Networks blog: Three for the price of one

It’s not a model of care; it’s three

There’s quite a bit of discussion at the moment about a new model of care for general practice.

But the discussion around these “models” tends to be around all-encompassing concepts and organisational forms:

Integrated neighbourhood teams

Primary care networks (PCNs)

Neighbourhood health

Helpful enablers for sure.

And sometimes the focus is on new roles (ARRS):

Clinical pharmacists

First contact physiotherapists

Mental health workers

Physician associates

Care coordinators

All game-changing in my fortunate experience.

But it’s not where we need to start.

Don’t start with the Who or the How; start with the What!

So, what do we do in general practice. Well, we do a lot! But I boil it down to three big important, and critically very different, areas (models)of care:

1. Acute care/ same day demand – we quickly (hopefully), compassionately and holistically assess and support people who have a new health concern or an exacerbation of an existing health problem. And we generally do it very well and extremely cost effectively. GPs are pivotal to this work.
2. Ongoing care for chronic conditions – we support people with long term conditions (one or more) with their medicine, their monitoring and the emotional and social impact of these conditions, for them and their families. We help prevent complications of these conditions (secondary prevention). Nurses and clinical pharmacists are key here.
3. Primary prevention – we are pivotal to the universal childhood and adult immunisation programmes as well as targeted immunisation programmes for at risk groups. We demonstrated in Covid just how good we are at this. We hold the population registered list, we are trusted, persistent and adaptive. We also provide or support screening programmes and help people to address unhealthy lifestyles, especially opportunistically through brief advice and referral for support.

These are the three Whats, the three models of care which need a clear head to think about how we currently address those challenges and what these three new models of care might look like. Only then can we start to think about how new roles and new organisational forms might enable those changes to take place.

Let’s take time to consider how we currently meet those challenges and how we might in the future, for the benefit of our communities, our patients and ourselves.

The table sets out our three models of care and how they are currently delivered and how they might be delivered in the future.  This is just a suggestion, there can be flexibility and it’s about working with local clinicians in neighbourhoods to find the best future way of delivering services in their area. The table highlights just how different the work is across the three areas and also how different the future might be, using different skills, different people (especially the patient), different tools (especially data and technology) and how the future could be better for everyone, including the workforce.

It requires a more nuanced view of the work of general practice, a “division of labour” as Adam Smith would have said, and a letting go of the mindset that that a GP must do a bit of everything and that all GPs must do the same. Whilst I understand this mindset and the good intentions, this has held general practice back in my opinion. I recognise that people in training need to do a bit of everything and many GPs and other clinical and non-clinical people would like to work across these domains, it doesn’t mean everyone needs to do so.  It’s about tailoring so the division of labour is right for your neighbourhood. However, I think it is important that these areas of work/ teams have consistent leadership.

Each model of care will need its own multidisciplinary team, its own pathways, leadership and ways of working, with the precise skill mix required to deliver its very specific care model.

And whilst I have purposely kept these three suggested models of care universal it is likely that for people with complex needs (and often high care utilisation across all care sectors – about 7% of the population consuming around half all hospital costs) there needs to be a team which delivers all the three care models together. This team needs extremely high levels of continuity of care, a highly personalised, holistic, proactive and anticipatory model preventing avoidable deterioration and inappropriate escalation, also known as tertiary prevention. It is here where the multidisciplinary team is likely to be made up of people from across different organisations including specialists, community and mental health teams, hospices etc. The population coverage for this cohort might be more than a single practice, a PCN or integrated neighbourhood team. Now we have thought about scope we can consider scale.  Scale will be different in different places it’s about working with local clinicians and designing what is right for the population and plays to the strengths of the clinicians in the area.

For the universal teams, for acute care and ongoing care models of care, there needs to be really easy, sometimes near real time, remote access to specialist advice and support and rapid access to diagnostic testing and monitoring. This is often not available in my experience, especially for the subspecialities like neurology and rheumatology.

So a lot of thinking and work needs to be done.

But if we try and think about a single model of care we will fail.

Three is a good number to start with.

It’s all very doable.

Dr Steven Laitner, GP, health consultant and PCC associate

We would be delighted to work with local areas to design future models of care that build on your local strengths.

NHS England’s Neighbourhood Health guidance provides further clarity that primary and community healthcare, together with its partners is critical to the government’s ambitions for the NHS. Without a focussed, reformed, and integrated neighbourhood health delivery system the NHS will not be able to achieve its three strategic shifts towards community care, digital care and prevention. Primary care has always been the NHS’ greatest assets in these areas and often the first to innovate in new delivery models.  Its time to get ahead and for primary care to lead. We can help you understand your population, design new care models and ensure you have the leadership and engagement in place to make it happen.

If you like an informal chat contact enquiries@pcc-cic.org.uk.