Role of integrated care boards to enhance primary care
My recent blog advocated a non structural NHS reform. Healthcare must be primarily at the centre of a social policy focused on communities and their individual citizens. In short a primary care led NHS – often touted but never delivered. If government does not commit, individual integrated care boards could commit to rescue a failing NHS.
Primary care can seize and be enabled to seize this opportunity? For momentum, I advocate a primary care triple aim – a title ‘borrowed’.
- Increase the range and scope of primary and community services whilst addressing quality issues and ‘unwarranted variation’
- To reshape hospital service
- To have a lead role in health and wellbeing by developing a public health for primary care.
Primary care being the only NHS service that can achieve the entire aim by combining personal care with population responsibility. Academic evaluation- ‘The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus. Primary-care physicians do at least as well as specialists in caring for specific common diseases, and they do better overall when the measures of quality are generic’. And ‘first contact, accessibility, co-ordination, comprehensiveness, and continuity are the enduring strengths of primary health care’.
Primary care when supported has also delivered on the wider aims.
Reshaping hospital care
Many current hospital-based services can optimally be provided in primary care personally or digitally; a radical diminution of outpatient services- a relic of yesteryear medicine; Comprehensive long term conditions care with a specific focus on those patients with multiple conditions (co-morbidity)- a cause of health inequity fragmented by specialist care. Care that can lessen admissions or shorten lengths of stay; Elective procedures integrated by primary care working in partnership with secondary care
The health of the public
General practice and pharmacy a part of local social capital. ‘Personal health services have a relatively greater impact on severity (including death) than on incidence. As inequities in severity of health problems (including disability, death, and co-morbidity) are even greater than are inequities in incidence of health problems, appropriate health services have a major role to play in reducing inequities in health’ The public health contribution of mainstream population based general practice is manifest – prevention advice, early diagnosis and treatment, vaccination and immunisation, cervical cytology screening, and long-term conditions care. The individual clinical consultation offers further opportunities to improve health – ‘make every contact count’. Community pharmacy is increasingly a welcome contributor. A local approach to the health of the public must be developed in and shaped by primary care. It is clear as for the Primary Care Home model, a predecessor to primary care networks, that primary care cannot wait for others to lead. Population health is ‘a logical extension to the strong generalist tradition within general practice. GPs and primary care staff are embedded in the community and well-placed to make the most of their knowledge of patients and the factors affecting their health’. I concur with the spirit of the statement but worry about the Orwellian undertones of managing the population. I am a strong advocate of community oriented integrated practice (COIP) involving citizens as co-producers of their health. Digitisation will transform clinical practice; learning health systems to obviate the need for some specialist referral; to receive early warning of even small populations who are at current or future health risk; and for patients the requisite knowledge and thereby confidence to co-produce their care. Locus of control confers health, too often clinical authority prefers patients as grateful supplicant.
Primary Care Networks
Being non-statutory offers hope of an enabling non-hierarchical role. The constituent community-based partners must have equal status to PCN management and together comprise the very embodiment of an optimal primary care system, clinical entities for localness, PCN level to provide support to constituent practices, supra practice services and importantly of a population size circa 50k to ensure primary care a presence at senior levels of the NHS and beyond. A harbinger of a shift in NHS culture? If we are serious about a renaissance of the NHS, we must major on relationship building to create enthusiasm, energy, and indeed excitement. In the world of healthcare, it is astounding how infrequently care services major on relationships, preferring to major on contracts compliance. Of course, contracts are necessary but not to set the abiding culture. Complexity such as paradoxes, dichotomies, downright disagreement and ‘the wicked problems’ are optimally managed locally.
A major new research project has found that the public wants the government to focus more on improving primary and community care than hospitals and is willing to pay more taxes to improve NHS services’ (Health Foundation May 2024). Primary care- well worth the investment for a more cost effective quality improving NHS and ideally placed to work closely with health enhancing local authorities to serve local communities.
Professor David Colin-Thomé, is chair of PCC, a not-for-profit community interest company that provides expert support to commissioners and providers of primary care. Contact enquiries@pcc-cic.org.uk to discuss how we can support you or visit www.pcc-cic.org.uk.