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Primary care homes explained

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By Angela Sharda
19 October 2017

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Dr Nav Chana, chair of the National Association of Primary Care, speaks to Angela Sharda about why we must develop an integrated, collaborative care system – and how the primary care home model can help

Dr Nav Chana has a plan to transform the health system with a revolutionary new way of delivering care in the community – namely, the primary care home (PCH) model.

Dr Nav Chana, chair of the National Association of Primary Care, speaks to Angela Sharda about why we must develop an integrated, collaborative care system – and how the primary care home model can help

Dr Nav Chana has a plan to transform the health system with a revolutionary new way of delivering care in the community – namely, the primary care home (PCH) model.

The brainchild of the National Association of Primary Care (NAPC), the association of which Dr Chana is chair, the PCH model is a new system to aid collaborative working between healthcare professionals.

In simple terms, PCHs aim to provide care to groups of between 30,000 and 50,000 patients in certain geographical locations. Care is provided by teams made up of healthcare professionals from primary, secondary and social care, and the aim is to eventually fund these teams with a certain amount of money for each patient they treat.

While the aims are easy to grasp in principle, they are more difficult to deliver in practice because of the lack of a single contract and budget for the multidisciplinary team. So Healthcare Leader’s deputy editor Angela Sharda sat down with Dr Chana to clarify exactly what a PCH is and how it could benefit patients.

How would you define a PCH?

It is a population-based model of care delivered by a collaboration of providers, focused on improving population health outcomes to support four characteristics.

These are: an integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care; a combined focus on personalisation of care with improvements in population health outcomes; aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards; and provision of care to a defined, registered population of between 30,000 and 50,000.

The PCH model features in the Five-Year Forward View over the next two years. What changes have emerged as a result?

One is what is happening locally within the alliance of providers in the PCH. Providers – GP practices, community pharmacies, community trusts and voluntary organisations – really help to bring a feeling of engagement of staff and people being looked after, thanks to a commitment to address the needs of individuals within the context of a population. We are seeing much better engagement between providers.

We are also seeing an improvement in morale. When GP practices start to work together in this way, it enables people to start thinking differently about the way they work. They are seeing a model of care emerging that enables them to focus on the right things at a local level.

Because their profile has been raised by the PCH, it is now being seen as part of the solution to developing integrated care solutions at clinical commissioning group (CCG) and sustainability and transformation plan (STP) level – as well as nationally.

How have PCHs improved patient care?

If we take a certain group of patients – those with frailty, say – many have a disconnected journey of care. A PCH prioritises the needs of these patients so they have a seamless journey. We have teams of people looking after patients. The patient is prioritised, rather than the needs of the organisation. We have much better connection between care professionals and agencies.

PCHs are starting to provide more care in a community setting. It is not just waiting for patients to fall ill and then doing things for them – it is about trying to engage our communities and patients. about joint production and building on what people can contribute, not just trying to design the response the healthcare professionals make.

Why do you think this model is needed?

It was developed as a consequence of the Five-Year Forward View, so it is a recognition that the NHS needs to change to work much more collaboratively to focus on improving population health. Ensuring satisfaction of care is about collaboration, as opposed to competition.

This model is an example of how you can build a local, integrated care system. The important thing is to keep it small. We have tried to focus on populations of 30,000 to 40,000: big enough to scale to a certain level, but not too big, keeping that sense of collectiveness with patients, that sense of belonging with care providers.

Do you think this will ease the pressure on the workforce?

This is not a solution to the fact there may be severe shortages in staff numbers in some specialties. It is important not to lose the focus that we need enough doctors and nurses to cope with the challenges of providing healthcare.

However, within our existing workforce, there are opportunities to encourage professionals to work together. If we can get clinical teams that already work across organisations to focus on the needs of a population, we will begin to see how those approaches can help solve the challenges people face. People will see the benefits, because a lot of time and energy is wasted at present in NHS bureaucracy.

In terms of workforce learning and happiness, what do you think people can learn from this model?

