London Primary Care Quality Academy - Proposition

Securing better value for citizens, reducing demand, and designing services fit for changing health needs.

Executive Summary

At the heart of primary care lies the collaborative relationship between local people and primary care professionals who understand the context of their community. This is where the solution to the over-stretched primary care system lies in enabling this core relationship to bring the capabilities of both into improving health. Using collaborative change practices, underpinned by data the Primary Care Quality Academy supports practices that increase satisfaction, reduce demand, and secure capacity to adapt to changing health needs.

Londons primary care is operating under considerable pressure. At a time of financial constraint across the health and social care system it faces increasing demand, increasing complexity of case load, rising expectations from commissioners and patients and a need to transform and diversify its skill mix and range of services.

The Five Year Forward view sets out a new vision of extended primary care with better access, coordinated care, personalised proactive care and new models of care with practices coming together to work at scale and provide population health to larger communities.

Strategic Transformation Plans set out how defined geographies of services will work together delivering better quality, efficient and joined up health and social care. For the STPs the role of primary care in these plans cannot be underestimated.

In order to deliver this transformation there will need to be a step change in the capacity and capability of primary care to lead and deliver the transformation required, in particular reducing demand.

The Primary Care Academy sets out an approach to equip key staff with the leadership, organisational development, collaborative support and quality improvement skills, which these changes will require.

The London Primary Care Quality Academy Overview

Across London there are varying levels of support and development for primary care and for reducing demand. Across the UK there are examples of new models of primary care emerging.

Primary care is struggling to provide the level of quality and access that is required. Where primary care has revolutionised how it organises there have been significant gains in terms of reduced demand, population health outcomes, better service quality, work-life balance for professionals, and better value (being able to deliver high quality primary care within budget).

The London Primary Care Quality Academy is seeking to catalyse this across London.

The London Primary Care Quality Academy seeks to:

1. Demonstrate approaches that work to secure reduced demand, better quality and capacity, and an approach to primary care that is fit for the future

2. Provide programmes of support where there are gaps based on the best intelligence and practice in data to support excellent decision-making, quality improvement, innovation and coproduction with communities.

3. Connect and spread intelligence about what works and how it works across partners in London.

The London PCQA will stimulate and support local PCQAs where needed in Federations/local practice networks and CCGs, to solve local issues and develop locally relevant models, acting as a connector and supporter where needed, and providing learning programmes, data skills and coaching in-situ where required.

The London PCQA will be located at London South Bank University, providing space for learning in teams and across London; and a significant online presence for sharing intelligence, tools and data to accelerate local change. The London PCQA is organised as a network, partnering and collaborating with the NHS across London.

The London Primary Care Quality Academy will facilitate:

Reduced demand for health services

Better value for stakeholders (efficiency and effectiveness)

Better quality of primary care provision, and improved staff satisfaction

Improved working conditions

The Context

The Five Year Forward View

Delivery of the GP Forward view will require significant and sustainable capacity and capability building in primary care. This will not only require improvements in efficiency and productivity but fundamental changes to the way general practice operates. New models of care are emerging with a wider range of services, skill mix and strategic aims an emphasis on coordinated care, navigation, prevention, health and well being promotion as well as improved access to traditional meet and treat GP services.

Many practices do not have the capability, capacity and leadership drive these changes and would benefit significantly from a local resource tailored to their development and training needs.

Sustainability and Transformation Plans

It will not be possible to deliver the ambition set out in sustainability and transformation plans without robust primary care delivering better access, coordinated care and proactive care. Collaboration across services is at the heart of STP ambition and the role of the extended primary care team in managing transitions between services will be essential. Primary care will increasingly be less reactive reaching out into communities working with partners from acute, community, voluntary and social services partners keeping people healthy and independent in the areas where they live.

This represents a significant change in the roles and behaviours of many staff and will require significant OD, skills and learning and development investment.

Primary Care in London

Londons population growth and complexity are placing unprecedented levels of demand on general practice and the current service is struggling to respond effectively to rising health needs. Furthermore London needs a general practice service that is delivered by sustainable and financially effective organisations. Practice finances have declined in real terms, exacerbating their inability to invest in service improvements and causing some to fold.

The characteristics of Londons population places significant demands on primary care. The population is highly mobile with some boroughs seeing 30% turnover per year, it is highly diverse with over 100 different languages spoken, there are high levels of deprivation and health inequalities and an increasing prevalence of long term conditions and complex co-morbidity often at ages younger than elsewhere.

On average primary care outcomes and levels of patient satisfaction with key indicators like access are lower than elsewhere in the country with these averages concealing significant often unexplained variations between practices for key aspects of diagnosis and treatment.

Finally London also has a high percentage of small and single handed practices than average proportion of smaller general practice premises, mainly in converted residential housing or older, purpose built, health centres.

New Models in Primary Care

The Future of the NHS is dependent on effective and efficient primary care, working in collaboration with local citizens to secure communitybased solutions. General practice is central to reducing avoidable demand on secondary care and is itself experiencing significant demand, with little headroom to find adaptive solutions. Changing demographics, the impact of austerity and increasing scrutiny are generating complex multiple demands.

In this context there are practices and primary care teams/ health and wellbeing centres that are securing more effective approaches. These:

a) Use data to review their activity and improve flow within their practices and across the system.

b) Look for examples and ideas to manage demand from outside their practice.

c) Work collaboratively with local citizens in an asset based approach.

Overall this means that these practices:

a) Use their skill sets more effectively to meet need (diversifying their skills and offers, targeting these effectively);

b) Use their contact time with patients more effectively having better conversations;

c) Improve their back-office functions to be more efficient;

d) Partner effectively with care homes/ other practices to manage the health of frail elderly in care and reduce hospital admissions;

e) co-produce new services with communities lead by communities.

A London Primary Care Quality Academy

This proposal has emerged as a result of two workshops with senior leaders of Primary Care and Primary Care development from across London (Appendix 1). The first workshop scoped the issues facing primary care and the potential for working across London, the second was a co-design event to produce the approach in this proposal.

Across London Practices, Federations and CCGs are collaborating (sometimes also with AHSNs / Universities) to secure a local development agency to enable and support improvements in capacity, improving quality, reducing demand (and failure demand), developing the assets of the local population, and securing back-office value.

Local primary care teams/Federations/CCGs have variable expertise to draw on locally in relation to:

Quality Improvement

Innovation

Data for change

Coproduction & Collaboration with communities

Systems Leadership

The Primary Care Quality Academy works as a development agency alongside the commissioning, performance management and governance frameworks.

This is best articulated by Berwick et at (2003), with this proposal focusing on Pathway 2. Pathway 1 is the dominant approach in t