Interface issues need to be addressed

Dr Claire Fuller, primary care medical director for NHS England, and her colleagues visited our North Central London (NCL) ICB to speak to the wider primary care and PCN leadership across our five boroughs about our interface with local hospital trusts.

There were around 25 people in the room with representation from local acute, community and mental health providers as well as ICB commissioners, PCN clinical directors and managers.

We were told that the NHS England Leadership team had been visiting ICBs across the country with a focus on meeting the 22 pilot, or demonstrator, sites and then broadening out to having these conversations with wider system leaders.

Naturally cynical, I was interested in whether this was a PR exercise or if there was something meaningful behind this engagement.

The discussions explored two main areas: integrated care models and interface issues between primary care and other providers. The conversation organically became more weighted towards the former as naturally people are always keen to showcase the great work they have done rather than focus on the aspects that are still challenging.

Indeed, there appeared to be a lot of successful projects and integrated services being delivered across the geography. However, this was seemingly driven by the availability of resource and the willingness of leaders from both sides to drive these initiatives forward. There was recognition that there needs to be an appetite from the system to evaluating and rolling out successful models as a next step. There is a fear from PCNs that the resources going into the PCN demonstrator sites could perpetuate further inequality.

Personally, I see integrated care models as the icing on the cake and the real issue, to address for most GP practices, is the unfunded shift of work out from trusts to primary care.

I went through my Docman workflow, the day before the workshop and at least 30-40% were actions to be completed for the discharging consultants many of which were onward referrals. This takes a disproportionate of time to navigate and is completely unnecessary as could be completed by trust teams who are generally larger and better resourced than individual GP practices.

This is also despite an interface consensus document having been agreed across NCL at the beginning of the year clear stating that this workload shift should not happen. Consequently, there has been an increase in the number of quality alerts generated by practices with trusts and to be fair there have been several very positive responses with recognition certain activities should not happen.

In the unfreezing stage of Kurt Lewin’s model of change, the enablers and levers for change have to outweigh blockers, and clearly there is a lot of work to do in changing systems so that these instances do not keep happening. Without the necessary support and motivation, trust clinicians will continue to do what they have always done. If consultants have to do more of the referrals that they are currently asking GPs to do, then their job plan will need to reflect this. They will require more protected time to implement transformation with controls and safeguards if this is to be successful.

The discussion was eye opening as I don’t often sit on such groups with trusts, and I sensed an appetite from the people in the room to seriously address the problems with the interface to improve care for patients and the wellbeing of staff. Dr Fuller and her colleague, Professor Tim Briggs, chair of the GIRFT (Getting It Right First Time) programme along with the local ICB Medical Directorate expertly steered the discussion, gathered views and understood the challenges.

Professor Briggs, especially, passionately advocated for change and there was a sense that this was a gentle precursor to more serious conversations where change would be mandated centrally rather than allowing local systems more flexibility in designing solutions for themselves. Time will tell if this is really the start of a significant transformation or another initiative that disappears into the ether like many similar programmes over the last decade.

I would hope that we are able to take control locally and build the relationships between providers to enable this to happen. Now that ‘red tape’ and the interface appear to be a NHS England priority, it will take drive and system leadership to deliver.

Dr Sarit Ghosh is clinical director of Enfield Unity PCN, north London, on Pulse PCN’s editorial board, lead partner at Medicus Health Partners and co-chair of Enfield GP Federation.