Introduction: There is increasing interest in the role of general practice as a vehicle of integration. This relates to its potential for direct delivery of an enhanced range of services, its role in the co-ordination of care for those with multiple morbidity and in its relationships with other services and organisations who work in primary and community care. A key issue in realising these aspirations is how to motivate and enable practices to take on these enhanced responsibilities and be willing to work differently with other professionals and services.
In England there has been a reliance on financial rewards to ensure that general practice responds to new ways of working and provides the required breadth of services. The nature of these rewards, and the improvements that they relate to, have been set by central government policy makers and local purchasers of primary care. Whilst this approach has led to some positive improvements, there has been inconsistency in the level and quality achieved, and the tight specification of the process to be followed has been seen to restrict opportunity for other innovations. There are also concerns that it has resulted in many general practitioners being deterred from identifying and developing their own creative responses to local needs.
Change in practice: This project was introduced within a clinical commissioning group (CCGs) responsible for an urban population of 300,000. CCGs are membership organisations which commission primary and acute health care services for the patient population registered with their member practices. The ‘pioneer project’ aimed to introduce a new purchasing approach which would motivate and liberate general practices to develop and adopt new integrated models of care through providing a more ‘enabling environment’. The key elements of this approach were -
- Requiring practices to work in groupings rather than as single practices
- Providing funding up front rather than in arrears on completion of required activity or quality
- Determining success by achievement of outcomes rather than by implementing process
- Embedding a culture of joint learning and reflection between the practices and with the commissioner
Key stakeholders were the staff working within the general practices, the commissioners, provider of community nursing services, acute hospitals and the adult social work division within the local authority. The university were funded to undertake an 18 month mixed methods action research project which would provide emerging data for discussion and a final summative assessment of what was achieved.
Key findings: The evaluation will be completed in December 2015. Emerging findings are:
- All groupings of practices have been able to provide enhanced diagnostics and treatment for key conditions such as diabetes. This has enabled diversion of these activities from acute to primary care and provided care closer to patients’ homes.
- The groupings have provided a firm base from which general practice can consider an enhanced depth and breadth of services, and have also resulted in a raising of quality within members of the groupings.
- The majority of groupings have developed new ways of working which respond to the needs of their local populations – these include the development of innovative model of shared care between acute and primary care regarding people with diabetes from south asian communities, the introduction of new joint protocols with accident and emergency, and community link workers to connect people with complex social needs with appropriate support from statutory and voluntary sector services
Highlights of learning
- The practice leads confirmed that the previous arrangements had stifled innovation and led to them not feeling able or motivated to suggest or lead more radical improvements. Adjusting to the new expectations and freedoms involved a significant paradigm shift for them (and the commissioner)
- Learning sets which brought together the pilot leads and commissioner were seen as key opportunities to share practice and challenges, albeit it with considerable opportunities for further strengthening of this reflective approach
- There was greater success in engaging with key services in the acute sector through engaging with key professionals – community health and adult social care were harder to influence due to lack of personal connection and alternative initiatives being pursued
- Conceptualisation of outcomes within the commissioner has changed over time and been subject to internal tensions.
- The pioneer project facilitated a more collaborative relationship between purchaser and general practice which encouraged and facilitated greater clinical leadership. For these groups of practices funding was an enabler rather than an incentive, providing ‘capacity and flexibility’ rather than ‘motivation and reward’.
- The final data gathering will seek to establish improvements in outcomes and quality, and the extent to which changes have been sustained when the project phase is completed.