A Way Forward for Community Based Care

This is the second of two guest posts by Professor David Colin-Thomé.
Part one: Primary Care Home

The Primary Care Home (PCH) is a concept I first described some ten years ago. It is a population budgeted, community based provider organisation able to provide an alternative to current NHS hospital centricity. A home not only for general medical practitioners and their teams but for all primary care independent contractors (Pharmacists, Dentists, Optometrists) and their staff, community health services and social care professionals. And potentially a home for many currently working in hospitals, in particular those clinicians who have a responsibility for long-term conditions care, for rehabilitation and reablement, and for the hospital specialists who offer ‘office based’ procedures. The population would be of GP registered patient lists aggregated to whatever size is locally appropriate.

The model is an extension as well as a forerunner of the Five Year Forward View Multispecialty Community Provider (MCP). It has the potential to be a disruptive technology and as such should drive a new approach to commissioning and, even more innovatively, a reshaping of the current NHS hospital model, which is still based on an age-old form and function ‘frozen in aspic’. Much of the current focus of commissioning is to drive quality into providers via a transactional contractual model. A budgeted PCH can make its own decisions to ‘make or buy’ value based care for which commissioners should hold them to account. An incentive to transform care as significant amounts of the care currently undertaken by hospitals could be better undertaken near the patient’s home.

The National Association of Primary Care (NAPC) has adopted the Primary Care Home concept to develop a model relevant to the Five Year Forward View Multispecialty Community Provider and received approval for this work by NHS England. Their Primary Care Home model brings practices together across populations of 30,00 to 50,000 patients to integrate primary, secondary and social care services, and is being implemented in 15 pilot sites to date covering around 500,000 patients. Funding will become merged into a single capitated budget, and the pilots are focused on personalisation of care, workforce development and improving population health outcomes. It is now set to be rolled out to around four million people across England.

Principles of the Primary Care Home

The Primary Care Home offers, in current vernacular, a ‘game changer’ for general practice and all community based services.

I am hugely supportive of NAPC’s model but emphasise all GP organisations, from single practice to large federations, are place based with a population responsibility (the GP registered patient list). My premise is that the principles of the Primary Care Home apply to all GP organisations, they being the only NHS provider to uniformly have a population responsibility. To be rigid about size may be constraining of innovation. If an organisation has a large population base, it needs to demonstrate localness, and if of a small population base, it needs to demonstrate connectedness. It is the vision and attributes of the organisation that matter most. The opportunity the NAPC model offers is a population size small enough for localness and yet large enough to be of strategic importance for the NHS. In NHS England’s latest advice on Primary and Acute Care Systems (PACS), they are recommending populations of 30-50 thousand as building blocks. The need to be concomitantly small and large may at last have found its time.

With flexibility of thinking, we can develop the Primary Care Home at different population sizes, if we are serious about spreading innovation and leadership throughout existing population based general practice, and offering an opportunity for all community based services to be part of a PCH and also take on a population responsibility. Leadership must be enabled at all levels of care, one of the successes of GP reforms in the 1990s. So how could an individual practice or small groups of practices take on the responsibility of a primary care home? A self-assessment coupled with assessment by the local commissioner is the first step. If the practice is a member of a larger-scale GP or primary care organisation, that organisation and the commissioner could determine if the practice has the vision, capacity and capability to take budgetary responsibility proportionate to its capability and size, even if not actually holding the budget. The expectation is the answer should be a yes unless there is good evidence to the contrary. Of course, even an organisation with a population of 50,000 may be too small to hold a budget for more specialised services. The final arbiter, if disputes arise, should be decided locally but probably will need ultimately to be the commissioner.

An actual budget cannot be devolved in the immediate future to nascent organisations but the responsibility to manage the population defined total clinical resource is essential. The goal of budgetary responsibility will ensure that as increasing amounts of value based care are undertaken in the ‘Home’, the monies will remain in the ‘Home’. With the ensuing increasing resources for community based organisations, an opportunity arises to offset the real cuts in social services and to achieve a public’s health focused community oriented primary care. Financial risk to small organisations can be mitigated by initially holding virtual budgets but with executive accountable decision making powers, and for real budgets, adopting specific techniques such as risk pooling and stop loss.

Of course, those whose minds are too tidy (and they are many) will think these arrangements too imprecise and disorderly. Managers, whether clinicians or non-clinicians, need to ensure a high value health service. The defining issue is: how do they achieve that desired outcome. Those whose view is that the NHS is too risk averse, is failing on value and very much unappreciative of local general practice, need an alternative to the frequent prevailing culture of top down controlling, to one that is locally focused, developing and enabling. The words of entrepreneur Clayton Christensen resonate: “Breaking an old business model is always going to require leaders to follow their instinct. There will always be persuasive reasons not to take a risk. But if you only do what worked in the past, you will wake up one day and find that you’ve been passed by.”

To reiterate, general practice must be forcing the pace on culture change. The growth of the large-scale GP/Primary Care organisation carries an inherent risk of them becoming the new ‘they’ — distant, impersonal and themselves controlling. Not the recipe for success if the aim is to enable the involvement of all general practice. The NAPC PCH model is more appropriately sized but even at that scale, two-way accountability must be the order of the day between the PCH and its constituent organisations, and indeed the PCH and its commissioner. Governance must also be about relationships and behaviours. In the existing NHS culture, which often does not lay much store in either of those attributes, it may be necessary to formalise such working practices into a governance framework utilising such tools as Alliancing techniques. We need to have relationships underpinned by contracts, not relationships defined by contracts.

The Primary Care Home quintessentially provides a necessary vehicle for community leadership to flourish at all levels, from the individual through to the whole organisation, in particular for those whose work is predominantly patient facing. It also offers an opportunity for other provider organisations and individual clinicians to provide services within primary care for the individual citizen together with a population responsibility, resource control and a transparent accountability. Clinical specialists must define a new role to optimise how specialist and generalist can work together to serve a population. For example, a rheumatologist, apart from treating the rare or unusual, could have a defined population responsibility to advise primary care clinicians on high quality care without needing to see the patient. An opportunity, for instance, to challenge the wastefully duplicative, expensive current model of outpatient care and to share rewards for new ways of working.

But what about the patient? There is much talk about integration, to the extent that it faces the danger of becoming another word in the lexicon of NHS buzz words and indeed another transient fad. Primary Care Home thinking and implementing provides an ideal opportunity to demonstrate that integration can make a real difference to individual patients who concomitantly should be able to hold providers to account.

The latest policy vehicle to ensure value in the NHS is to create Sustainability and Transformation Plans (STPs). As the British Medical Journal put it, ‘If general practice fails, the whole NHS fails.’ It will be interesting to know to what extent general practice features in the STP plans; early feedback is that it is limited and NAPC is currently undertaking such a survey. NHS England has published an aide-memoire aimed at STP leaders to ensure delivery of the GP Forward View in local plans. In any initiative to hugely support general practice, and indeed a wider primary care, and to sustain and transform the NHS, general practice, working with other community focused services, needs to be centre stage, as this paper promulgates. Ultimately only community based services with as much support as they can muster can change and indeed transform the prevailing NHS culture to one which is community focused, clinically led and managerially enabled. The optimal path to sustainability.

David Colin-Thomé

Indpendent Health Care Consultant, Honorary visiting Professor of Health Policy and Management Manchester Business School, Manchester University. Formerly GP Runcorn for 36 years, National Clinical Director Primary Care Department of Health England, and Honorary Visiting Professor of the Centre for Public Policy and Health, School of Health, Durham University. For more information, see www.dctconsultingltd.co.uk