New models of primary care

13 April 2016

“You have a core customer who has changed and you have a legacy model of care that needs redesign. That redesign would be to more planned, proactive, co‑ordinated care with others who work close to [the person’s] home.”

That was my oral evidence last December on behalf of National Voices to the Health Select Committee inquiry into primary care. It was also the dominant theme of Reform’s Who cares? report and roundtable on the future of primary care.

Reform’s contribution is particularly valuable for identifying the places – Lakeside Healthcare, Taurus Healthcare, the Hurley Group – where GPs are taking reform into their own hands (‘practice without policy’) to produce new models.

More than half of England’s GP practices now belong to some larger entity, but as Paul Corrigan notes in a related blog only some of these – the ‘super practices’ – really set out to redesign care.

For National Voices and its 140 charity members, a key question is whether care redesign will be done hand-in-hand with service users and expert patients.

In the private sector most consumer-facing companies wouldn’t innovate without being sure they were meeting consumer needs and preferences.

In healthcare we need to get reform right first time, and, particularly where we have in mind people living with conditions over time, it is the patients who know best what works for them.

Take records, for example. If you started with what works for people, you would not end up with the current electronic health record system.

You would be designing an interactive record, at the front of which is the person’s individual care plan with their goals, priorities and preferences clearly outlined. The person would be able to correct, add notes, and use it for daily self-management tasks including recalling the reasons for decisions about medications and other treatments.

This points to the need for primary and community care to adopt an ethic (or ‘business model’) of supporting self management; work with patient experts and groups to design it; and then put in place the interventions that work for people.

These interventions are well described in literature and in our evidence booklets; and some are being further studied in the Realising the Value programme. Who Cares? cites many examples.

They include information and education for self-management; peer support; personal budgets; care coordination; self-held records and care plans; and training for frontline practitioners in risk communication, health coaching and other relevant approaches.

Personalised care planning should be the key vehicle to identify and deliver these to individuals. The ‘tailored approach’ described in NICE’s new draft guideline on multimorbidities approximates this.

When providers reform, they often default to provider-centric models. They often focus on what clinicians should do. But we do not just need ‘more clinicians’. We need a range of expertise and support roles – and to make the best use of community assets for holistic care and support.

Providers do not ‘implement’ self management. People with conditions self manage, 24/7. What they need is a primary and community care system that proactively supports them to succeed. Can we design it together?

Don Redding is Director of Policy at National Voices



Adrian midgley

20 April, 2016

Abandon the idea of health records and think about automation. You may care to consider that while running a calendar conveniently accessible to the patient/citizen or as you put it consumer (which is pretty much built in to their phone, actually) is great, the doctors who built the early systems did so to support doing doctoring. Overlays and distractions - from Pharmacy reimbursement quirks driving adverse changes to the model of listing drugs, to various hobbyist or interest groups demanding the ability to program people via the computer - have not made systems actually better at that. If you want to reuse information, which is a good idea, then look at quite old ideas and standards similar to VCAL and write code to do the new things you have in mind on the machines of the people you want to do them for.