The secretary of state for health has recently announced the new priorities for the upcoming ICSs to deliver health and social care. These include prevention (public health and primary care), personalisation (patient centered) and performance priorities (measurement and accountability). While the new health and social care bill is being drawn into an act and law, primary care contracts themselves are nearing their review period at the end of 2023/24 and gives an opportunity for both commissioning teams and GPs/front line staff to test new models that can cater to the ever-changing health care needs of the new post-pandemic patient population groups.
Vertical Integration Model:
As part of this review of primary care, one such model that is being discussed and tested successfully is vertical integration (related distantly to the former PACS based model). In health and social care, vertical integration (VI) refers to the coordination of primary, secondary, and tertiary health care services within a tiered service delivery system. Having corporate and experienced teams managing NHS hospitals take over the operation of GP practices means that patients can continue to consult a range of health care professionals at the local practice rather than seeking healthcare elsewhere. In several places in the UK, GP practices are now being run by NHS hospitals, enabling some GP practices to continue that would otherwise have closed, says a new study by the National Institute for Health Research (NIHR) undertaken by researchers at the University of Birmingham and RAND Europe. Part of the on-going review is looking at how to better integrate GPs with hospitals and incentivise to link up with trusts.
This would include ‘academy-style’ hospitals that are similar to the Wolverhampton model.
Benefits/opportunities of Vertical Integration:
- Successful vertical integration can lead to improvement in the continuity of care for each patient across the various tiers of health care delivery. For example, care necessary after a hospital stay should be provided by a primary care facility; in a successfully vertically integrated system, a patient’s primary care provider would be in communication with the hospital team caring for their patient and receive all the necessary documentation of the hospital or post-acute facility stay and discharge plans.
- VI could offer solutions for some primary care challenges such as rising demand and a high number of workforces nearing retirement
- Work activities can become equitable for all, and hours invested are paid appropriately
- Historically, GP practice staff have restricted career development opportunities and this model of working at scale with larger workforce and patient numbers can offer broader career opportunities
- VI can bring GP practice staff under the scope of NHS pensions, improved salary and redundancy packages, sickness benefits, cover arrangements, and other corporate perks available to Trust based staff
- In today’s workforce, having the opportunity for a more flexible, work/life balance is becoming an increasing priority. This new VI model can help reduce some of the current burden in primary care, through streamlining some non-value-based functions.
- Front line clinical and patient focussed time can increase if the VI model can subsume back-office administration, HR, finance, estates and other non-clinical maintenance and support function roles
- Anecdotal information has suggested that GP’s working lives have been broadly positive under VI model
- GPs also have access to professionalised governance, which supports things such as CQC processes, complaints, and incidents, while patients have access to more services from their practices.
- Practice staff can have access to high quality training and personal development package which is more often lacking in a traditional small practice
- Practices can improve their outcomes by piggybacking on the Trusts intelligence and data driven teams for population health management focus style patient prioritisation
- There is protection of employment for staff and access to unions and basic employment rights
- There is a good relationship between GPs and the trust where it is working
Challenges to consider:
- There has been no extensive independent evaluation of outcomes for such an approach in UK, but models do exist and work well where they have been implemented elsewhere (such as in USA, Canada, Australia) – but this can be developed prospectively, and one can learn from local UK models where these have been implemented in the past few years.
- There is limited evidence, to date as to improvements in patient satisfaction, GP workload reduction or better health outcomes – this must be built in and captured at every stage in the first few years of implementation.
- There is also a question of choice being limited for patients if most practices are run as such, and more so, if the same Trust also offers acute or community care as well in the locality.
- Some patients prefer smaller boutique style local practices closer to their homes and workplaces and shy away from large healthcare providers (although this can be mitigated by having local branch practices in the traditional sense).
- Loss of autonomy by some GPs has been noted and have described feeling more like locums or salaried GPs, although this can be averted by including willing or experienced GP reps on Trust boards which will only improve their influence on combined pathways.
- For commissioners, there is a concern that a two-tier service could develop in local places, where patients at trust practices get priority access.
- It has also been pointed out that once a practice joins, it is difficult to leave – partly because staff move to different terms and conditions.
Implementation support we can offer:
PCC is experienced in implementing models such as these through our experience working at scale, including development of GP Federations, and working across community and acute trusts. Through our experienced team of experts and associates well versed in years of such experience, they are aware of what works and what does not, and where trusts can face challenges or have historically suffered failures. Primary and secondary care work very differently and it is not a case of ‘one type fits all’, rather working with organisations to help identify which model and approach would be most appropriate for them. Primary care is a very sensitive area and localities have their own unique issues and challenges. The single most important consideration is for both parties/sets of organisations to understand each other’s cultures and to agree a vision and journey to become one over a period of time.
PCC can help develop and implement vertical integration through a system of modelling and GP engagement with trust partners and leads. Successful vertical integration relies upon active collaboration and cooperation from stakeholders at all levels of the health care system. To that end, PCC can help each member understand its clearly defined role and range of services that can be offered and proactively participate in the communication system.
While higher-tier trust teams can be guided to offer support in the form of technical assistance, mentorship, partnership, workforce development, and/or supervision to lower-tier facilities, they should not be the sole (or even primary) drivers of the integration. The GP practice teams equally must contribute bottom up and be viewed as gatekeepers of health care. PCC thrives in its experience and engagement skills and having relationships with PCNs and practices. When one considers VI, there are various models that can be tested as per the local requirements, and often having an external partner such as PCC present, to act as a coordinating and facilitating stakeholder in the building phase, can prove beneficial. Where such VI models have been implemented, often they have been treated with suspicion at the time but have been viewed as a ‘lifeline’ for the practices involved.
PCC can help remove the various challenges highlighted above and help to build the trust between partners from day one, allowing the creation of successful and long-lasting models. Such approaches should not look like a top-down done deal, but rather an engaged, informed, and equitable partnership. We can help you realise your aspirations and develop a VI model to establish an integrated primary healthcare-based health system.
