The second in a series of interviews with primary care leaders, Dr Tracey Vell and Rob Bellingham talk to Healthcare Leader editor Victoria Vaughan about integrated working and the Greater Manchester primary care blueprint that has recently been published.
Victoria Vaughan (VV): Could you tell me about your roles at Greater Manchester ICB?
Dr Tracey Vell (TV): I’m a practising GP and chief officer of our primary care provider board, which brings together all four disciplines of primary care so we can co-produce strategy and make decisions more effectively in Greater Manchester. And I’m medical director at Health Innovation Manchester, which also dovetails in the transformation space.
Rob Bellingham (RB): I’m chief officer for population health and inequalities at NHS Greater Manchester. Amongst other things, it makes me the lead exec for primary care in the ICB.
It is significant that you’re interviewing myself and Tracey together. It’s deliberate that you rarely see us apart for sessions like this.
We have developed a close partnership between the provider and the commissioner; Tracey represents the primary care provider community, and I represent the ICB. We’re quite proud of that because it is quite unusual for providers and ICBs to work together that way.
It’s how we’ve done the primary care blueprint for Greater Manchester (see box) and it’s how we’ll implement it.
VV: How is care shifting into primary care in your area?
RB: The blueprint looks at that – in particular the chapter that talks about working as part of an integrated neighborhood team. That’s moving forward at a pace, and we can see that working particularly well across Greater Manchester (GM).
We describe the blueprint as a response to the integrated care partnership (ICP) strategy, which our ICP signed off in March. And, although we’ve still got some distance to go to make sure that primary care is absolutely everywhere it needs to be, it is in most, if not all rooms where decisions are taken.
That’s the only way that we’re going to deliver a shift towards primary care. We need to make sure that primary care is a partner in decisions not the recipient. We’ve been clear since day one, that the only way you can really engineer and facilitate change in the system is by working in partnership.
TV: I think the fact that he’s still involved when devolution occurred some eight years ago is a sign of the importance that we put on primary care and its consistency of leadership.
In terms of population health systems, there’s a lot of investment required in primary care. NHS England is lacking that vision because they talk about population health and inequalities, but actually don’t put the levers in place.
We’re hampered by the financial planning regime of NHS England because it doesn’t really correlate with the population health system that we have in GM. Everybody knows that you’re not going to really turn the dial on the shift to primary care fully in year and financial planning is a little bit more difficult for us when we’ve got a long-term vision that’s probably only visible in 10 years’ time.
VV: You’ve been working in this integrated space for quite some time. Over the past 18 months, what work have you been able to build on and move forward?
TV: One thing we’ve achieved that’s probably unique is working outside an NHS practice in retail units. Our PCNs set up in those units to reach hard-to-reach communities – people might just drop in when they’re shopping, but they wouldn’t normally darken the doors of GP practice.
We have retail premises in three localities out of the 10 and in our blueprint, it’s making every PCN operate once a month out of their NHS properties. Many are collocating with the voluntary sector, so it’s not just in retail.
RB: Dental access is something that we’ve implemented this year. Like other areas of the country, Greater Manchester has significant issues with regards to access to NHS dentistry. Thanks to a partnership with dental providers, we have developed a dental quality scheme, which sees us making access available to new and urgent patients within our GM dental practices.
This scheme formally launched in June and, by the end of September, we’d seen about 50,000 new patients who wouldn’t otherwise have been seen by an NHS dentist in that time and a similar number of urgent patients as well.
We don’t pretend that we’ve solved dental access in Greater Manchester, but we do believe we’ve done something that would have been impossible without collaboration and partnership with our dental colleagues.
Also, for the last three years, twice a week, we have been running the primary care system board as a collective place where we bring together the system. It started during the pandemic and we continued it.
It’s primary care providers from all four disciplines, people from the ICB, people representing the locality and so on, and we work together and solve problems. We take the joint approach that helped us get through the pandemic together.
Tracey and I also co-chair the strategic group so, again, we’re not doing that separately; it’s a joint endeavour. It means that when issues occur, we are working together with others to address them.
TV: Rob and I have achieved an inclusive way of working that is now being copied by other systems. We’re able to influence dispersed groups of providers and make them feel like they have a voice. And to me, that is probably the most important core achievement.
