Fiona Adamson: We are well placed to innovate, but we need courage and experience

Matthew Taylor

Hello. Despite the Herculean efforts and massive sacrifices of Covid and the success of the vaccination programme, a concerted critique of the NHS seems to be building up in certain quarters. One newspaper that's in the past criticised the health service for failing to modernise, is attacking GPs for promoting digital consultations.

Another describes the NHS funding needs as a bottomless pit, despite health spending per capita in the UK being below the average in similar countries. Joining the predictable critiques of NHS managers, The Daily Telegraph has expressed astonishment that more than half of NHS staff are not medically qualified. Today, on Health on the Line, I'm speaking with an NHS leader who supports the work of GPs, who's been at the forefront of local efforts to promote vaccination and to deal with ever-growing demands. How does she see the challenges facing primary care now and in the future?

So, I'm delighted to be joined by Fiona Adamson who’s chief executive of Hartlepool and Stockton Health GP Federation, and also co-chair of the NHS Confederation's Primary Care Federation Network. So, Fiona, welcome. How are you?

Fiona Adamson

I'm very good. Thank you. Thank you very much for having me.

Matthew Taylor

It's a great pleasure. Now, as a newcomer to the health service, I have to say I'd not heard of federations, primary care federations or GP federations, there sometimes. So, tell me what they do?

Fiona Adamson

Yeah, so I seem to spend quite a large part of my life explaining GP federations, and I was a newcomer to the health service about five years ago, may even be longer. So, in order to sort of describe the jigsaw of primary care and healthcare, I always start with us, as individuals. So, I think health should start with us. I'm not a great example of that, but we should be looking after ourselves and then if we can't look after ourselves anymore, we tend to go to our GP. And we all know our GP, they're on the, you know, the corner of many streets in many communities.

And as a society, we've, I think become quite medicalised. So, we expect our GP to give us a pill. And if that can't happen, then we turn up at our hospital. And I think you find a federation somewhere in between those things. So, our GP will get to know us, we hope, that will provide that continuity of care that people with lots of healthcare conditions need, and outcomes are better.

All research shows outcomes are better when a GP or a nurse knows someone with long-terms conditions. So, if you then come up to the new world of primary care networks... they came along after federations and they fit in between our practice and our federation. So, I love the idea of a primary care network. A group of GP practices and other healthcare providers in their community, really getting to know the neighbourhood and being able to provide things that actually, you know, where I'm sitting in Durham, what our neighborhood needs might be different to what one of the villages needs three miles outside of the city.

So, a real neighbourhood-type approach, but then actually above that, you don't want, for example, an urgent care service on every street corner, because you'd never find the staff, you wouldn't find the expertise and that's where you find a federation. So generally, we are groups of GP practices. Usually 15, 20, 30, 40 practices working together as a family under one umbrella and doing things at scale that can't be done individually or can't be done on a smaller footprint. So, we tend to be integrated into our local system, we know the council and we work with hospitals, and we really sort of try and fill that gap between general practice and hospitals.

Matthew Taylor

Tell me what can happen in Hartlepool and Stockton, because you've got a federation, that wouldn't happen if you didn't.

Fiona Adamson

Yeah, I think there are a couple of things that really spring to mind. One of which is very current at the moment, and that is about access. You will often find a federation providing seven-day access to general practice appointments. And by that I don't just mean GPs, but also nurses and those people who perhaps need daily nursing care, perhaps they have dressings that they need help with or something like that. So, you often find a federation providing that seven-day access. And the other thing that you find very often and quite growing, I think this element, is urgent care. So urgent care or same day acute care or lots of different names for that. And you find that, and in our instance, ours is open 24/7, that's not unusual. It's GP led, again, that's a real growing theme. Having that doctor on site enables you to do all sorts of things as a team of practitioners. And if you think about your sort of average practice, maybe 5,000 or 10,000 patients being looked after, you don't have enough staff to provide that 24/7, 365 days a year. So, by taking that pressure away from general practice, and operating at scale as a federation, then you enable them to do some of that continuity of care that I was talking about earlier.

Matthew Taylor

So, one of the things of course, that people outside the health service might find difficult to get their heads around is that primary care is a lot more than GPs. And that's the idea behind primary care networks and also behind federations really, isn't it? That you're trying to provide a much wider service. And in a sense, only use GPs when GPs are actually necessary?

