Both general practice and hospital services are working under extreme pressure with increasing demand from patients who often have several complex problems. But could working together in a different way provide a more sustainable care system, both for patients and for the workforce?
That is the question being explored in Wolverhampton, where GPs from three practices covering 23,500 patients are now working with The Royal Wolverhampton NHS Trust (RWT).
The impetus for this change came as a result of both sides feeling the pressure of increasing demand across the system. The trust – which provides both acute and community services – had a £38m new urgent care centre but it was already seeing the level of demand that are far ahead of planned projections. Primary care is also feeling the strain with issues of insufficient GP capacity, increasing case complexity, problems with recruitment and retention and large practice based administrative burden. ‘A conversation started between ourselves and a group of practices about how we could do it better,’ says Sultan Mahmud, director of integration at the trust.
But driving the momentum on both sides, says Mr Mahmud, was a strong sense that things could be changed to make them better for patients – both those who needed help now and the anticipated increase in demand in the next few years. The proposed structure allowed a much more integrated approach to managing demand.
On June 1 this year the vertical integration programme went live.
It is early days but there are already some positives coming out of the scheme. One is a greater understanding of different clinicians’ roles and stresses. ‘We have got the consultants and GPs talking to each other in a way they have not done before.’
This has allowed some pre-conceived ideas and stereotypes to be challenged – Mr Mahmud jokes that it is a ‘truth and reconciliation’ process – and a better understanding to emerge. ‘It is energising and can drive behaviour change,’ he adds. ‘Sorting out relationships’ is a first priority, he says.
Patient access to GPs has also been improved with the practices now open fully over five days,. ‘That is a 10 per cent increase in primary care access for patients,’ says Mr Mahmud.
‘We are increasingly aware of social need during GP consultations. We have developed social prescribing clinics with the help of Wolverhampton City Council.’ Patients who really need social help rather than medical input can be seen and advised immediately, freeing up GPs to see other patients and hopefully providing a solution to patients’ real problems.
The skill mix in primary care has also been boosted with pharmacist, physios and other allied health professional input. The Wolverhampton Public Health department is also working with the practices to identify list based public health priorities – this will lead to targeted lifestyle interventions at practice level.
However, one of the big drivers of change in the future is likely to be shared data. ‘We are connecting the data dots across primary, community and acute divide,’ says Mr Mahmud. ‘We can see what has happened at a practice level before an emergency admission and what happened afterwards in community care, for example. Having that whole granular picture is very helpful.
‘There is ongoing interrogation. We know from the data that about 10 per cent of the population in our population has three or more co-morbidities and 1 per cent have had 3 or more emergency admissions in the last 12 months. We will use an enhanced data set to redesign care delivery with a unified clinical team across primary, secondary and community care.
We are delighted to have worked with the trust on this innovative project which would not have been delivered without the ambition and determination of the trust and GPs
Jamie Foster, Partner, Hempsons
We have done it with quite a lot of help from Hempsons
Mr Mahmud, Director of Integration, The Royal Wolverhampton NHS Trust
So what happens now? The number of practices in the scheme is set to increase – one is due to join in December and another in January – and there are many others interested in the model.
Ultimately the trust and its primary care partners could move towards an accountable care organisation covering the urban Wolverhampton region. This could be coterminous with the city council, which is already working closely with the trust.
The project is not a formal vanguard – it emerged too late to be eligible for vanguard funding – but has a lot in common with the primary and acute system vanguards. Setting up a scheme like this is not easy. He identifies a key need to ‘have the time and space to really listen to GP colleagues and understand their issues they have fantastic ideas around integrated care , we just need to create the infrastructure to give those ideas a chance to flourish. The pressures facing primary care at the moment are such that GPs are keen to work in a transformative way. The trust’s offer to them included taking some of the strain off back office, offering more change management support and being part of a strong clinical community at RWT.‘
A shared interest in improving care for patients is essential, however, says Mr Mahmud. ‘When people want to work together and come together willingly there is a great deal that can be achieved.’
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