How integrated care systems can support primary care integration

Background

In November 2021, the chief executive of NHS England and NHS Improvement, Amanda Pritchard, asked ICS leader and GP Dr Claire Fuller, to conduct a national stocktake to understand how newly formed ICSs could support primary care integration. The final report from the stocktake aims to provide clear next steps for primary care integration and a vision for the future of primary care. It will also set out practical actions for ICS leaders, informed by working examples already taking place across the country.

By representing both primary care providers and integrated care systems, we have been uniquely placed to inform the final report and will support members with the implementation of its recommendation

Our members, across primary care and ICSs, have been actively involved in the stocktake, helping to build a vision for a more integrated primary care system that works for everyone.

By representing both primary care providers and integrated care systems, we have been uniquely placed to inform the final report and will support members with the implementation of its recommendations. Over recent months we have hosted events to enable members to share their views and showcase what they are already doing locally to improve patient outcomes across the breadth of primary care.  

This report captures key insights from our engagement with primary care members. It reflects the significant pressure on primary care, the need and appetite for change, and the key role that integrated care systems can play in improving population health outcomes, prevention and reducing health inequalities. Through our engagement we identified three overarching principles that are core to the future vision for primary care within integrated care systems. We also found six priority areas, aligned to the principles, that our primary care members believe ICS leaders could focus on now to best support primary care on the journey to improve patient outcomes.

It is important that Dr Claire Fuller’s report, informed by such large-scale engagement, and the actions that follow, bring people together under a shared vision for primary care, and provides clear direction for how system and national leaders can support primary care to go on this journey. As NHS Confederation chief executive Matthew Taylor wrote in a recent blog on the subject: “The question is not so much about the destination as the route there and what will be needed to sustain the journey.” We hope the core principles and priorities from our engagement are reflected in the final report.

The current state of primary care

Primary care has played a crucial role in the last two years of the pandemic, including working at scale and collaboratively to drive the biggest vaccination programme we have ever seen. As the immediate COVID-19 pressures ease and more patients come forward, primary care continues to support its local communities with the latest figures showing that its teams carried out over 30 million appointments in March, including 0.4 million COVID-19 vaccinations. This is far more than the 25.4 million appointments reported for February 2022 and far more than in the same month in the previous two years. It comes as the workforce faces significant shortages with the NHS, having lost nearly 1,500 GPs over the last eight years.

Significant demand ¹ and a gap in capacity are causing frustrations for patients and for the primary care workforce. This is has resulted in workforce burnout and falling patient satisfaction levels. Significant variation in the primary care offer across the country regularly results in those most in need not receiving the care they require and adversely affecting the most deprived areas ² . This is all exacerbated by the COVID-19 backlog and a sense of endless top-down demands.

If primary care is to be ambitious, solution-focused and take advantage of its unique role in local communities, it needs to be enabled to step off the demand and capacity ‘hamster wheel’

Primary care has continually risen to new challenges and, as the front door to the NHS, is equipped with the skills and local expertise to respond and mobilise quickly for its local populations when supported and resourced to do so.  While there are countless examples where primary care has harnessed its unique position to drive population health improvements, target care to those most in need, build services around patients using local assets and economies of scale, there is undoubtably more support needed to encourage and enable this type of work.

If primary care is to be ambitious, solution-focused and take advantage of its unique role in local communities, it needs to be enabled to step off the demand and capacity ‘hamster wheel.’ This would enable it to work in a more integrated way at neighbourhood, place and system levels to make the most of system resource and expertise; build a shared focus on population health; and help shape local health and care services around the patient.  

Key principles for a vision for primary care

From our engagement with primary care members, three overarching principles stood out and need to form a golden thread throughout the stocktake report. They are central to the future vision for primary care within integrated care systems.

Understand primary care is core to system success

Integrating primary care in systems is not a ‘nice to do’ but essential if ICSs are to meet their four fundamental purposes.

In our recent report on the progress of integrated care systems, interviews with primary care leaders highlighted that in many areas there is uncertainty about how the experiences and insights of those leading primary care services at neighbourhood level inform system-level planning and strategy. Primary care is fundamental to integrated care systems: it is a core source of intelligence and expertise to inform system-wide strategies for prevention, secondary prevention, anticipatory and virtual care to improve population health and reduce health inequalities.