Fiona Adamson

Yeah, and one of the things, one of the first messages that really struck home with me when I started working in healthcare was this idea that we're all more efficient and our populations are better looked after if everyone operates at the top of their skill set. So, if you have a GP really getting to grips with those difficult diagnosis, those perhaps complex patients, and actually, you have not just clinically trained people nowadays, but actually you have people who are real specialists in the system. So, if you're an older person perhaps living on your own and you have a lot going on both medically and non-medically, perhaps with your house or your benefits, we operate in a complex world and it's quite difficult to navigate that system. And so, round GP practices and primary care networks and federations, actually, you often find people like social prescribers or care coordinators, and these people can almost hold the hand of patients and help them navigate the system. And I think you could apply that to pharmacy teams and pharmacy technicians. I often say much to the dismay of GPs that actually a GP isn't necessarily an expert in medicine and drugs. You want a pharmacist, actually, who, if something isn't available or something isn't working quite right, you want a pharmacist who really specialises in that to say, well, have you tried this? Have you tried that? So, this idea that everyone has a valued specialism that they can bring to the table. And I'm sure we'd all love more GPs, but actually, we're not going to have more GPS in the next five or ten years in all likelihood, so we've got to all operate together as a team.

Matthew Taylor

I want to talk more about the future of primary care, Fiona, but before we do, I think the federation, your federation, played a major role in the vaccination programme as well. So, tell me about that experience.

Fiona Adamson

Well, actually again, I would say sort of up and down the land federations were quietly, in the background, doing things like, for example, mobilising really quickly. So, federations were mobilising vaccination services. If you and I were talking 18 months ago and someone told us that there would even be a vaccine that would be effective against Covid, we'd probably have been dancing a jig.

When the news came along that the vaccine was available, we got it really quickly. And I think that's where a federation can do something, again, once, interpret the guidance, look at the safety aspects, put together a model, and mobilise that really quickly. But other federations were doing things like sourcing the right staff and making sure that they were recruited and they were trained.

I loved watching, for example, the bus in Bolton. Anyone on Twitter can't have missed the bus in Bolton, and that was one of the real forerunners, no pun intended, of taking vaccinations out to communities. And again, we had a great time doing that in Hartlepool and Stockton, and we worked really closely with some of our local mosques. They really opened their doors to the whole community. And then we started working with our local authorities and some of the voluntary sector, who really know those communities who have really specific needs and can get overlooked. So, we went out to homeless shelters.

We had one memorable day when we had a great number of people turn up, but one of them turned up on a horse and four of them turned up with their dog and one of them actually turned up with a snake around his neck! And you need a really good nursing workforce who will take all this in their stride and really help you to interact with communities.

Matthew Taylor

I don't suppose dealing with a snake is in anyone's job description, but one of the things about that is there's two sides to that aren’t there Fiona? On the one hand, although we talk about the NHS being there to provide a service on the basis of need, it's actually there to provide a service on the basis of demand. So, we respond to demand, not need, and they're not necessarily the same things, which is one of the debates we're having about waiting lists, people on the hidden waiting lists. But also, the vaccination programme taught us that if we do reach out and we are imaginative, we reach into the community, we can get to those people who might otherwise put things off, not want to address concerns they've got.

So, what are the lessons that we can derive from the vaccination programme for the wider challenge of addressing health inequalities?

Fiona Adamson

For me, it comes back to relationships, and I think that word covers all sorts of eventualities. So, by relationships, I mean being able to talk to the public health teams in the local authority, being able to then be pointed in the direction of those people who actually are influential in their local community. So, whether that's perhaps a Roma community, whether that is some of our local mosques. So just using relationships. And I think it'd be really easy to go back to our usual silos, particularly when we're all dealing with the demand that you've just described. And I think it's vitally important that we don't. Because actually, if you can use those local relationships and that trust that's been created between, not just individuals, but actually between organisations in a local footprint. Then if you can do that for vaccinations, why couldn't you do that for all sorts of other things?

I think the other thing is, it's amazing the speed that we can move at when we need to. And I think the vaccination programme was a perfect example of that. And I do think, and I may be slightly biased, federations are really well placed to innovate. And sometimes that needs a little bit of courage. Sometimes it needs experience, which often you find in a federation infrastructure. You find people who've come from all over with different experiences.

Matthew Taylor

Just tell me about your view of the kind of criticisms of GPs that we're hearing at the moment, and particularly in relation to the use of kind of digital appointments. I've spoken to a number of GPs in the last few days, and I think there's a real sense of almost despair about that kind of criticism and also it's now seeping into the behavior of some patients.

Fiona Adamson

Yes, it is. And it makes me really sad actually. And I think we do need to remember that it is a minority. And if you look at things like some of the latest surveys, for example, you'll see it's up in the mid-eighties, the number of patients who really rate their practice and their GP highly. GPs and nurses are always top of the tree when you look at the professions that the public trust. But actually when, if you're perhaps a receptionist on the end of a phone, and it never stops ringing and the next person's furious because they couldn't get through, that's really hard to remember.

