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Monday 24 October 2016
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The super practice

The Five Year Forward View’s ambition has been to bring health and social care together and streamline services. The Primary Care Home model is a community-based provider that does just this and offers an alternative solution to the heavy demand hospitals face

The Primary Care Home (PCH) is a population budgeted community-based provider organisation that can provide an alternative to current NHS hospital centricity.
The PCH is a home not only for general medical practitioners and their teams but for all primary care independent contractors (pharmacists, dentists, optometrists) and their staff, community health services and social care professionals. And potentially a home for many currently working in hospitals, in particular those who have a responsibility for long-term conditions care, for rehabilitation and reablement and for the hospital specialists who offer ‘office-based’ procedures.
The population would be GP lists that are aggregated to a locally appropriate size.
The model is an extension as well as a forerunner of the Five Year Forward View multispecialty community provider (MCP) model.
It also has the potential to be a disruptive technology and as such should drive a new approach to commissioning, and even more innovatively, a reshaping of the current NHS hospital model that is still based on an age-old form and function ‘frozen in aspic’.
Much of the current focus of commissioning is to drive quality into providers via a transactional contractual model. A PCH can make its own decisions to make or buy value-based care, for which commissioners should hold them to account. This is an incentive to transform care, as significant amounts of the care currently undertaken by hospitals could be better undertaken near the patient’s home.
General practice’s heritage, strength and popularity is an important part of social capital; virtues that must be maintained but can be enhanced by also being part of a larger organisation; to be both ‘small and large’ in its impact.
The PCH further offers an opportunity for other organisations and individual clinicians to provide care for the individual, together with a population responsibility, resource control and a transparent accountability. This is not a rigid model, but more a way of thinking, delivering and transforming care.

Where it all began
America has seen a focus by some to fashion a system for co-ordination of care out of their country’s non-system approach to health care delivery (citizens having to pay for health insurance).
The concept of the medical home has been discussed and debated there for some 30 years.
President Obama’s National Protection and Affordable Health Act includes the concept of accountable care organisations.
So what of England? Where is our medical home? Or even potentially a model accountable care organisation? To me, it already exists even if it’s not universally acclaimed as such. It is list-based general practice where primary care workers combine one to one personal care with the potential of population care.
The success of general practice in the UK is based on continuity of care serving a practice population. Good general practitioners have an on-going trusting relationship with and a responsibility for their patients .
So what of primary care? The late Barbara Starfield, professor of family medicine, Johns Hopkins University, USA, described the merits of a primary care system as: “That aspect of a health service that assures person focussed care over time to a defined population. Accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only those conditions that are too uncommon to maintain competence and rare or unusual manifestations of ill health are referred elsewhere. And coordination of care such that all facets of care (wherever received) are integrated.”
Her academic research demonstrated the following benefits of a primary care system: higher patient satisfaction with health services, lower overall health service expenditure, better population health indicators, fewer drugs prescribed per head of population, and the higher the number of family physicians the lower the hospitalisation rate. No wonder the Five Year Forward View stated: “The foundation of NHS care will remain list-based primary care.”

Challenges and opportunities
An actual budget cannot be devolved in the immediate future to nascent organisations, but the responsibility to manage the population-defined total clinical resource is essential.
A budgetary responsibility will ensure that, as increasing amounts of value-based care is undertaken in the ‘Home’, the monies will remain in the ‘Home’.
Some commissioners are already defining a capitated budget and how to devolve population budget management responsibility while remaining accountable – a welcome advance on ‘top down’ management. The best managers maintain necessary control by ‘letting go’ – a relatively rare NHS commodity.
These new organisations must not become hierarchical and top down. Two-way accountability, shared responsibility and support must be the order of the day between the PCH and its constituent organisations. Governance must also be about relationships.
Clinical specialists, whether in the PCH or not, must define a new role to optimise how specialist and generalists can work together. For example, a rheumatologist (apart from treating the rare or unusual) could have a defined population responsibility to advise primary care clinicians on high quality care without needing to see the patient.
This is an opportunity an opportunity to challenge the wastefully duplicative, expensive current model of out-patient care, and to share rewards for new ways of working.
This is a chance for currently pressurised general medical practice to receive support in the way good GP federations already accomplish.
There could be increased, sustainable resources by transforming care, rather than relying on winning individual contracts, more integrated clinical support when caring for patients with complex problems, and more readily available multidisciplinary clinicians to share the often-duplicated work load. And, equally as important, there could be a feeling of controlling your present and future.

Final thoughts
The PCH is an ideal opportunity to demonstrate that integration can make a difference to individual patients, rather than the danger it will become another bureaucratic NHS fad.
The only costs that may be incurred are for set up. NHS England is offering some funding for identified test sites.
Local health systems can use development monies that are currently being used for non-integrated initiatives.
It is important to remember this is mainly about current providers working differently. And with increasing resources for community-based organisations, this is a possibilty to offset the real cuts in social services and to achieve a community-oriented primary care.

Professor David Colin-Thomé, independent healthcare consultant, former GP and national clinical director for primary care.