To prevent this being viewed as additions to a long list of expectations on ICS leaders, the Stocktake report will need to emphasise primary care’s role in ICSs delivering their four core functions and reflect other ongoing reform, including the integration white paper, Messenger review of leadership, and the NHS Long Term Plan refresh.

Enable primary care to drive change

Primary care should be encouraged to change at neighbourhood and place with autonomy and accountability enabled by ICSs. We know that many in primary care are driving local service improvements by working creatively with others across neighbourhood and place, but we heard that top-down prescriptive expectations and requirements can limit and disincentivise this activity.

Despite local-level ambition and expertise being core to population health improvements, there is often not the right national and system incentives and support to allow this to flourish. While funding and contracts are not in the scope of this stocktake, it would be remiss not to reflect our members’ views on the role they can both play in primary care improvements and leadership. This is not just about general practice. We often hear that many of the current contracts across primary care deter innovation, increase siloed working and result in increased national expectations with reduced funding.

The report should focus on identifying national and system barriers to locally led improvements and understand what can be done to remove them.

Recognise the investment and different levers needed for change

As mentioned above, there are significant changes already taking place across the health and care system. If previous reforms have taught us anything, it is that too often inadequate time and investment are given to embed change at all levels of a system. Change needs to be driven from all levels if it is to be effective: top-down (strategy, resources), lateral (culture, values professional ownership) and bottom-up (individual aspirations, responsiveness to patients/citizens).

The stocktake report will need to recognise the investment needed in the short and medium term and the role of different levers for change to deliver a long-term shift to proactive integrated care that works for local people, both staff and patients.

How ICSs can support integrated primary care

With these core principles in mind, we asked our members what ICSs should be focusing on now to support primary care to be more integrate more effectively, lead health improvements locally and help deliver the core functions of integrated care systems. Six key issues were identified:

1. An in-depth understanding of population needs

A core part of primary care must continue to be its role as first point of access to health and care services. Increasingly, primary care is facing demand that exceeds local capacity, with episodic care often taking up a considerable amount of GP time. Demographic shifts and demand increases require systems to focus more on preventative healthcare, not simply managing illness. Service planning must be informed by differing needs of patients if it is to be proactive and take advantage of the full primary care offer.  

Primary care, the voluntary sector and community providers are rich with knowledge of the communities they serve, but we heard that there is not the capacity, capability and resource at practice and neighbourhood level to translate this for service planning. Primary care should be able to draw down on expertise and skills at a greater scale to analyse and interpret data to inform service planning and population health management at all levels. ICS leaders will want to make clear what system-level expertise is available and how primary care can maximise this capability.

2. Care that is built around the individual and local communities

If integrated care systems are to improve the health of their local populations, they must start with the individual. Systems need to build out from the community, developing services and a workforce that work for local people and prioritise reducing health inequities within and between communities. This may seem simple but too often when new systems develop with a focus on form over function, it results in a top-down pyramid of governance that is very distant from the people it aims to serve.

General practice plays a huge part in delivering care in the community, but so does wider primary care and other key community assets, including the voluntary sector and community providers. More can be done by systems to optimise this wider offer. This is particularly important for patients with complex care needs where dedicated relationships with health and care service professionals can play a huge part in their care pathway.

ICS leaders can use their relationships and expertise to encourage greater collaboration between all these teams at a neighbourhood and place level, to empower local communities to build services that wrap services around local people, in their local community.

So that the right care can be prioritised at neighbourhood level, ICS leaders should work with primary care to identify service that could be delivered at a larger scale through GP federations, networks of networks and other at-scale providers.

3. Maximising the value of the full primary care workforce

Many of the fundamental issues creating workforce pressures in primary care are currently out of integrated care systems’ control and require national contract changes and investment. Nevertheless, we heard of innovative ways that primary care is sharing workforce, using the expertise of all pillars of primary care across neighbourhood and place; upskilling their current workforce informed by workforce planning tools; growing their non-medical workforce and recruiting new staff, including through the Additional Roles Reimbursement Scheme, based on understanding of local need.

ICS leaders will want to support this by building system-wide understanding of staffing capacity and expertise, informed by local care needs, so that staff can be deployed to areas that need it most, prioritising community-based care. This will also help focus training programmes for the primary care workforce on what is most needed for a local community. Supporting training opportunities for medical and non-medical staff not only builds expertise but improves workplace satisfaction and improves the primary care career pipeline.

