Blog - after Covid-19 we can't just leave primary care to the health service

In this blog, IPC Associate Director, Keith Moultrie, considers what lessons might be learnt from the Covid-19 pandemic in terms of primary care delivery. He observes the current barriers that challenge the creation of a more integrated, patient-centric service and shows how post-crisis this might lead to changes in future provision.

Since the foundation of the NHS, leaders, professionals and commissioners have had to deal as best they can with big differences between health, social care and wellbeing services in things like delivery systems, funding streams and public expectations. It has never been satisfactory, and in many communities across the UK partners who should be building integrated or seamless provision have ended up working to opposing agendas and different priorities.

Different agencies have developed services either independently or (at best) in parallel, instead of taking an integrated, collaborative approach across system boundaries. We have built a hugely complex web with different access criteria, payment arrangements, professional roles, service responses, communication systems and expectations on individuals and families.

Responsibilities have been sharply differentiated and boundaries and budgets have been closely guarded. Each service and profession has been tempted to look at the overall network from its own perspective and to interpret the activities of others in terms of how they help them deliver their own part successfully. The result has often been unintended service failures, overlaps or gaps, and behaviours characterised by:

• Leaders and professionals wanting to define very exactly differences between similar jobs, tasks and roles and to use this differentiation to protect terms and conditions or sometimes to blame the ‘failings’ of other partners.
• Boundary disputes, particularly over financial responsibility and liability, requiring a disproportionate level of management and professional time.
• An over-reliance on contracts and formal assessments which fix ongoing service delivery and do not recognise the day-to-day changes in need that individuals have, particularly those with long-term conditions.
• Limited responsibility and influence of patients in the delivery and development of care.
• Heavy reliance on the acute sector making some interventions unnecessarily extensive and expensive.
• Management of demand through waiting lists and triage, with case-finding, recovery, early intervention and prevention playing a relatively small part in responding to need.
• A strong boundary between health and social care in the UK as a result of different funding regimes – most obviously in the charging for complex nursing and residential care – and complex, time consuming and stressful negotiations between the NHS, the individual, voluntary and family support, and local authorities in individual cases.

The response to the Covid-19 crisis has shown that many of these problems are not inevitable. Given the urgency of the need and the will to respond, partners can quickly build a whole system response. As the crisis works its way through from the current lockdown, the question which we will all need to consider is: do we return to the past or do we try to find a very different ‘future normal’ for health, social care and wellbeing services in the community?

Much of the answer to this question will need to be led by national governments in the UK. They will need to address issues including: public sector funding; charging and social insurance arrangements for social care; recruitment and retention of staff; and the legislative and policy framework underpinning integrated services. However, at a more local level, leaders in the sector will have a huge influence on how patients, professionals and the public experience health, social care and wellbeing. One way in which they can exercise that influence will be to build from the current emergency response to change our normal language for care - so that all partners are driven by a whole system perspective into the future.

A key change here could be to redefine what is meant by the term primary care. Currently that term tends to be seen very much as about primary HEALTH care. For example, this from the Centre for Academic Primary Care at Bristol University:

"Primary health care is the first point of contact for health care for most people. It is mainly provided by GPs (general practitioners), but community pharmacists, opticians and dentists are also primary health care providers."

This is a perfectly logical and succinct summary of how the term tends to be used currently in the UK (and the term is often actually shortened to primary care in this context). There are similarly specific meanings attributed to other sectors such as social care or wellbeing, all of which fail to recognise the importance of thinking more widely about the responsibilities of all stakeholders in a whole local system, and as a result tend to re-enforce siloed thinking and acting. However, if we only start with the idea of primary health care as one of a number of separate (or at best parallel) local services we will continue with the piecemeal approach we have had across these services ever since the introduction of the NHS in 1948. As we move to a new future normal perhaps the concept of primary care needs to expand to cover how the World Health Organisation defines it:

"Meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services.

Systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors.

Empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others."

In this definition primary care is a much more comprehensive concept, not at all limited specifically to health care or to the NHS. It describes the full range of services, pathways and activities which optimise people’s health and wellbeing in a community or local area. If we start from here, primary health services are incorporated within a much wider partnership. Perhaps by employing this term to describe the wide range of services and professionals involved, then the growing recognition of the importance of all of our carers that we have seen amongst the public and policy makers in recent weeks can be solidified into a firm ongoing understanding of the importance of an integrated primary care network to our population health and wellbeing in the future.

So, for example, if primary care is a shared responsibility we might expect to see local partners building on their experience of working together in recent weeks to commit themselves to a single set of shared long-term primary care goals, no matter what specific legislative and policy context they are working within. These goals, and the health contribution to them might look like this:

The crucial characteristic of effective primary care will be that it is operating as a single network not a series of independent agencies, that leaders in the system are working together on a shared primary care agenda, and that professionals are undertaking their specific jobs as part of a wider team. To deliver this, partners might need to:

• Work on the primary care network as the basic design unit - not the individual service, practice or the profession. Create professional and leadership partnerships to drive this forward.
• Create a common language and frame of reference which recognises the shared contribution to effective primary care across the network.
• Work together to develop the local primary care model that partners agree they are working towards.
• Build whole systems solutions to problems, based on effective pathways across services rather than traditional service boundaries.
• Work up joint and common population assessments, analyses of needs across health, wellbeing and care boundaries.
• Engage together with local people on the kind of care and support they want to see in the future.
• Work together jointly on projects to build common information systems, common staffing and workforce frameworks, performance monitoring and management.
• Develop integrated commissioning arrangements based on the primary care boundaries so that partners are working on the same key service changes at the same time.
• Look to pool budgets and resources wherever this will create more flexible working between agencies.
• Move teams towards greater integration including through co-location, shared or single management of teams, place-based multi-professional services.

In the coming period we need to decide what lessons have been learnt from the Covid-19 pandemic, and how we should work together in the future. Perhaps seeing all of our local services as part of a single primary care network will be one part of that way forward.