This paper was developed by a group of primary care clinicians for the Labour Shadow Health Team at their request. We hope it helps illuminate the next steps for primary care.

WHAT ARE THE RISKS, OPPORTUNITIES AND CHALLENGES FACING  PRIMARY CARE PROVISION DURING AND AFTER ITS RETURN  TO A NORMAL STATE OF OPERATION?

 

“We will be facing some tough challenges over at least the next year: managing more consultations (and clinical risk) remotely by phone or video; catching up with resurgent patient demand, catching up with the care of long-term conditions (whilst trying to protect groups of vulnerable people from a continuing threat of Covid); managing a backlog of people who need to be referred; and coping with any spikes in Covid. This comes on top of the usual (preceding) strains on limited resources and lengthening ‘winter pressures.’ I don’t think that we will be seen as ‘NHS heroes’ in a few months!”

 

DIGITAL WORKING IS TRANSFORMING CARE

Opportunities

  • Easier and more flexible for people and practices, so may aid GP recruitment
  • The complex and subtle nature of the consultation seems to be maintained
  • Communication across sectors can be dramatically improved. One GP described helping a patient with lymphoma – in 10mins he was able to include a Ca nurse and consultant in a conversation with the patient.
  • Telephone triage also successful
  • Bricks and mortar general practice may become less necessary
  • Combining online personalised advice with online access to records opens the way to improved self-care

Challenges:

  • Digital can widen inequalities and disenfranchise. Experience suggests it is the elderly rather than the poor who struggle the most.
  • The best balance between remote and face-to-face is unclear. Video may be best for follow-ups.
  • Video is seldom preferred by people. The telephone or face to face are most popular.

Actions:

  • Support the elderly to become more digitally able while ensuring that traditional approaches remain available
  • Support digital cross-sector working: GP/hospital/Social Care
  • Encourage digital mentoring to improve self-care for people with LTCs

 

SHIFTING TO PROACTIVE WORK WITH COMMUNITIES

Opportunities

  • The spontaneous rise in mutual community organisations has been remarkable, often outwith the traditional voluntary sector, improving safeguarding and perhaps saving lives.
  • Primary care has been able to embrace that.
  • It offers a model for the future
  • There have been many examples of successful cooperation with communities, but they have been dependent on local circumstances and local heroes.
  • The health gain comes when communities can take more control over the area and their lives
  • The NHS and local government need to create the conditions whereby communities can work collaboratively with the statutory sector sharing decisions with their communities. We need a systematic approach for mobilising civil society, working with NHS and LAs.
  • PCNs offer a good base for such cross-sector working

Challenges:

  • Sharing decisions with communities is a difficult skill the NHS would have to learn, perhaps from LAs and housing associations.
  • Building on existing work and with councillors would be essential. No new unnecessary initiatives.

Actions:

  • Jointly fund, via NHS and LA, community development workers in each PCN, working with social prescribers. They would support the statutory sector sharing decisions with their communities.
  • Primary Care to be encouraged to support community groups and community development by, for instance, enabling practice space to be used by communities.
  • Asset mapping with LA and PH colleagues would be one early step
  • Encourage and incentivise cross-sector working.

 

PRIMARY CARE TO ACTIVELY WORK ON THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES

These have been thrown into sharp relief through the pandemic.

Opportunities

  • Essential to make any progress on health improvement
  • Community development can assist
  • Local work on poverty, race issues, migrant issues, housing
  • Cross-sector working is essential to do this.

Challenges

  • The independent contractor status of general practice may hinder this process.
  • Cross-sector working is difficult
  • It is political work

Actions

  • Promote training GPs with a Special Interest in Public Health, sitting astride the PCN and LA
  • Support areas to become Marmot towns.
  • PCNs to link formally with LAs
  • Boost the status and effectiveness of Well-Being Boards
  • Borough-level linking (not merging) of LAs and NHS.