A lot of our primary care providers are really busy. People don’t have time to stand back and think about how they can respond to the workload facing them. If you start to work together in the way that we have been saying, it can create a bit of headspace; clinical teams can start thinking differently about how they provide care.

This leads to opportunities to build the right skill mix in your workforce, with doctors focusing on what they should be doing, supported by colleagues from nursing, allied health professions and management. Just creating that team-based feel of working collaboratively creates headroom and improves morale.

What were the main challenges you faced?

Imagine you have a group of GP practices that have not worked collaboratively before. Trying to encourage them to do so can be difficult. It is down to how you show people the benefits of that style of working. We have overcome this challenge because we have 191 sites. Being able to showcase the opportunities has been important.

We must not underestimate the number of people who are busy dealing with day-to-day demands. Sometimes a resource is needed at the local level to allow people to step back and think about how to engage with this sort of programme.

There are a lot of initiatives focused on primary care, some of them coming through the GP Forward View, some focused on improving access. This can cause a bit of confusion, particularly for clinical colleagues. One of the opportunities for us is to show that the PCH is a vehicle for many of these initiatives.

The other thing is the word being used. There are primary care networks, integrated systems and multispecialty community providers – what do these terms mean and how do they relate to each other? This is something we think about when we tell the PCH story.

What is your biggest achievement?

Spread. We are very proud that we have 191 sites and a population that is pretty big. It has happened over a short time frame. At a time when people feel that general practice does not want to engage with this sort of thing, it is reassuring to see that a large population, and our colleagues, do.

What are your development plans?

We are part of a broader conversation about how to spread integrated care initiatives. The programme is part of the new care models programme of NHS England. It is not a takeover. If people are interested, we can offer support, learning and connections.

But there are many similar initiatives and we should not be precious – it is important to focus the care model on what people need. The more we can get people working together, the more we will improve outcomes and cost-effectiveness.

However, we have a particular view of how to do this. Without the four characteristics, we do not think you can deliver this model. Sometimes people only focus on one or two. That doesn’t lead to an integrated care model.

How can PCHs help deliver the 44 STPs across England?

I have read some of these plans. By and large, there is a focus on improving population health outcomes and delivering integrated health care models. In many of them, there is a focus on localities or population sizes of the type we are talking about. We are saying: here is how 191 sites are doing it, here is a way you can do it.

How will PCHs operate in these systems?

That is a big question; I am not sure even the people writing the policy on this know the answers to some of it. An accountable care system (ACS), as I understand it, is a large, population-based group of commissioners or commissioner providers.

It is a commitment to focus on improving outcomes over a large area, moving towards an integrated budget. As the policy emerges, so will accountable policy organisations, also focusing on population health outcomes and taking responsibility for a budget under a contract to deliver those outcomes. Then there are PCHs, which are small-scale providers.

All these should be aligned across the system, whether at the level of the ACS, the accountable care organisation or the PCH. The PCH will form part of this architecture of accountable care, perhaps as part of an accountable care organisation within an ACS. We need to work through the engineering and policy around this.

What is in the pipeline for the next year?

We must consolidate some of the tools and resources the PCH sites need to become effective in the next 12 to 18 months. One is how to build your workforce model; we are developing an approach for how to do that. One of the key things is the rollout of our support programme and our ongoing discussions with STPs and ACSs to make sure we can bring the PCH to the solutions they are developing. The PCH should not be seen in isolation – it is about how it all connects with the system.

It is really important that the primary care model is based on the registered list of general practice – the model must be built around it.

However, while having scaled-up general practice is an important component of the PCH, it is not enough on its own. You also need to have community services, mental health services, appropriate specialist services, voluntary and charitable organisations and local government all built around the model, otherwise it will not have the necessary high-level integration to succeed.

Dr Nav Chana: fact file

• Chair of the National Association of Primary Care and a clinical adviser for workforce redesign and new care models at NHS England

• A GP at Cricket Green Medical Practice, Mitcham, Surrey for 25 years

• Formerly a director of education quality for Health Education South London

• Prior to this was postgraduate dean for general practice and community-based education

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