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.
London’s 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:
- Demonstrate approaches that work to secure reduced demand, better quality and capacity, and an approach to primary care that is fit for the future
- 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.
- 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 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
London’s 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 London’s 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 community–based 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 the NHS, with a concentration on performance measurement as the route to stimulating and requiring change. In high performing health systems the balance is the other way round, with most of the effort focused on improvement and innovation. This shift in effort from a hierarchical performance management top down model to an innovation and improvement focus has generated significant benefits in these systems.
How it will work
The Academy will partner with local primary care teams/ Practices/ Federations and CCGs at a range of levels dependent on local need / capacity:
· Deliver: Providing local solutions and programmes where there is a gap until there is local or accessible capacity/ training/ skills, in Leading Quality, Data for improvement and innovation, QI methods, Coproduction and Innovation.
· Deliver: A database of evidence-based tools and methods
· Coaching & supervising local newly developed teams in these skills and approaches.
· Facilitating strategic development in these areas
· Hosting pan-London communities of practice, and
· Catalysing the development of data scientists, data literacy for improvement and innovation in professionals and citizens.
· Advocating for improvement and innovation in Primary Care across London
For more detail see Appendix 2: Results from the Co-design workshop
The Academy draws on the research on place-based collaboratives (Amoo, Malby, Mervyn 2016), which identifies the key conditions of:
• Strong relationships and inter-professional working, which should be linked to leadership training programmes and development.
• Culture of learning- neutral space partnership between academia and practice
• Leadership that is dedicated, focused, distributive and cedes territory
• Shared purpose and narrative
• Solving problems through data enabled communities of practice
• Incremental change based on repetition, reciprocity, peer leadership, collaboration with citizens
Organisation
The London Primary Care Quality Academy is a Membership Network, which operates through the core principles of:
1. Reciprocity and exchange
2. Centrality of the knowledge function
3. Accessible to all
4. Translates doesn’t replicate
The PCQA will have a physical presence at London South Bank University and a significant online presence for its intelligence function.
Challenges
At the first scoping workshop a number of challenges to the development of the London PCQA where identified, and these where taken into the co-design workshop to ensure that we generate a best -it approach.
a) Timing/ logistics: Getting the timing right to really encourage change; It will take a long time to develop the academy and people want QI support NOW
b) Sustainability/ scalability: GPs don’t have capacity/time to engage; Maintaining momentum; Picking up late adopters; How do we come together pan London; Keep it local VS centralisation; Need to establish measures of success & evaluation framework
c) Platform/ methodology: Need to foster innovation & disruptive innovation to support QI
d) Alignment:Without wide ownership this won’t represent diversity of views/approaches VS diversity of approaches diluting the effectiveness of the academy; Huge variation is what practices & organisations want, need and resources; Collaboration vs. competition; Language, labels & shared understanding of quality; Adds to number of interventions in this space VS helping with alignment; Lack of buy-in; Data sharing agreements/ IT interoperability
e) Funding
Achieving Change – The Work in the London PCQA
The development required for this evidence-based approach to innovative primary care requires skills in improvement at a micro-systems level (the practice/ team), coproduction through asset based development with local communities, securing economies of scale in back-office functions, and systems leadership (for pathways and to secure the permissions for new models of primary care).
Some examples of great practice in these areas are provided in Appendix 3. For example
· In Tower Hamlets GPs now see 24 patients in 3 hours rather than only 16 making them 40% more “productive.”
· In Leeds the sharing of back office functions has saved one practice £165,000 this year; they have secured a 57% increase in list size (4,500 people) without any increase in demand on primary or secondary care.
Quality Improvement
In our experience Primary Care needs a more holistic approach from the acute sector’s experience with improvement models. GPs need a proper business case and models developed that release capacity, and resources. One of the biggest gains for general practice is to work on failure demand, and this is where we have had most success – as a focus for change work it releases the most capacity and learning. Generating data, learning and modeling options is a powerful catalyst to new ways of working. However there is an issue of readiness, particularly in the quality of data in general practice.
All practices require the core practice of improvement – although practices differ in which method they favour.
Coproduction
Significant gains can be made where primary care incorporates an asset-based approach to the local population. Many of the problems of chronic disease, isolation, and the challenges in the acute sector can be alleviated by the development of community connectors working in neighbourhoods with the third sector, and community/ practice champions (local volunteers) collaborating with general practice to provide the resilience needed in communities. This partnership between professionals and communities generates new approaches to seemingly intractable local and individual problems.
Using a system’s model of organisation development and an evidenced-based health champion approach to citizen involvement, we work alongside practice teams and citizens to design an intervention which allows the Practice and the population they serve to co-evolve, identifying practices interested in developing a new model of care designed to help them to deal with the rising levels of failure demand generated by patients whose health and wellbeing needs can’t be met by a clinical intervention alone.
Innovation
There are two immediate innovation gains – technology assisted self-management and the harnessing of back-office functions and business models. There are gains to be made in data enabled self-management which can reduce citizen’s demand on health services, and through securing business capacity through combined resources across primary care teams and practices. Innovation capacity can be drawn into developing primary care models through partnering with accelerators, and local prototyping. In addition there are innovation opportunities in technology and digital solutions that can be harnessed in primary care. This is an emerging skills set in the NHS which needs to be harnessed in Primary Care.