26 October 2015, National

Building a primary care revolution

Today’s ambitions for great, modern primary care demand a revolution in infrastructure and buildings.

The first task is to understand what is required.  Next, we need the right decision-making structures to commission it.  Finally, contractors with the right mix of skills must be developed to deliver it.

Extraordinary possibilities for improving patient services

This revolution is driven by extraordinary possibilities for improving patient services.  Half of all hospital out-patient care could be shifted to properly resourced primary and community settings, relieving pressure on hospitals, enabling patients to get more support in their communities and reversing the enormous pressures on general
practice, one of the most cost effective services in the world.

Best practice examples

In Tower Hamlets, we’ve already made the shift for diabetes care, with some of the country’s best clinical outcomes.  Next are renal care and other long-term conditions.

Instead of the 1 or 2 per cent of NHS births being delivered in home or community settings, we could have 25 per cent, achieved in parts of Holland. 60 per cent of people with terminal illness die in hospital, though most want to be at home with loved ones.

In one of the Vanguards, the rate has been cut to 14 per cent, thanks to a clever mix of IT and traditional skills: expert nurse consulting delivered via Skype.

Utilising primary care to reduce the burden of urgent care on hospitals

Reducing the burden of urgent care on hospitals, especially during evenings and weekends, requires excellent primary care facilities. Additionally, complex care – proactive management of patients,particularly the frail and elderly, with multiple health issues – is our growing responsibility. In Tower Hamlets we manage 5 per cent of patients this way with multi-disciplinary teams.  That will rise to 20 per cent in a couple of years.

This weekday service reduces patient flows into hospital, with the next step being to plug weekend gaps, cutting hospital admissions and facilitating discharge on Saturdays and Sundays.

Managing expectations

A modern ambition for primary care means keeping up with expectations.  They vary with age.  People with chronic and complex disease, particularly the frail and elderly, regard continuity of care highly. Younger people care more about immediacy.

Flexibility key to meeting requirements

So we shouldn’t offer everyone the same.  An older person may need comprehensive patient checks and longer appointments. 

For a younger person, seeking contraception, a 10 minute, easy access appointment may suffice.

The influence of IT

IT is also driving once undreamed of possibilities.  This morning, for example, I had a three-way consultation with the acute obstetrician on call. The patient sat beside me and was delighted at receiving comprehensive care and avoiding a hospital visit.

'Not just about buildings'

Put these possibilities together and it’s clear that primary care facilities need a rethink - fast.   It’s not just about buildings.

Top class IT and Wi-Fi are must-haves.  This support for remote consulting may shrink some property needs.  But shifts towards social prescribing could require more buildings, albeit shared and more flexibly used.

Every public sector building – be it a school or a surgery – must be considered in terms of improving health and well-being.

Making the right connections

At Bromley-by-Bow, we have 100 different projects under one roof and the practice can connect patients to potentially 1,100 voluntary organisations locally. 

All this complexity means that decisions about buildings and infrastructure should be made locally by the CCG and the local authority.  Centralisation of community property management creates too many barriers to the changes required.

But CCGs need support from, for example, Community Health Partnerships (CHP), to research, commission and deliver integrated health infrastructures – both buildings and IT.   CHP helped transform primary healthcare through the LIFT programme, growing specialist skills within the building sector.

The coming wave of modernisation requires its own particular supports to commission and deliver infrastructure needed for the primary care revolution.  We must ensure that these are readily available.

CHP has helped transform primary healthcare through the LIFT programme, growing specialist skills within the building sector.

Sir Sam Everington, Non-Exec Director, CHP Board, GP & Chair of NHS Tower Hamlets CCG