Federations one option in the Nuffield Trust/King’s Fund report on the future of primary care

To inform the challenges facing primary care

Nuffield Trust/King’s Fund, 18 July 2013

To inform the challenges facing primary care, the former Midlands and East SHA (now NHS England Midlands and East) commissioned the Nuffield Trust and The King’s Fund to undertake a review of UK and international models of primary care, focusing on those that could increase capacity and help primary care meet the pressures it faces. While the focus of the report is on general practice, it has implications for the whole of primary care.

The report begins by examining the pressures on primary care, such as shifting care into the community and out-of-hours provision, while also noting the current general practice workforce has insufficient capacity. Furthermore, any changes to primary care provision have to be made in the context of a new NHS regulatory framework that requires evidence of appropriate contestability. This combination of factors has led to a debate about the changes needed to ensure that primary care will be sustainable for the future.  The authors believe GPs and their teams are ”caught on a treadmill of trying to meet presenting demand whilst lacking time to reflect on how they provide and organise care”.

In order to identify the characteristics of high quality care, the authors review a selection of frameworks, adapting the USA’s ‘Patient Centered Medical Home’ for the UK context. The report explores 21 different models of primary care organisations in both the UK and abroad, covering 12 different organisational types. Analysis was undertaken to identify those which have the greatest potential to enable high-quality provision. Four models were selected as a result of their ability to offer an extended range of services, including local and rapid access to specialist advice, population health management to address inequalities and new forms of care for those with multi-morbidities. They were:

Networks or federations – A concept developed by the RCGP, federations or networks are an ‘association’ of practices that come together to share responsibility for a range of functions, most frequently for the purpose of developing service provision. The authors were struck by how the practices involved were able to use collaborative working for improving clinical services management. Financial incentives and commitments to stretching clinical targets have enabled practices to deliver new forms of long-term conditions care and support public health priorities.

Super- partnerships – A large-scale, multiple-site single partnership structure. One in seven patients in England is now registered with a practice of ten or more doctors. Practices often choose to merge in order to offer a wider range of services, career development opportunities and enhanced clinical governance.

Regional and national multi-practice organisations – This model tends to rely on salaried clinicians rather than partners to lead practice sites and other services, with staff supported by a centralised leadership team and infrastructure providing HR and information management. The appointment of an executive team is felt to be a strong level for remaining competitive and enabling efficient responses to tenders without any adverse impact on GP workload.

Community health organisations – These combine patient-centredness with population-orientation and often have an ownership model that emphasises public and community involvement. This model seeks to develop extended services, often to underserved areas or to suit specific local challenges. Many aspects of provision and organisational arrangements are similar to the other models, notwithstanding the different philosophical underpinning.

The report goes on to propose twelve design principles that should be applied when reviewing and redesigning primary care provision, which include:

• Entry to the system – a senior clinician, capable of making decisions about the correct course of action, is available to patients as early in the process as possible.
• Continuity and access – patients are offered continuity of relationship where this is important, and access at the right time when it is required.
• Making the most of the multidisciplinary team – primary care is delivered by a multidisciplinary team in which full use is made of all the team members, and the form of the clinical encounter is tailored to the need of the patient.
• Patient records – there is a single electronic patient record that is accessible by relevant organisations and can be read and, perhaps in future be added to, by the patient.

The report highlights the importance of sustained clinical and managerial leadership in the development of larger networked primary care organisations. The authors argue that reliance on a ‘heroic’ model of leadership where an individual drives the development of an organisation will no longer suffice in a context of more complex primary care organisations and a majority of part-time and sessional GPs. Instead, sustainable GP leadership for the future requires an approach that regards leadership as being distributed across different levels of the organisation.

Recommendations

• The report calls on NHS England to work with CCGs, patient groups and professional bodies to create a national framework for primary care.
• A new alternative contract for primary care is required, in parallel to the current general medical services contract, setting objectives and parameters, but not specifying details of local implementation. The contract should encourage groups of practices to assume collective responsibility for population health (and ideally also social) care.
• An alternative or intermediate approach to a new contract for primary care is for CCGs to be given a mandate to commission  additional services from general practice and other providers. This would be another way of encouraging the formation and extension of primary care federations and networks, with groups of practices bidding to provide services in accordance with the design principles proposed.
• There is a need to think carefully about how services such as pharmacy, dentistry and optometry can play a full part within new primary care organisations or networks.
• In developing guidance, Monitor needs to examine carefully the experience and potential of the four models discussed, in order that the benefits of ‘at scale’ primary care are not compromised by concern about limits to choice and competition of practices working in more collaborative ways.