Hampshire and Isle of Wight ICB primary care director, James Roach has worked in the NHS for 20 years setting up Southend clinical commissioning group and running Mid Essex and then Wiltshire CCGs, before moving into system integration and leading West Essex integrated care partnership. He discusses current plans for primary care in Hampshire and Isle of Wight with Healthcare Leader editor Victoria Vaughan
Victoria Vaughan (VV): What are your top three priorities for primary care in Hampshire and Isle of Wight?
James Roach (JR): The number one priority is primary care resilience and quality. In addition to the national contract and the ongoing discussions in relation to that, we are looking at how, as a system, we can support the future sustainability of general practice with the development of a primary care quality and resilience scheme, and that has six pillars.
The first is how do we build on primary care networks to develop primary care services at scale, develop more transformation out of hospital, and look at integration with other partners within the ICS.
The second is around quality improvement (QI). How do we support practices to deal with some of the long-standing quality issues? That could be preparing for a CQC visit, it could be QI in a particular pathway or clinical area. Within that you would have things like medicines optimisation, workforce development and estates transformation as well.
Number three is how do we develop the infrastructure with general practice, with more support, listening and evaluating. So that’s very much a focus on changing the way we do our communication across general practice and primary care. We’re working on the concept ‘it takes a team’.
It’s not just the GP, it’s the nurse, it’s the pharmacist, it’s the multidisciplinary team (MDT). We’re then looking at addressing particular challenging areas.
So for winter – additionality – how can we invest more into our primary care services so they’re better able to deal with levels of demand, enhanced same day access, and how they can work differently at, say, the front door of the hospital or in partnership with the local authority around discharge of patients.
Then we’re looking at a fairer funding model. We all recognise that nationally, Carr-Hill was for a point in time, but those times have changed. So how do we understand local funding needs? We’ve established a ready reckoner process, which gives us an indication of where each practice is in terms of their income, their pressures, their demography, their challenges, their cost base. Trying to use population health as a force for good in terms of contractual value and making sure that we’re aware of healthcare inequalities and disparities and we’re targeting investment to meet that.
The sixth pillar is integrated neighbourhood working so ‘shift left’, recognising the direction of travel is very much about more investment into out of hospital care, more integrated collaborative working on the local level. We’ve really pushed for integrated neighbourhood working, as not just a key transformation initiative, but ultimately our key planning, delivery and engagement footprint as well within the system. How do we build on that concept to develop a more resilient general practice through its partnership and integration with other players in the system, to hopefully result in a more sustainable general practice moving forward.
VV: What does integrated neighbourhood teams mean and look like in Hampshire and Isle of Wight?
JR: Its very much developed within General Practice. It is the point of clinical leadership. We’re going to do it on a place-based basis. We’re going to use our PCN footprint to sort of drive the model moving forward.
VV: Are PCNs to drive an INT forward or are they a member of it?
JR: It’s different for different geographies – Hampshire, Southampton, Portsmouth and Isle of Wight – but PCNs have created such a great foundation in terms of at scale primary care and driving forward transformation. We see that as a real foundation of strength. In terms of how we do things, we focus very much on what we would call priority neighbourhoods. Where are the areas that potentially have the biggest level of healthcare, inequality, deprivation, utilisation of emergency care, missed opportunities in relation to ambulatory care conditions and that type of thing, and broadly, it tends to fall back to PCNs as our planning and delivery footprint.
VV: Which areas have you identified?
JR: We’ve identified 11 areas which is based on our risk stratification data, Healthy Intent, we’ve probably identified a cohort of patients, high intensity users, or a particular clinical cohort, whose care would be best suited by integrated neighbourhood.
But because of the diversity and range of our geography, we’re not always going to have the same priority neighbourhood for each area. In lots of instances, it will be frail elderly, but in some we’ve got a younger population cohort in a particular deprived area that have a particular set of needs.
We’ve also seen in some areas mental health is an issue, or child health. And for some, we’ve seen quite a large proportion of working age adults with one or more long term conditions. The data drives the intervention. I think that’s important, particularly in terms of articulating what that return on investment looks like and needs to look like to encourage that investment shift moving forward.
VV: How good is your data? Where is it coming from?
JR: We’ve got some really good data in terms of our risk stratification. How we target the top 3% of people with the most complex needs, at the highest risk of hospital admission and the highest risk of long length of stay. Recognising that often leads to quite a high proportion of activity across our across our system. Obviously, that could include people who are end of life as well. We use that to drive what we do in terms of proactive care, what we do in terms of specialist care in a community setting and where appropriate, what that would mean for end-of-life care as well and people with particular specialty needs.
VV: You mention changing the funding model for primary care can you explain what you’re doing there? In Leicester, Leicestershire and Rutland they are using the Johns Hopkins University adjusted clinical group (ACG) system, are you?
JR: It’s a similar model, a similar algorithm, but positioned in a different way. We all use different companies and different approaches. But ultimately it’s a similar model using Healthy Intent.
VV: What funding can you make available to support tackling health inequalities given the savings that are required?
JR: We have the established funding routes, the money that goes into PCNs, service development funding, we have a process by which we can review potential innovations and make investments as a system that would go through a financial governance process, but there is a way in which commissioning cases can be submitted and reviewed and decisions made, and we’re looking to support our practices so they’re able to do that.
We’re currently going through a planning round for next year, and the key part is the primary care quality and resilience scheme, which I’ve mentioned. We see that as the vehicle for more investment into primary care. Primary care is very much at the planning table.
VV: As an experienced primary care leader do you think that ICBs will succeed in getting that long talked about transformation of care into the community?
