Future models of primary care, integrated care and the Fuller stocktake

In late 2022, GGI and Reset Health - a care provider championing an innovative approach to long-term health conditions - collaborated on a piece of research exploring the future of primary care. The research culminated in a special webinar looking at new models of primary care and discussing how the recommendations of the recent Fuller Stocktake report on integrated primary medical services can be taken forward by systems.

This short report brings together some of the key findings from the work and highlights from the webinar which featured Dr Claire Fuller, the author of the Fuller Stocktake report, and Grant Harrison, director of strategy at Reset Health.

Fuller Stocktake report

The report was produced by Dr Claire Fuller, a long-standing GP and the CEO of Surrey Heartlands Integrated Care System, who was asked by NHSE CEO Amanda Pritchard to look at integrated primary care within systems.

The report followed conversations with around 500 people in roundtables and about 300 in one-to-one discussions, as well as 12,000 people accessing the review website.

It was sent to Amanda Pritchard with a letter that was signed by all 42 ICS chief execs, all of whom committed taking the review to their ICBs and acting on the recommendations. Claire said: “For the first time in my career we’ve got general practice and primary care and system working on every single agenda across the NHS.”

Claire said the themes of how to improve access and how to improve continuity quickly emerged as the big issues. She said: “At the moment people will either prioritise access – by seeing someone they don’t know more quickly and perhaps in a different setting – over waiting to see someone that knows them. And that can sometimes be a difference of weeks. At the moment there’s no way of differentiating between how people either make a phone call into the practice or walk into the service as to whether it’s right and safe for people to wait or whether we should be doing that differently.

“We also had agreement about what we needed to do. Primary care networks have been around for a number of years and at their best they work brilliantly but at their worst they’re a series of contracts held between NHSE and individual practices that result in two hours of a pharmacist’s care and three hours of a paramedic that don’t impact on either the workload or on the way we deliver our business. So in the report we talk about how we migrate from PCNs to integrated neighbourhood teams – and the important thing about them is that they wrap around our practices, who will still do the lion’s share of the care.

“I became a GP to deliver cradle-to-grave care. There are some transactional things where it’s ok to be seen quickly by anybody anywhere – if you have a swollen knee because you haven’t done sport for ages and suddenly you start up again or if your baby’s got a really high temperature – but if you have ongoing investigations, your outcomes will improve if you always visit the same person.

“GPs will all talk about those cases where somebody will come in with their tennis elbow and as they get up to leave, they’ll put their hand on the door and say: ‘While I’m here, can I just ask you about…” As we all know, the ‘while I’m here’ is actually why they’ve come in and creating space to have those ‘while I’m here’ safe conversations is what keeps the NHS on the road. That’s why neighbourhood teams are important – because it protects our practices, to make sure GPs can continue to build relationships within the context of where and how they live their lives and understand what is important.

“We also talk about creating the right environment – primary care estates has been neglected throughout my career. So we need to do something about estates, and in the report, we talk about making it not just about NHS or primary care estates, it’s about one public estate, making better use of commercial estates and doing things differently.

“We also talk about data and digital, and about making sure everybody has access to their data and records, including patients, including secondary care, and including social care so that we can make informed decisions about people’s care with them in a timely way.”

Stark statistics

Claire added: “East Surrey is an area within Surrey Heartlands with a moderately affluent population of about 200,000. They’ve identified that they’re moderately high users of health and social care. Looking at the health and care contacts of the top 600 people in that community over the last year, they’ve had 1,900 A&E admissions, 450 outpatient appointments, and 400 inpatient admissions. But they also had 54,000 GP contacts over that same timeframe. That tells you everything you need to know about the importance of general practice to the NHS today. That’s why GPs are exhausted and that’s why GPs are leaving the profession.”

In response, GGI principal consultant Simon Hall made three points. He welcomed the fact that primary care is on the agenda. “There was a feeling since the demise of CCGs that primary care was being downgraded. People wonder if this is just about primary care networks. And they wonder how place works.”

Simon also wondered where the resources to sustain primary care would come from. He said: “It’s interesting that in the report you talk about the sustainability of primary care and the urgent and emergency care pressures being two sides of the same coin, which is right. I think that’s really welcome. One of the things I worry about is where is that resource? There’s always a tension on the urgent and emergency care pathway, for better or worse, but where’s the same attention and funding coming to the sustainability of primary care?”

Finally, Simon questioned whether the way primary care is currently funded would allow for change. He said: “I welcome the practical steps you suggest that ICS leaders should be taking – it’s great to see the CEOs of ICSs signing the report – but what should leaders be doing about primary care workforce, data and so on, and can this really happen?

“Are ICBs going to be able to empower change to happen when there are still some slightly anachronistic ways of funding and doing things that relate to primary care? We need ICBs to be bold to enable flexible use of funds and not restrict initiatives to one-year funding notified part way through a year which make it impossible to undertake effectively.”

Reset Health's alternative care model

Grant Harrison, co-founder and chief strategy officer of Reset Health, offered an example of how involving non-clinical people can change people’s behaviour when it comes to chronic conditions – and thus relieve some of the pressure on primary care.

Reset Health works with people to deal with metabolic syndrome, particularly type-2 diabetes and obesity. Grant said: “We built a tech platform which connects doctors to patients – and as Claire said, we think it’s important to have one doctor dealing with a patient. There’s a bunch of automations too. The whole thing’s driven through the mobile phone because what we believe – and we’re finding it’s absolutely true – is that chronic conditions need engagement all the time. But how do you do that? You can’t have doctors just sitting and waiting to provide a very fast response. You have to build a system and get other people involved as well.

“So we’ve built a mentoring system of successful patients, who have been living with obesity or type-2 diabetes and who have reversed their conditions through our programme, to start helping others. We pay them to do this – we started by paying people £5 per month per person they were mentoring. But then we asked ourselves ‘how do we make the financial benefit of helping others significant so people would start talking about it and potentially start to manage their own conditions because they can see, down the line, the financial benefit?’

“So we’re building a system where we’re going to pay you for who you directly mentor and, if you can get those people to mentor others, who they mentor, and if they can get those people to mentor others, who they mentor. So we go down four levels, paying people who would otherwise be dealt with by a clinician to help others by saying things like ‘I understand what you’re saying about having trouble sleeping last night. Have you tried this? It’s what worked for me.’

“We’re talking about giving these mentors between £1,000 and £5,000 per month. That’s how much they’ll be earning for building up their network. These are not ‘frequent flyers’ – they’re not people who are an endless problem – they’re people who’ve been through the programme and interacted with clinicians, who we give support and training to. The doctors are still running the overall process with the patient, but you’ve got someone helping you to manage a chronic condition, helping you to manage a metabolic syndrome, which is something where you have to make very small decisions all the time.”

Absolutely committed

Closing the session, Claire Fuller commented: “The terrible state we have at the moment is that there are people who know what we want to do, know the people we want to help but are just not able to because we don’t have the resources, the time or the energy.

“What I’d like us to do is to protect people that are working flat out to enable them to do the job that we all trained to do, which is to look after people in the context of their lives and not just provide sticking plasters to the problems they have at the moment.”

She added: “I care about this stuff. And I’m absolutely committed to making sure we get this rolled out and we keep general practice and primary care on both the national agenda and in front of all of our ICS chief execs.”