So, I think the media coverage is unfortunate, to say the least, and rather unfair. I think fundamentally we need to remember that there is more demand for appointments. There are literally more people. But actually, there are less GPs and that's a really simple equation. And I think for every person who is angry that they can't get to see their GP face to face, there are other people like me, for example. I had a GP appointment last week and I probably wouldn't have been able to have it if it hadn't been online. So, if I can do that because it suits my lifestyle, hopefully I free up some time for other people who do need to be seen face to face. And I think there have obviously been moments when it's been difficult to see a GP during the pandemic, but there've been any number of other practices and federation services and primary care network services that actually have been open face to face the whole time.

And I think it's something about balance. But actually, when the workforce is really tired and remembering being clapped for on a Thursday night, it's sometimes quite difficult to put that in perspective.

Matthew Taylor

And I'm sure that you analyse the data about your patients and your population. And of course, one of the characteristics of that is that more than half of the people that you serve use the GP very occasionally. And one reassurance often is just to be told that the whatever ailment they've got, isn't something serious they need to worry about particularly. And those people, I suspect overwhelmingly, you know, someone like me, someone like you, would be very happy with a digital consultation.

And then you've got the other end of the spectrum. People who are coming to the GP surgery almost every week because they have multiple conditions. And sometimes that will be genuinely because they need to see a GP, but often it will also be, just be because they're lonely, because in the sense all their problems connect in one way or another. And as you say, people trust GPs, and the irony is because GPs are popular, everyone wants to see their GP, regardless of whether that's the right person to see. So that's part of the problem here, is that when we talk about what we want from GPs, people want very different kinds of things, don't they?

Fiona Adamson

The GP model, if you like, has changed very little over, probably decades. So that GP has probably eight or nine minutes to decide, you know, is this... well, at the moment... is this someone that I need to see face to face and if so, when can I do that? But also, is this someone who has something going on? Is this someone who actually, as you described... it's Mrs. Smith and she does like to keep in touch just for her own reassurance.

I think people are getting to understand, both clinical staff and patients, that there are lots of other things that can affect our health. So, if you go right back up and look at the World Health Organization’s definition of health, then it's not just the absence of disease, it's actually having a good social health, good mental health, etc.

And actually I could tell you a fantastic story from one of the first social prescribing projects that I was involved in. It was what brought me into healthcare. And we rolled this service out across 32 practices at once, which was quite a challenge, and it was brand new. It's about four or five years ago maybe. And GPs were quite skeptical. They were nervous that their patients would be passed on to someone who wouldn't necessarily know what to do with them.

But we persevered and we had some brilliant people that we recruited for their attitude and what they wanted to do to help people. And one of those skeptical GPs took me to one side after about nine months and said: "Do you know, Fiona? I thought that a couple of my patients had died." And I said, oh no, that's terrible. He said: "No, they haven't died. They just have been sorted out by the social prescriber." And what he meant was the prescriber had sort of re-engaged them with life. They'd found them a group that they could attend. They'd found them someone to come and help in the garden. I forget the details now, but the GP was absolutely astonished. He had these patients who appeared to be very needy, but actually were really happy to have had a different kind of help entirely. And that was a bit of a light bulb moment for me.

Matthew Taylor

Now I was in a conversation the other day and somebody used the phrase, but I'm interested in whether you agree this is the vision, but more importantly, how do we get there? So, what they said was that we all know what we want. What we want is horizontally-integrated, vertically-coordinated services, which are incentivised to improve population health and to prevent unnecessary demand.

Fiona Adamson

Where would we start? I think we are at a really pivotal moment. And I suppose from my point of view, I'm thinking about this in a sort of front door of health way. And also, starting with, which I think is always helpful in any system conversation, is to start with what patients would want and ask them.

So that's always a good starting point and it's not always easy to achieve. So, I do think that we need to create really good foundations, so that horizontal integration part. A lot of that is built on what I would call the front door of health, which is actually primary care, whether that's a pharmacy, a dentist, or a doctor. And I think that's something that many people in the system have struggled to get their heads around, have struggled to understand, how do you fix the front door of health? And if you think about 90 per cent or so of interactions will happen somewhere in primary care, then it would seem to be a really important thing to get right.

And I think, you know, coming down to general practice and how we're structured and how we respond to the ICS, there is a real opportunity in there to develop those relationships, I've talked about, to help people understand what happens, and help people understand the other roles and the other things that can be done for patients, whether they are clinical or non-clinical.

One of the answers lies in one of those words there, and that is ‘place’. I think place is generally of a size that perhaps matches a local authority, perhaps matches a federation and a group of primary care networks. And I think you can start to build relationships that break down some of those silos. I think you can start to communicate together to patients. I think you can start to talk to local people about what they want and need and what they perhaps struggle with. I mean, wouldn't it be amazing if primary care networks were all on first name terms with their local head teachers. And, you know, you can start to think about the wider impact on society of people in school, thinking about careers in health and social care, and local systems working together to provide the right training for existing staff and to recruit new.

