Have you ever ordered something, perhaps in a restaurant, and then realised when it arrived that it wasn’t what you thought it was? I was in Paris recently and ordered a pizza. I chose to add the optional ‘egg’. When it arrived I had not expected that the egg would only have briefly glanced at the pizza oven and essentially still be raw! What do you do in these situations? Sometimes you can send things back, but sometimes you have to accept that your understanding or interpretation was not quite right and re-frame your thinking. I got on with eating my pizza and raw egg.
I wonder if there is some confusion and re-framing that needs to be done around what we are talking about when we describe General Practice Networks, Primary Care Home, Care Communities and similar. To my mind these terms are not all freely interchangeable, and I wanted to describe what I think a couple of these mean, and the difference between them.
Locally we have encouraged the development of what we are calling ‘Care Communities’. We have also encouraged the development of a GP Federation. The question I guess I have is whether either of these constitutes a General Practice Network, and does it matter? I think it does.
GP Federations and GP Networks
GP Federations and GP Networks are about General Practice (the clue is in the title). They are about how GP practices can work together in potentially different and more efficient ways. This might include hub working to provide services for patients across a larger footprint than individual practices can manage themselves. In Winsford, where I work we already have two such examples. We offer extended access appointments whereby practices provide appointments open to patients of neighbouring practices –this means that patients in the town have access to appointments every evening even if their registered surgery is closing at 6.30pm. We also currently have a scheme operating a paediatric clinic weekday evenings. Children can be booked into these slots each evening, regardless of which practice they are registered at. Working in a collaborative way like this ensures improved access for patients in an effective way for the GPs and their practices. To my mind, GP Federations are likely to cover large numbers of practices and large geographical areas, and GP Networks likely to be smaller units within the Federation. In other words, a Federation might cover several towns and outlying rural areas. While a GP Network might be restricted to a single town and surrounding area, fitting in with the 30-50,000 population coverage we hear so much about.
A GP network might also look at sharing some back office functions, thus working more efficiently and reducing costs. There are a number of examples of this around the country.
GP Networks and Federations can also negotiate with local commissioning groups to bid for and then provide services for local patients. It is much harder for individual practices to do this than it is for a larger federation on their behalf.
As you can see from the above examples, I think a GP network or a GP Federation is very focused on General Practice, on the services they provide and on how they operate and work. I would like to suggest that this is distinct from what a Care Community might be.
Once again, I think the clue is in the name. Care Communities are about the local community. They obviously need to include the local GPs, and therefore likely the local GP Network, but they are wider than General Practice. To my mind, for a Care Community to be effective it needs to be as broad as possible and think as widely as possible. The NHS has not traditionally been very good at this. We tend to think ‘health’ and struggle to raise our eyes up and beyond that. GPs can also fall into the trap if thinking just about General Practice, and not even about the entire community health system (I say this as a GP myself). We need to include the wider Primary Care team – district nurses, Occupational Therapists, Community Physio, Midwives, Dentists, Opticians, Pharmacists and others I am sure to have missed out (apologies). Care Communities also need to think ‘whole community’. By that I mean social care, education, housing, town planning, local employers, third sector, local sports clubs, leisure facilities, industry and more. I believe that by tapping into the resources within the community as a whole could unlock solutions to many of the public health problems we are struggling to solve.
As previously mentioned, I work in Winsford in Cheshire. We have a Primary Care Home model in place supported by the National Association of Primary Care (NAPC). Team Winsford meetings include more than GPs. We are thinking whole community and need to continue to do so. As I have already suggested, if we try to solve the healthcare problems in our communities by looking to just the GPs and health professionals to do something, we are likely to fail. In this time of budgetary constraint we need to include the community and fully utilise the resources we will find there. As I write this I am aware that tomorrow I have a meeting with Town Council representatives to talk about how we could think about smoking cessation in the town. When it comes to smoking we could take a medical model in how we approach it, but we immediately come up against whose responsibility it is (Public Health or NHS?) and who will pay of the prescription and support services. This, unfortunately, will probably get us nowhere. If, however, we take a community approach, we are likely to come up with very different suggestions and solutions that are not based around who can or should prescribe medicines to help, and based more around the other ways we can support smokers to stop.
Want more examples?
The Somerset town of Frome is a good place to start. By working as community they have managed to reduce hospital admissions. Check it out here: https://www.theguardian.com/commentisfree/2018/feb/21/town-cure-illness-community-frome-somerset-isolation
Somewhere else? Look further North to Fleetwood in Lancashire. They are using the Primary Care home model championed by the NAPC to work as a community to improve health. You can see what they are doing in this short video. https://www.youtube.com/watch?v=ontqsXah0x0
I started this blog asking whether you had ever ordered something and found it was not what you thought. I think that many GPs have entered into GP Networks and Care Communities, thinking that it is about GPs, and are only now realising they could be about something very different and much bigger than anticipated. This could be scary for us. A medical model of health is deeply engrained within us, and it is hard to step out of this and embrace something different. We need help and support with this. I hope that when this realisation occurs that we will not be sending our order back to the kitchen, but instead going with it and changing how we think and view community. Thinking of it as a resource and not a problem to solve.
Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group.
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