4. A sustainable primary care infrastructure that can optimise resource, capacity and capability

Unlike their secondary care partners, many GP practices and PCNs do not have the infrastructure and management support for operational development, core back-office functions and relationship nurturing that can be central to sharing resource and improving models of service. Often primary care staff are expected to do this outside of their usual working hours.

By having an infrastructure that works above neighbourhood level, primary care can share core resources, such as estates and workforce. This can also improve capacity in other parts of the system.  We heard that other providers often find it difficult and time-consuming to engage with primary care because of the multiple providers involved. At-scale primary care infrastructure can offer a collective voice that can be accountable to its respective parts and reduce vacuums in the system between general practice and system level.  GP federations, networks of networks and other provider vehicles are already using their scale to build these structures around PCNs. Integrated care systems should encourage and invest in these infrastructures for primary care and help build them where they don’t already exist.

5. Cooperation and integration between primary care, secondary care and other local partners under a shared goal of improving local health outcomes

We heard repeatedly that the relationship between secondary care and primary care needs to improve. Failure demand across the system is often fuelled by poor information flow between different parts of the system and this perpetuates a lack of understanding of how services work across providers and inevitable frustration for patients and staff. Where primary care and secondary care have worked together to improve a specific service, we heard that care pathways improve and resource and capacity are better distributed to where it is most needed. For many, these collaborations were successful, not because of formalised structures, but because time was dedicated to building relationships and a shared set of goals, helping create a culture shift away from competition between providers.

ICSs can create the environment that enables and encourages this culture shift. We heard that giving primary care ‘a seat at the table’ when key system decisions are made can help to make this shift by building a shared understanding of what is happening across different providers and a united responsibility for local health outcomes.

On a practical level, vertical collaboration has often been difficult when different systems do not talk to each other. Building interoperability and data-sharing agreements between system providers can enable these relationships to grow and improve information flow. By investing in this at a system level, all providers can benefit and reduce duplication of efforts.

6. A strategic commitment to investment in long-term population health improvements informed by primary care

We have reflected throughout this report the need to shift from reactive to proactive care. But to really deliver the core functions of integrated care systems and improve the primary care offer, this needs to go beyond understanding demand. Integrated care systems should be ambitious about long-term population health improvements and build plans and strategies that reflect that ambition.

Through our engagement we heard of innovative projects already in development that aim to have long- term benefits for local people, including:

• data collection now that will inform person-centred, technology-driven care solutions in the future
• investment in non-medical solutions to care by improving non-medical career pathways
• building estates that house multiple community services to support the wider determinants of health
• working with local education providers to build training packages for young people so the future workforce is rooted in local communities.

As a core part of communities, primary care is well versed in what impacts local health. The qualitative and quantitative information within neighbourhoods will be essential to build ambitious plans to improve population health across the system. As PCNs are the building blocks to integrated care systems, ICS leaders can ensure there is a strong and representative role for primary care at all levels. This will require ICSs to help develop the primary care leadership pipeline, offer recurrent funding streams to allow year-on-year investment and support for innovative local projects so there is the expertise, ideas and local drive to inform ambitious planning across the whole system.

What’s next?

Any recommendations that come out of the report, whether relatively unsurprising or bold, should be clear and aid ICS leaders on their improvement journey to support integrated primary care

The key test of the report’s success will be through its implementation locally. Any recommendations that come out of the report, whether relatively unsurprising or bold, should be clear and aid ICS leaders on their improvement journey to support integrated primary care. Effective change management requires a top-down, lateral, and bottom-up commitment to the intended goal. It will be important that ICS leaders are supported to deliver these recommendations but also are locally accountable to deliver improvements.

We will be supporting our members to understand what the final report means for them, with on-the-day briefings, a bank of case studies modelling some of the recommendations, a webinar to unpick key issues from the report and a session with Dr Claire Fuller at NHS ConfedExpo. Going forward, we hope this report is not viewed as a ‘quick fix’ for primary care but the first step on the journey to supporting and improving regenerative integrated primary care. We will ensure we use our unique position as hosts of networks for ICS and primary care to support our members as they navigate the task ahead.