So, it's almost daunting. There are so many places that you could start. But I think if you start, for example, with something like demand. If you start, for example, with something like local health inequalities, whether that's in the centre of Manchester or whether that's different in the centre of Bath, etc, etc.

And I think primary care needs to take some responsibility for engaging. So, I think this is a two-way street. We're quite often heads down concentrating on the next day or the next ten minutes. And actually if we can organise ourselves to do the right things at the right scale for the right patients, then you come back to this, everyone operating at the top of their skillset, patients understanding where to go for the right thing, people who will follow through and follow up and help people to navigate the system. So, you can see how it would all come together.

Matthew Taylor

So Fiona, tell me about how you do your job because you know, I've come into the health service from outside and I know I'm on a steep learning curve and I'm being highly deferential to everybody I meet who knows more about health, and even more deferential to people who actually provide health services.

But you have a kind of credibility challenge when you come from outside. Yet, when we look at primary care networks, for example, there are primary care networks that have ambition from the bottom-up in the sense that they really reach out into their communities. They're not satisfied with meeting demand. They want to understand about need. They want to connect with the voluntary sector and other services. Those same networks would also be ambitious in a kind of horizontal sense. They'll want to do more to add more services and there'll be ambitious looking up into the system and wanting to be players within that system. But a lot of primary care networks, for completely understandable reasons to do with the fact that they've got a pretty limited leadership capacity and are incredibly busy and that some of the incentives don't align with this, probably have a much, much more modest way of going about things, which is really kind of in the end meeting the demand that is placed in front of them and maximising their kind of activity levels.

How do you as an outsider, how do you persuade the GP practices that you engage with, to be as ambitious as they can be in terms of those three domains of reaching out into the community, widening the services they provide and seeking to be players within the local system?

Fiona Adamson

First of all, I think I understand that credibility piece. I am actually a banker by background and at one time that would make people boo! But I think lots of the things that I've learned in my career translate into healthcare because actually they are about clarity of purpose. They're about communicating regularly. They're about being honest and operating with integrity. They're about being authentic. And I think if you are looking at any organisation that is trying to achieve something worthwhile, that's what you want. So, I think the responsibility for people like me, for federations, for clinical commissioning groups now, and ICSs in the future, hospitals, all those large organisations that surround practices and networks. It's our responsibility to give them the space to develop. And that might be by doing practical things. So, that might be by taking away some of the workload that might be by providing literally more access for patients, or it might be by sharing expertise, it might be by taking away some of the administration. I would love to see a world where those smaller organisations were supported in the background with infrastructure like a hospital would be. So, recruitment and finance and perhaps some quality improvement work.

If we could really enable networks to do what they do best, to provide the right care and to talk to their patients who trust them and understand them. I think organisations like federations can be really influential in trying to create that space so that they get to do that innovation, they get to provide those extra services, they get to have the conversations about the pathways that perhaps sometimes go onto the back burner because the demand is so big. So, I do think it's a turning point. I do think ICSs have given us a bit of impetus and an opportunity to start to have those conversations.

But of course they do come at a difficult time because we're dealing with complex demand. We've still got an enormous vaccination programme on the go. Seventy-five per cent of which will probably be delivered somewhere in a GP practice near you. I do feel a sense of excitement. Certainly, it's a tough challenge.

Matthew Taylor

And I think people sometimes think that federations and primary care networks are alternatives or even in tension with each other. But what I hear is that for a lot of primary care networks, the clinical director role... it's overwhelming. People are finding it onerous. People are walking away from that responsibility because it's just too much.

So actually, I guess it would be your view, Fiona, that GP federations, by lifting some of that burden, by helping with the finances or the staffing or the management, can make primary care networks more viable than they are when there isn't another umbrella organisation to help out. Would that be your view?

Fiona Adamson

Yeah, that's definitely my view. And it's been very interesting working with the Confederation just to actually try and work out how many federations there are. So, it can be quite a lonely world as a GP federation, but actually we're discovering more and more federations. The things that I've learned since I became chair from other federations operating all over the place have been absolutely brilliant that I can then take that to the day job and use to help my practice members and PCN members. There is a lot of good work going on out there. Now not every area has a federation, but actually the majority certainly do. And many of those who don't, I think one of our jobs, as Confederation, and also as a general system, is to try and help them create those collaborative arrangements so that primary care can operate at scale. I think we need to enable those people who have the expertise to do what they do best. And I completely take your point about clinical directors being very much overwhelmed. They've become almost all things to all people. And I think we need to get away from that and let them do what they signed up for. Let them achieve things like have been achieved in Fleetwood, for example, which I find a really inspiring example of what networks can do.

Matthew Taylor

Well, Fiona it’s been fantastic talking with you. I'm looking forward to working with you in your role as co-chair of the Confederation's Primary Care Federation Network. Thanks for giving us your time.

Fiona Adamson

Thank you. Absolute pleasure.

Outro

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