored and holistic health and wellbeing support where needed.
The NAPC also delivers its CARE programme in all 42 Integrated Care Systems (ICS) in England. This learning and development programme ‘empowers staff to lead, innovate and shape services based on population health needs, resulting in happier and more fulfilled experiences at work,’ says Ms Taylor. Evaluation of CARE shows 93% of participants experiencing better emotional wellbeing, 82% seeing their job satisfaction improve, and 95% seeing leadership skills improve, she says.
There is no single ‘cure-all’ approach to solving the workforce problem. ‘One of the problems with trying to tackle the crisis is that people are looking for relatively simple, quick fixes. But instead, we need to focus on the whole breadth of the problem – including recruitment and retention. They all go hand in hand,’ says Mr Palmer.
To deal with workforce challenges, primary care will need the kind of support and expertise that ICBs can leverage,’ says Ms Baird. ‘And so, while ICBs are considering how to address workforce, they really need to think about what they can do to support primary care.’
