Re-designing primary care
A new and proactive response to people's needs
Where are we?
Primary Care Networks are in their early stages, in many cases understandably pre-occupied with issues round legal form and the employment of new staff working across multiple practices.
All well and good, but we see an opportunity slipping away. With all the focus on getting a PCN up and running, the discussions tend to be focused on improving relationships and insuring things are ‘equal’ amongst members.
In many cases it seems PCNs are seen as vehicle for adding a little more capacity into the system; essentially re-enforcing the current model. But ask yourself the question – is a little more capacity going to be any more than a temporary fix for the problems the primary care system faces?
What we often hear….
There is a lot of rhetoric and dialogue about the state of our primary care system. Said often enough, these views often become a ‘truth’ and dominate planning and thinking:
Demand is limitless. If we get more efficient, we end up just letting more people in.
Access trumps effectiveness. Seeing as many people as possible, as quickly as possible is the priority.
Managing risk at a presentation level is more important than long-term risk to health.
Plan based on last year. Based on who we helped last year, not who tried or should have tried to seek help.
Work is exhausting and not very rewarding. It is not what I envisaged when I joined the profession.
The solution is elsewhere. The key to solving the issues faced is for other parts of the system to change.
I need to be funded to change. That things cannot change without ‘new’ money.
These views shape our response to the pressure we face. But our view is they are in many cases shaped by flawed assumptions and / or epistemology, rather than fact:
Why this does not stack up
In primary care, we don’t really know what our demand is. Our data systems only count what we let in. At the other end of the spectrum population health data is often abstract and leads to little practical change. So the cycle is reinforcing. If we base our services on what we let in last year, they will always look like last year’s services.
Given the pressure on activity and access (it is generally what is counted by commissioners), in many cases we don’t meet the underlying demands (needs) of patients. We end up managing activity, not meeting demand (need). If we don’t meet need, it comes back.
The nature of the work is changing, the nature of the communities we serve our changing, but our very strong professional identities, in many cases, lock us into the current model.
The notion of quick wins, IT solutions and blaming other parts of the system is appealing and in many cases seductive. At best this slows down the improvement of services and at worst it paralyses it.
Our view on the characteristics of a new general practice system
To reduce demand, you have to meet need. Not manage it, not send it elsewhere, not ignore it.
This has to be done as simply as possible. In a way that involves the fewest number of services and individuals (reduce fragmentation).
Practices need to work together to figure out how to meet the needs of their communities. It is clear, some of the needs of communities can only be met by practices working together at scale.
We need to build new data perspectives that are not solely focused around activity, history, governance, differentiation and exclusion. But rather build data perspectives that help us understanding the true nature of our work and flow.
We need to be flexible in our response to need and not just concentrate on the bio medical. To reduce demand we need to respond to the following needs (Source Julian Pratt):
Bio-medical (treating and preventing disease)
Healing (acting as a witness and supporting meaning)
Messy (issues that require intimate knowledge of context over time)
Caring (empathy)
To do this we need to reduce the reliance on GP led, face-to-face clinical (bio-medical) model.
The wider system needs to consider
All high performing health systems have, at their heart, robust primary care teams. Without this, the rest of the system fails.
Those primary care teams work need to work at different scales, which is determined by the needs of their local population.
The nature of commissioning - to drive down cost at service level - is increasing the overall cost of the system.
New set of working assumptions creating new models
Our current ways of working and the outcomes we achieve are no surprise, they are no accident. They are shaped by dominant sets of assumptions. How we see the world at the moment, determines what we do in the future
If the current assumptions that shape our general practices are carried over into Primary Care Networks, then we will end up in with more of the same. Same pressure, same issues.
We need to avoid these traps
The first step is to be explicit in describing the current model. Why do we do what we do?
The second step is to then describe the new set of assumptions for a new, PCN enabled, model of care.
Without this clarity, the work of PCNs will always drift back to the same issues and ineffective solutions.