The development of integrated neighbourhood services will support improved health and wellbeing, managing the demand for care, and delivery of better preventative services and outcomes. In doing so, we should also improve productivity and reduce some of the cost pressures facing health and social care by providing more timely and optimal care. The economic case for change is strong, but there is also an argument that the model can help to meet other important challenges facing primary care, hospitals, and the wider system.

Supporting and developing general practice and primary care

Flourishing and effective primary care is vital to the success of the NHS and there are reasons for concern about its current condition and its ability to deliver what is required in future. Whilst this is an issue in all regions, there are specific concerns around the situation in London. High levels of workload and demand, staff shortages, economic challenges for GP practices, and a range of other pressures including an increasingly complex set of population needs and pressures on other parts of London’s health and care system have led to:

• London seeing a 20% reduction in GP practices over the last 10 years.
• London having the lowest rate of GP full time equivalents (FTEs) per capita of any region (and falling).
• London having the highest rate of GP appointments per GP FTE.
• London having the highest proportion of GPs over 60 (double of all other regions combined).
• London having the highest rate of leavers and the lowest rate of joiners to general practice.
• London’s most deprived populations having a lower number of GP FTE per capita in all five integrated care boards (ICBs).
• 40% of practice premises in London dating from before pre-1948.

All of this is contributing to burn out and poor morale – with research by the Royal College of General Practitioners (RCGP) indicating that 42% of GPs are unlikely to be working in general practice in five years’ time, and a quarter of GPs saying it is very unlikely.

Without significant change, London will experience a further acceleration of these trends over the next 10 years. Without sustainable and accessible primary care, including general practice but also community pharmacy, dentistry and optometry, the neighbourhood health service in London will fail.

Increasingly patients have needs for support that go beyond what would normally be offered in primary care, (or are bringing issues such as housing problems as they do not know where else to take them), but which are related to known determinants of physical and mental ill-health, for example in the relationship between poorly heated and ventilated homes, increasing prevalence of respiratory conditions, and exacerbation of feelings of anxiety and depression.

It is dispiriting for professionals not to be able to deal with these issues, either because they are outside the scope of the care they can personally provide, or because they will take more time than is available in a short consultation. This applies equally to issues where a brief or motivational intervention to support prevention is of greater value and impact than a bio-medical response. Bringing front line professionals together from a range of services, working collaboratively with patients, service users and carers, will enable clinical and professional teams to provide the help people need, when and where they need it, rather than just constantly having to refer onwards with little hope or expectation of a resolution. This is needed both to improve access for patients and service users to the support they need, and to maximise the impact of that support in the short, medium and longer term.

Creating capacity for GPs to provide continuity of care to those who need it, is critical to improving our system responses to the growing numbers of people in London living with complex needs. Better managed systems for rapid access, approaches to provide continuity to those that need it across sectoral boundaries, and empowering other professionals and services to act where appropriate, will in turn help to provide GPs with more time and more satisfying work. There is a risk of creating new supervisory and oversight challenges and pressures; but if we can achieve this effectively, it will not just improve the lives of patients and service users but also of the professionals, including GPs, who are providing this support.

One of the most serious obstacles to developing integration and new models of delivery is the availability of time to develop the relationships, new systems, and other important aspects of change management. Smaller organisations have more difficulty in doing this. Even for larger teams and organisations, it is difficult to plan major changes in short meetings squeezed into a busy schedule, but they have more opportunities to do this.

Across London, our PCN clinical directors and wider stakeholders have indicated how the development of PCNs has often not delivered on some of the promises, beyond the narrow objective of providing a vehicle for the employment of additional roles. It is important to note that although some have incorporated, PCNs were designed to be networks, not organisations. However, there are opportunities to get the benefits of increased scale in primary care without damaging the local focus which has made it so effective. This would allow for more joint working to improve back office support, extended hours, the (re)development of GPs with a special interest, and other aspects of the type of extended, community-oriented primary care that is the goal in many health systems across England and around the globe.

Improving interfaces and relationships with wider partners

The policy focus on access and changes in patterns of work has meant that continuity of care, which is very important for patients with more complex needs, has suffered. The increase in the number of people with complex problems means that changes in how care is organised and delivered will be needed.

These patients will need continuity of care and, in many cases, the support of the wider team including community, mental health, and social care as well as voluntary and community sector partners, through a “whole family” based approach.

Relational continuity is important but increasingly difficult to deliver with high levels of demand and an increasingly part-time workforce. Micro teams and the development of informational continuity can help to support this. Very small practices have often been able to provide this well but it is becoming increasingly challenging to do so as demand increases, and the GP and wider primary care workforce becomes more part time.

The acute sector is facing continuing increases in demand and rising costs driven by new technologies, population size and age structure. The Health Foundation estimate that this could require between 21,000 and 37,000 additional beds by 2030/31. This would not be a cost-effective investment and runs against the (so far unsuccessful) attempt to shift work and resources from secondary care. Improved primary and community care, and a social care system that is properly funded, provide part of the answer to this problem. Better prevention, improved management of long term conditions, investment in rehabilitation and end of life care, all offer a prospect of reducing the rate of increase in hospital activity and in some cases making absolute reductions, but will require a new model of secondary care as part of this shift. It will require significant increases in the capability and capacity within local services and a more navigable health and care system in which the emergency department is not the first port of call when patients or referrers can’t get what they need.

Addressing waits for treatment, outpatients, and diagnostics is a major priority. Across many specialties, a change in the outpatient model, closer working between specialists and primary care, and the development of new pathways with primary care will provide one of the few ways in which we will successfully increase capacity and provide different and more appropriate ways of meeting demand, in the short and longer term.

A lot of unhelpful bureaucracy has developed to manage referrals between different parts of the system. In some cases, this is because of the proliferation of specialist teams whose remit is not always clear and which may overlap. Whilst there have been some positive developments, for example from existing advice and guidance models, wider triage and referral management often introduces a layer of additional administration where the value and benefits are unclear. Attempts to manage demand may actually increase overall work, as time is spent dealing with the complexity and overcoming barriers to providing the care that patients are identified as needing from the start.

Additionally, and as highlighted in recent engagement work by NHS England and the RCGP, including the Red Tape Challenge Early Findings, a high proportion of primary care contacts currently are patients who are on a secondary care waiting list, and are related to the issue they are on the waiting list for. There is a need for simplification and standardisation and in some cases the complete removal of duplicative services. This will be helped by the development of more locally coordinated and less fragmented services. Teams based on relationships and clear understanding of each other’s roles, do not need to rely so much on bureaucratic methods of coordination1.

The Fuller Stocktake highlights the need to align hospital specialists to INTs. A recent report by National Association of Primary Care (NAPC) supports this recommendation, demonstrating indicatively across a range of specialties how a population of 50,000 generates significant outpatient activity. The table below shows the weekly activity for a sample2:

Patients per week for a 50k population