Anthony Fitzgerald is senior responsible officer for primary and community care across South Yorkshire and Place director for Doncaster. His career began at the NHS Modernisation Agency before working at acute providers, regional authorities and Doncaster CCG. He tells Healthcare Leader editor Victoria Vaughan about early findings from PCNs participating in NHS England’s PCN pilot scheme and partnership working in South Yorkshire.
Victoria Vaughan (VV): How’s your ICB supporting a move to care closer to home and into primary care?
Anthony Fitzgerald (AF): It’s very much the mantra of the integrated care system as a whole. A move towards a more preventative and community/ primary care-based approach is right for patients, but we also see that things are no longer sustainable from a financial perspective. Our estate and facilities won’t support any increase in demand anyway, so there’s a fundamental need to shift.
Neighbourhood development is a focus in each of our Places and local authorities, and it’s supported by our combined authority across South Yorkshire. They may differ slightly in terms of approach, but it’s about being appropriate for the challenges faced by each neighbourhood.
We’re putting integrated neighbourhood working at the forefront of redesign. Like many towns and cities, Doncaster has seen leisure and shopping facilities move out of town, so we’re looking at health and social care services being part of city centre regeneration.
In Barnsley, they’ve put diagnostic and outpatient services into the town centre. There’s great access because of transport links and it’s increased the footfall of people through the town centre; people come for their outpatient appointment and, at the same time, do some shopping and go for lunch. We’re doing the same in Doncaster with swathes of services that don’t need to be at the hospital.
We’ve tried to align the health and social care provision with the council’s strategy around access to the city centre and leisure facilities, shopping, and retail. The key is that you can’t do this in isolation. It needs to be done as part of a multi-partnership strategy.
VV: Do you get a sense that ICBs have a greater chance of success than attempts in the past to move care out of hospitals because they are working as part of a system?
AF: The size and partnership opportunities that come with being an ICB have allowed us to accelerate work.
The South Yorkshire authority can bring political input, and we have sources of funding that we wouldn’t have had previously, such as levelling up monies. South Yorkshire has just been successful in an application to be one of the health and growth accelerators being set up across the country. That in itself brings significant investment and political momentum.
What I would say, though, is that we’re very keen to avoid a one-size-fits-all approach to neighbourhood working and integrated neighbourhood teams. There is recognition across South Yorkshire that it has to be appropriate for the towns and communities, for what those residents need, and for what those teams can do.
VV: How do you decide what’s appropriate for a community or neighbourhood?
AF: We’re running a big integrated neighbourhood team event and we’ve commissioned the help of the National Association of Primary Care.
We’ve created a series of alliances and federations across South Yorkshire, which include primary and community care, acute, mental health and learning disabilities, voluntary and faith sectors. And we’re bringing them together to say, actually, how are we going to work at Place level? What would be an appropriate integrated neighbourhood approach in the south of Doncaster, for example?
So, the first thing is a high-level sign-up by chief executives and then we hyper-localise it with PCNs. The clinical directors can say, right down to the kind of pathways of care, who needs to be involved, and how we get to a more preventative approach for people.
I’ll give you an example. In Doncaster, we’re looking at high-intensity users of A&E. We’ve been more proactive and used our volunteer and community sectors to take a personalised approach to the top 50 users. The impact is massive. We’re talking about people who could be attending A&E 15 or 20 times a month and now they’re not. It’s a resident-by-resident approach.
VV: The Government has introduced initiatives that puts focus on acute care, such as the elective recovery plan and 18-week target. How difficult is it to be in a primary care space in the ICB in that environment?
AF: It’s a complex environment and it always has been with primary care. Our primary care strategy focuses on five areas.
The first is access. Our patients told us that they struggled with access – getting through to the practice in the first place and then getting appointments. So, there’s an unashamed focus on access and I’ve seen some really good improvements in that area.
The second is integrated neighbourhood working and looking at what that means and how you get that approach.
The third is workforce – a focus on recruitment and retention of the workforce across primary care.
The fourth one is the primary and secondary care interface. Feedback from professionals in South Yorkshire was that if the interface could be worked out, life would be better. So, we’ve invested a lot of clinical time in trying to make that smoother.
