Just over halfway through the NHS Five Year Forward View, pockets of the country are developing primary care homes (PCH) as their route to primary care transformation. The PCH model aims to encourage GPs to work collaboratively and align incentives with their local colleagues in community, hospital, mental health, social care and voluntary care settings to improve the way care is provided to groups of 30,000 to 50,000 registered patients.
Last summer we were commissioned by the NAPC to undertake an evaluation of the implementation of the PCH model, with the aim of feeding in to its design, and have published our key findings and lessons today.
We focused on reviewing 13 of the 15 rapid test sites that launched the model and examining three case study sites in-depth. Robust quantitative analysis on patient outcomes was impossible so early on in sites’ evolutions, so we instead focused on systematically capturing the enablers and barriers perceived to impact progress. They made good progress but like most large-scale change, it will take most primary care home sites many years before they are delivering the model in full. Below I summarise some of our key findings.
What did early progress look like in rapid test sites?
Rapid test sites typically built on existing initiatives and assets. They tended to focus on distinct interventions and patient cohorts, and where possible, they co-located primary and community teams together, and trialling and iteratively adapting completely new services. There was no ‘one size fits all’ approach to building the PCH model, but the commonest population group that was targeted was complex patients at risk of hospital admission. The sites used a variety of approaches, for example:
- Beacon Medical Group developed a virtual ward
- Breckland Alliance implemented practice-based care planning
- Healthy East Grinstead Partnership developed an integrated practice and community team to undertake care planning
- South Bristol Primary Care Collaborative hired a prescriber to carry out home visits
- Thanet Health CIC adapted an existing hospital-based proactive frailty service.
What did they achieve?
Launching these new initiatives was not straightforward, but within six months the PCH approach had stimulated partnership working and developed or improved services for at least one patient subgroup across most sites. A few rapid test sites were also operating as pilot sites for local commissioners who were looking to expand the model.
Within nine months, the three case study sites we looked at (in East Grinstead, St Austell and Thanet) were able to quantify the impacts of their interventions, which demonstrated progress towards improving collaborative working (something that had been lost in recent years), freeing up time in general practice, improving patient wellbeing, and reducing hospital admissions.
How did they do it?
Progress was helped by a shared history of working together among GPs, and driven by hard-working multi-organisation operational teams who were able to think creatively, shift staff around projects, and had the ears of their respective executives.
In some sites commissioners were part of the PCH leadership team, and were better able to pull in resources and staff to deliver the model than sites that didn’t involve commissioners. Where providers and commissioners were distinct, securing buy-in from local commissioners was easier where they saw the emerging PCH as a delivery vehicle for the local plans or STP.
Leaders described gaining engagement and support for shared accountability from the front line by communicating the aims and plans of a specific intervention rather than describing changes as part of the primary care home evolution. And much like the vanguards, most of the work carried out in rapid test sites was rapidly enabled through memoranda of understanding (MOUs) rather than formal contracts.
What held them back?
Many sites were worried about longer-term funding to sustain their PCH initiatives, particularly if they were unable to get buy-in from their local commissioners, which made forward planning difficult. Leaders also often engaged staff by describing the short-term goals of interventions, which meant that months into implementation some staff did not understand the aims of the PCH model.
Resources to undertake an evaluation, including access to linked data, were limited in most sites. A minority of sites had carefully thought through their ‘logic models’ and the complex links these plans needed to demonstrate between their aims, existing resources and expected outcomes. An even smaller number of sites had detailed plans on how they would collect outcomes data across partners and none were measuring costs.
Looking to the future, the lack of formalised governance structures may also slow PCH sites’ progress in taking on financial risks and gains.
What should we expect in future?
The real challenges for the PCH model are similar to challenges we have identified in previous work on new models of primary care. These things take time, need money, and crucially require people to work creatively and collaboratively across organisational boundaries. There is no doubt that the goals underpinning new models of care are the right ones – the trickier thing is delivering and evaluating them.
Kumpunen, S. (2017) "What we learned about the Primary Care Home model" Nuffield Trust comment www.nuffieldtrust.org.uk/news-item/what-we-learned-about-the-primary-care-home-model