JR: I think there’s been a long-standing commitment, and the message has been consistent in terms of ‘shift left’ of resource. I think we’ve already started to position our primary care quality and resilience scheme into the planning round, and we’ve seen some initial investment into the winter additionality program.
There’s a commitment now to take that scheme through for investment and make sure it’s going through all the various checkpoints. We’ve got an active and energetic group of clinical leaders, not just in general practice, but in nursing, but in pharmacy and everything else.
A lot of these sort of signature schemes for the system have been very much informed by primary care. If the systems are signing up to these initiatives, there’s an absolute recognition of the role that primary care plays in that. I think there’s a level of national planning reality and system operational reality as well. We always say the platform is burning, but I think it really is burning, and I think it does need all of us to work differently to take things forward.
The other opportunity in Hampshire and Isle of Wight, is we’ve moved towards one single provider of community services. By its nature, an integrated community trust with an integrated primary care offer, I would suggest, would create an at-scale, more dynamic out of hospital model.
VV: How’s the interface between primary and secondary care? How does the ICB support with that?
JR: We actually started quite early in terms of primary/secondary care interface. We set up a system board where we brought together GPs, hospital consultants and other clinical leaders in the system. We established a one-page consensus document that articulated all the key principles in relation to improving process and care at the primary, secondary care interface, improving outcomes, etc.
We launched that and it has a place within our provider contracts and the quality schedule. We’ve got a set of principles for the system sign up to, and a lot of our transformation in 2025 will be about how we continue to improve processes at the interface, reduce bureaucracy and ensure there are pathways mirror that approach.
VV: How does the ICB support your primary care with digital transformation?
JR: We’re resetting the digital offer for primary care. We delivered a lot of the primary care access recovery plan, so we’ve had a lot of investment in our digital telephony. We’ve done a lot in terms of improving patients access to apps.
We’ve started to use things like Anima and other systems in a better way to inform our same day access models. Another opportunity for us is how we align with our community provider in terms of a single digital strategy.
What’s quite unique, is we’re using the Apex data system. We’ve started to get a daily track now of activity and demand into primary care. That gives us an understanding of what’s happening. It gives us an indication of the difference some ARRS roles are making and pressure that general practice is dealing with day to day.
VV: What impact is Pharmacy First having?
JR: What we need to do for pharmacy first now is build on where we’ve got to in terms of the numbers, were at about 100,000 referrals, and start to define some real targets around redirection, and start to establish some pathways so in terms of use of the system, volume of referrals, type of referrals, it’s absolutely going in the right direction.
VV: What impact is the ARRS having?
Our care navigators and social prescribers have had a massive role to play in helping us to tackle the 8am rush and provide more triage and more patient contact. Our pharmacists have done some excellent work in terms of meds optimisation, reviews, the prescribing and ensuring that people maximise their medicine. And I think our nurses have played a significant role in supporting people with long term conditions, extending service pathways. All of that is starting to contribute to freeing up our GPs so they can deal with some of the more complex patients. That’s going to be the game changer when the system is going to see the real benefit of an integrated, proactive primary care model, because we’ll be able to deal with more complex patients out of hospital, but we will be able to free up our clinical leaders so they can deal with some of these people in a different way, in partnership with hospital and community teams.
VV: Does bringing GPs in through the ARRS help?
JR: I don’t think it’ll suit everyone. I’m not suggesting our workforce challenges are solved. We’ve still got some big issues, but there are other areas, I think, with bigger issues than ours, and I think what you’ll probably find is that individual parts of our system probably mirror some of the national challenges. Portsmouth is an area where traditionally, we’ve had quite a low number of GPs per 100,000 of the population. We certainly improved on that over the last 12 to 18 months, so we’re not where we were, but there’s still a long way to go, and there’s always challenges as well, with coastal communities. Take Isle of Wight. There’s always going to be challenges. But, we’ve got a better understanding of those issues. We’re working in partnership with other organisations to address it, but ultimately, we’ve all got to keep making people see the general practice is a good place to work.
VV: Are you struggling for GPs in your area?
JR: We have got vacancies, and we have pockets of workforce challenges. It has improved. We’re better able to isolate where there are issues now and respond accordingly. I think we’ve got a good pipeline of trainees coming into the system as an ICB, we’ve invested in the new to practice fellowship. We’ve invested in all the levers that we can to encourage people to work in and stay in the system, and we’ve got quite an ambitious recruitment and retention strategy for primary care as well, and an integrated workforce model.
VV: Can you explain a bit about your workforce plan?
JR: We’ve got an integrated workforce strategy. Within that, there’s a range of different pillars, focusing on new entrants, recruitment and retention. How can we support GPs have a portfolio career? How do we expand the other roles within primary care? How do we support our nurses and our pharmacists to work the top of license? How do we create an environment where the GP can develop a specialty area of interest? How do we expand the workforce model. We’re looking at apprenticeships, we’re looking at new ways of working. We’re equipping teams to deal with the digital opportunities. It’s not just recruitment, it’s the environment, it’s the MDT working, it’s development of professionals that will keep people enrolled as well.
VV: Will you get involved at all with the concerns around the National Insurance hike?
JR: What we’re currently doing at the moment is just trying to understand what the impact is, on an individual practice level and across our ICB area. Clearly, we can’t change Treasury decision making, but we’ve got to be better at understanding impact and acting accordingly. Like other ICBs, we’re starting to quantify what that global impact is, clearly it can have an impact on the sustainability of general practice as a business. We need to be aware of that, understand what we can do to support.
VV: What does that support look like? Is it financial?
JR: There isn’t a lot of additional money. But one thing we are doing, is articulating the value that primary care brings to the system and transformation, etc. Our primary care quality resilience scheme at least demonstrates a commitment to resolving some of these issues of resilience. And look at how we can address it as a as a commissioner.