 

PRIMARY CARE AND LONG-TERM CONDITIONS INC COVID

Opportunities

  • The importance of community service provision has been made plain by the pandemic
  • Extensive primary care services and rehab re likely to be required for people recovering from Covid

Challenges

  • Managing more serious illnesses outside hospital may require differently trained primary care staff such as District Nurses

Actions:

  • Use a range of approaches to contact those who have delayed seeking help for potentially life-threatening illnesses
  • Digital self-care with remote links to home monitoring such as BP, weight, Peak Flows
  • Secondary care doing remote consultations to reduce the backlog
  • Explore a range of differently skilled staff for primary care

 

RELAXATION OF RULES HAS BEEN HELPFUL

Opportunities  

  • There has been relaxation of some bureaucracy
  • Flexible approaches have enabled doctors to return to the workforce.
  • These changes have enabled GPs to devote more time to patient care.

Challenges

  • Some of this bureaucracy is useful. We don’t want wholesale deregulation: that has often been dangerous
  • It is difficult to know which parts need to be kept and which don’t.

Actions

  • Explore with the profession which regulatory aspects need to be kept and which don’t.

 

FUNDING, TRAINING AND STAFFING

Challenges

  • Primary care, GPs, HVs and DNs remain substantially understaffed. This must change.
  • Different training requirements may be needed for a different future.
  • The RCN is calling for wage increases for nurses

Actions:

  • A system to support on-going review and remodelling of workforce capacity is needed to ensure that the primary care workforce is responsive to emerging need which may increase over time.
  • Clarification of plans for student health visitors and others who have had their training disrupted during the pandemic

 

STAFF SAFETY IN THE TIME OF COVID

  • Continued need for PPE to protect staff and patients
  • Mental health support for staff

 

PRIMARY CARE BUILDINGS

Challenges:

  • Many primary care buildings were inadequate before Covid
  • Many more now need redesign to cope with new patient flows and requirements for cleaning etc

Actions:

  • Funding must be found where premises need improving
  • Consider links with housing associations

 

BOOSTING DEMOCRACY IN THE NHS

Challenges

  • The NHS has used the Coronavirus Act to push through significant changes to the infrastructure of ICSs. This is baking in the risks posed by them: privatisation, fragmentation and cuts.
  • Hosp reconfigurations are happening rapidly without consultation and no equality assessment

Actions

  • Call out these dangerous changes and use them to explore new approaches to democracy. For instance:
    • PCNs run with a Board with a broad representation of opinion
    • Link PCNs and local government through local forums with budgets – a form of participatory budgeting
    • Community development would assist participatory democracy

 

ADVANCED CARE PLANNING

Opportunities

  • Advanced care planning will need to sensitively change for the better.
  • General practice is well- placed to have discussions that allow patients to express their wishes, which will reduce unnecessary and possibly undignified hospital admissions.

Challenges

  • There seemed to be sporadic inappropriate behaviour from CCGs and practices issuing blanket DNR notices to care homes
  • The pandemic seemed to cast a harsh light on relationships between some practices and care homes

Actions:

  • Patients suitable for advanced care planning conversations could be identified— perhaps informed by frailty scores — and discussed in multidisciplinary meetings as part of routine care.
  • The public need to be involved, and the sector need to emphasise that these discussions are about providing quality of care.

 

SOURCES:

https://www.rcn.org.uk/news-and-events/blogs/covid-19-out-of-this-crisis-we-must-build-a-better-future-for-nursing

 

https://ihv.org.uk/our-work/publications-reports/health-visiting-during-covid-19-an-ihv-report/

 

A brave new world: the new normal for general practice after the COVID-19 pandemic.

https://bjgpopen.org/content/early/2020/06/01/bjgpopen20X101103

 

https://www.rcgp.org.uk/policy/fit-for-the-future.aspx

 

CONTRIBUTORS

Dr Onkar Sahota

Dr Duncan Parker

Dr Joe McManners

Dr Robbie Foy

Dr Brian Fisher

 

CONFLICTS OF INTEREST

Dr Fisher:

I am Clinical Director of a software company called Evergreen Life www.evergreen-life.co.uk . We are accredited by the NHS to enable people to access for free online their GP records, to book appointments and order repeat prescriptions. We try to help people stay as fit and well as possible.

Both comments and trackbacks are currently closed.

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 683 other subscribers.

Follow us on Twitter