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Sunday 25 September 2016
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The real coalition: why primary and secondary care must partner up

Patients & Services

ANN BECKE

Non–Executive Director
The Dudley Group of Hospitals NHS Foundation Trust

Ann has been a non-executive director for four years and has a lead role in safeguarding. She is a trustee of Dudley Clinical Educational Centre and a member of Dudley Children’s Trust Board. A graduate in World Class Service Management, Ann’s prior career was mainly in sales and marketing for a global communications company. She is also Vice Chair of a link of Chernobyl Children’s Lifeline

No one would argue with the assertion that these are challenging times, not least in the NHS. However, challenge is not always bad and certainly it offers us a real opportunity to change. Politicians – of all persuasions – are to blame for driving a wedge between primary and secondary care, justified under the banner of competitive forces. Has this improved the level of care? Not if you believe the statistics that say we are one of the poorest in terms of outcomes in Europe.

As modern healthcare becomes more complex, with more people needing more co-ordinated care from both primary and secondary care, partnership working becomes ever more important in delivering good quality healthcare.

Coming from the private sector, I am always asked how I think the public sector differs. In my experience, the private sector lives by putting the customer first; they don’t always manage it but they certainly strive to achieve it. They know from experience that their customers can make or break them. Their customers can demonstrate their displeasure by literally taking their custom elsewhere – something our patients find difficult to do.

The NHS has a near monopoly on healthcare. That is why I believe that, while we all try to put our patients at the heart of everything we do, in reality we may struggle to achieve this. However, I feel the tide is turning and there is a genuine will to give our patients a better experience.

No place for pigeonholing
I find compartmentalisation in the NHS difficult to justify. Care should be delivered by one service, not divided into primary and secondary care. It should be delivered by the community for the community, and in a way that allows all stakeholders to have an equal say. The acute hospital should be an integral part of the whole. It should not be viewed as an outsider whose sole purpose is to revenue farm.

However, the differences in perspective, resources and cultures across different branches of the medical profession can make it difficult to deliver a seamless patient experience. We all tend to focus on our individual business plans and less on the health economy as a whole.

The Dudley Group of Hospitals (DGoH) constantly faces new challenges and continues its journey of development as an NHS Foundation Trust. With the continued imperative to improve standards and performance, the future direction of the trust will be shaped by changes in the wider NHS. The reconfiguration of services and the plans for redesigning patient care to meet the needs of the future will influence the priorities for us all.

Locally, we have started to work in closer partnership with our primary care partners both clinically and with respect to health economic issues. We are looking to share resources, which will provide both primary and secondary care with the advantages of improving efficiency and reducing costs.

With goodwill on both sides, we are working hard to build a close working relationship between GPs and consultants, enhanced by social events and the setting up of a clinical forum. The latter is a meeting of clinical leaders from primary and secondary care, without any managers present – the aim is simply to increase understanding and communication on both sides.

We have come a long way in developing joint working with social care. Together with Dudley Community Services, we have looked at the benefits of integrated care, but there’s a lot more for us to do. The Transforming Community Services programme, introduced at the beginning of 2009, has really brought integrated care opportunities to the forefront.

From 1 April 2011, most of the adult services within Dudley Community Services will join DGoH. Importantly, the quality of care delivered to patients must be maintained, but there will be a drive to transform the services and improve the pathways and experience for patients.

We hope to be able to streamline the interface between hospital and community. We want these improvements to be driven by the staff who deliver the services and who are experts at identifying opportunities where we can improve, which will truly make a difference to our staff, our patients and their families. Over the next few months, we will be working to enable this transfer and start to look at how we make sure policies and procedures align. However, we see this as a joint partnership and will be open to any ideas that will help us to improve the services.

Our patients expect an integrated journey, which includes consultation, investigation, treatment and follow-up, irrespective of where the care is provided. Many patients complain about the apparent lack of continuity when moving from one part of the system to another.

For instance, interpreters are a very good example of where primary and secondary sectors both have separate resources. At present, the patient may have to change interpreter (sometimes several times during their pathway), which they may find difficult.

Funding and resources
Public confidence in the NHS is a challenge that must be faced. Some patients may still feel that, for instance, minor surgery is more appropriate in a hospital setting than in a GP clinic, and consequently prefer to be treated in a secondary care setting. This is despite the fact that minor surgery can be offered safely in a primary care environment, often within quite short timescales.

This is a potential waste, as treatment in primary care can offer better value for money for the NHS as long as services are not duplicated. However, patients are not really interested in economics. They are interested in receiving safe, prompt and effective treatment at a time when they are often at their most vulnerable. It is our job to educate and reassure patients about treatment options. Perhaps we should all listen more to what our patients want, and not always design services around what we think they need.

If primary and secondary care offered more shared services, perhaps we could remove some of our patients’ concerns and deliver improved quality of care more cost-effectively. This can be difficult to achieve in practice, as we know. Patients want GPs to ooze confidence, and they rely on GPs to offer guidance they trust. “Choice” needs to be taken into account when designing joint services, but we also need to encourage self-help and self-management to enable us to cope with the increasing demand for healthcare.

Inevitably, the care of the elderly and the most vulnerable is going to be an even greater challenge as we move into more financially difficult times. Social services are being hit hard just as the demand for care is rising. Trying to get medically fit patients, who require care packages or residential care of some kind, discharged in order to accommodate new admissions takes up too much valuable time of both managers and clinicians.

GPs are finding this more and more frustrating. They know some of their patients are in hospital unnecessarily, while they can face difficulties in getting other patients admitted. We all, as partners in healthcare, need to look again at how we can better utilise funding and resources and understand each others’ roles and problems in order to work together to address them. Those that want to step back need to be persuaded to come to the table.

Partnership working
Can primary and secondary care ever be true partners or will we always be competitors? Can we do anything about it at a local level, given the weight of bureaucracy laying its heavy burden on us all? I believe we can if we follow several steps:
We need to be brave and find a better and sustainable model. This concept might be radical, but it will also make people take notice.

We need to think more widely about how we can better use money invested locally, and we need to come together with a single purpose to maximise our use of resources and skills.
We need to understand how our resources can be utilised best, while at the same time recognising the importance and viability of each intrinsic partner.

We need to understand how better to communicate with one another and how best to share good practice and information to benefit both our patients and ourselves. We need to remove the stressful working conditions that many endure in the health service as a result of their heavy workload 
and professionalism.

Through partnership working we could solve some of the fundamental blocks that arise on a daily basis for each of us, and in doing so free up time to deliver the care our patients deserve. Most people I speak to say they want more time – with their GP, their practice nurse, their consultant, or indeed any other health professional they come into contact with. Could we gain that time if we worked as one? I firmly believe we could.

What I can’t predict is to what extent the increasing demand for healthcare will offset any capacity generated by more efficient working. We need to achieve better triage and better communication for self-care and self-management, and we need to try to manage rising expectation.

In putting our patients at the centre of our strategic thinking, managers must remember that clinicians are key to helping us deliver high-quality care more efficiently and more cost effectively. My vision is to see the walls between primary and secondary care disappear and a new enterprise formed that includes all the local health professionals that deliver care in the community. Such an enterprise would allow us to work as one to deliver healthcare in a new and exciting way and best serve those who really need us.

If we are to deliver quality care, which we all believe in, then primary and secondary health sectors need to create a true partnership.