It means that we can fail fast. So, if we suggest some crackpot scheme, we can speak to providers and commissioners in the same room to ask if we can make it work. And our inclusive way of working means we can identify areas that need a little bit more project management from the team.
It’s also really good to centralise support. My team give a lot of support to providers on behalf of the ICB. It’s peer support which works better because it’s not a performance management stage. It’s about getting alongside, helping and encouraging.
And there’s the GP excellence programme, which is a scheme we set up with the RCGP at the start of devolution to use resilience money in a more directed way within our system. It does rescue, resilience, quality improvement, and being research-and-innovation ready. So, we’re not just rescuing practices; we’re also assisting highly evolved PCNs and practices.
It helps with quality improvement methodology and practical-on-the-ground help. For example, we have an employment HR specialist that we recruited centrally who helps with ARRS employees. Our HR worker helps with the knotty issues of risk, employment planning and how to manage those sorts of things.
VV: What about the interface between primary and secondary care? How’s that going?
TV: We’ve got lots of groups in our localities that are reinventing the liaison between clinicians in secondary and primary care, and there is an opening up of those relationships. There’s an infrastructure that means people can liaise more easily with secondary care.
Our medical director is leading that programme and we’re hoping to drag some services out of hospital and into primary care spaces. We’ve already started that and hope to go a bit further into that interface.
RB: The integration agenda is what Greater Manchester is all about. I’ve got a social care reform team reporting into me. It’s fully funded by local authorities, but sits within the ICB – I think that’s unique in England, actually. And you’ll see in the blueprint that we talk about primary care and public service reform – the connection to the voluntary community, social faith and social enterprise sector – so it’s integration beyond NHS and health.
So, when we were creating the primary care blueprint, we set up something called the primary care assembly, which was to mitigate against the risk of primary care talking to primary care about primary care. The primary care assembly brought the whole system into the room, all the way through the development process – so we had hospitals, ambulance service, social care, public health, voluntary sector, and the combined authority.
The thing that’s gratified me most is that when you go out and about in the system, people know about the primary care blueprint. So an elected politician – Andy Burnham or the mayor of Salford or another senior politician – will talk to you about the blueprint.
VV: In the blueprint, you suggest PCNs should identify patients as an actual measurable deliverable on the health inequalities agenda. Could you talk about that?
TV: A major issue is high intensity users and those with long term conditions who are particularly frail. They may be the same people, they may not be. But we want to alter access for them. We might colour code them, so they get differential access to practices and services. The MDT can wrap around particular cohorts of patients. It’s actually changing the model of care over the next five years.
First, we’ll identify them then stage two would be increasing investment. Some of that will be business planning where we could say, by year three, we will actually deliver a whole different service to those high intensity users.
The same applies to those who don’t darken the doors of general practice. We need to go out and deliver something different to make sure we’re in the prevention space. Prevention is the poor relation in the NHS but it’s the one that will blow up the NHS if don’t focus on it.
So, in five years’ time, you may see us delivering in different spaces with different teams that reach different issues.
VV: Obviously, last winter was dreadful. How are you approaching this winter?
RB: Centrally, we’ve taken some of our urgent and emergency care allocation as an integrated care system. And we are using some of that to support the establishment of at least one surge hub in each of our 10 localities.
We have specified what a surge hub is and what we expect to see and we’re using the same infrastructure in terms of data reporting and requirements and so on, but then we’ve passed the responsibility for delivering those search hubs to the local partnerships, i.e. through the local GP boards, and the locality system more generally.
We’ve also set aside money from central allocations to support the other disciplines to set up some winter schemes. All of those things are being put into place as we speak.
And some parts of Greater Manchester have found additional money from locality, urgent care allocations to support specific initiatives in primary care. I think most areas have got some provision in their locality allocation.
None of us can predict exactly what’s going to happen this winter, but we have to listen to the system as we move forward because we need to know what’s going on. We have a system that we use, year-round actually, but particularly in winter, and we have these twice weekly meetings with the primary care system group where we have those conversations.
So we have to listen and then we have to act. I think the opportunity that we’ve got through our partnership means that we can work together to hopefully provide support to the system when it struggles.