Our final one is digital. So, South Yorkshire has four PCNs participating in NHS England’s national pilot programme – three in Sheffield and one in Rotherham. I spend a lot of my time on that programme. Not just for those four PCNs and how the findings might inform a future GP contract but also for the learning I can take to the rest of South Yorkshire. We’ve got over 30 PCNs across South Yorkshire and more than half of them were interested in applying for the programme.
VV: Obviously, it’s early days for the pilots, but what kind of things have they found so far?
AF: The first thing is getting much more usable data for transformation. In general, the visibility of actual demand and capacity data across primary care is quite poor and the indicators that we use for success are quite blunt. For example, the national primary care recovery plan focused on more appointments and, actually, this has to be about appropriate appointments.
So, a lot of the work in the first instance has been about better information and visibility of what’s going on within those PCNs and practices. The first few months have been time and motion studies for practices. It’s been quite labour intensive for them but already we’re starting to see some very interesting data in terms of capacity and demand. You can see that PCNs have it cracked in certain areas – whether it’s same-day access or continuity of care – but nobody’s got it all.
The second thing is the additional capacity. One of the reasons so many PCNs wanted to be involved in the programme was the offer of additional capacity. We’ve recruited quite a lot of people to those PCNs as part of this programme. So, when you talk about recruitment and retention into primary care, there is a want to work for good organisations in the sector.
The third thing is group interventions. The programme strives to do things together. Continuity of care is coming out again and again as something that we need to facilitate. It’s not necessarily the old-fashioned way with a GP who’s got a list of people to see. It’s looking at the best use of the capacity for what’s needed by those particular patients. So, it’s continuity of teams, really.
VV: Has the ICB done any remodelling of primary care? Are there things that the ICB has stopped or changed?
AF: We’re in the midst of that at the moment because we’re embarking upon a review of local commissioned services. We’re learning from our colleagues in Humber and North Yorkshire who have a core offer across their geography and then, for any that are particular to Places, evaluating them and seeing whether they’re still fit for purpose. We’re going to take a similar approach here in South Yorkshire.
In some ways, I advocate removing some of the ringfencing of monies because the short-term nature of non-recurrent monies means that I have the same conversation year-on-year about whether or not something can continue. Things like digital funding need recurrent funding to embed and be used well. We need to be a lot more sustainable and robust about what that funding is going to look like for the next three to five years.
At South Yorkshire ICB, we’re talking about having a proper prioritisation framework against the whole gamut of transformational funding. That means it’s directed at our main aims and objectives.
VV: How’s the primary care workforce in South Yorkshire? What have been the positives and negatives around ARRS?
AF: We commissioned our workforce hub to do an evaluation of the ARRS roles.
In my opinion, ARRS has improved patient access and primary care capacity. But there are more opportunities to impact wider, multidisciplinary team working.
We need to look at how GP capacity for supervision can be maintained to improve multi-professional working, and we always need to work on the ARRS roles being seen as part of the team.
There’s still work to be done on consistent job descriptions, terms and conditions, salaries etc. because, at the minute, some of our better practices are inevitably more likely to recruit to ARRS roles than others.
And there’s still communication to be done with the public around ARRS roles, particularly physician associates, for example.
VV: Where do you want primary care in South Yorkshire to be in five years?
AF: Primary and community care will be at the beginning of any ICB strategy and operating response. If we’re going to shift fundamentally, then it needs to be right at the beginning of all our conversations.
The second thing is that we would have facilitated a genuine resource shift through the mechanisms we’ve got. That would mean that more resources would be in primary and community care, which would have meant some shift away from our secondary care providers. And we’ll be able to show the impact of that.
Thirdly, I would like to see real tangible benefits of integrated neighbourhood working so that our residents can tell us that they feel their care is a lot more joined-up across our partnership than five years previous.
The final one is much more digitally enabled care in our communities. For example, today in Doncaster, there are over 100 people on virtual wards who would have been in hospital. I’d like to see a lot more digitally enabled care in primary and community settings that facilitate people being cared for in the most appropriate fashion.
