As we have built our devolved health and social care system in Greater Manchester,
the critical role of primary care has been emphasised throughout. This has been further underlined as the 10 areas of Greater Manchester have developed their locality plans. Primary Care is now increasingly viewed as a core component of an integrated, community based, care system rather than a separate stand-alone entity.
Primary care services provide the first point of contact in the healthcare system, acting as the ‘front door’ of the NHS. Primary care includes general practice, community pharmacy, dentistry, and optometry (eye health) services.
There are around 2,000 points of delivery for primary care across Greater Manchester, with somewhere over 90% of all NHS patient contacts taking place therein. We want to expand on the traditional concept of primary care to foster a much wider primary care system including, for example; physiotherapy, midwifery, podiatry, social care along with voluntary organisations in order to enable people to access the most appropriate professional and service directly.
The Greater Manchester vision focusses on the place and the people who live in it, rather than the needs of specific organisations and professional groups. This will require close working between patients, service users, local communities and front line staff, not just in health and care, but across public health, housing, education and skills, leisure, welfare and benefits, with the aim of achieving properly integrated public services.
Primary care – whether provided by doctors, dentists, optometrists, pharmacists or other health and care practitioners who support people outside hospital – already benefits our local population. It offers easy access, high- quality care from professionals who know their patients and can make a big difference to health outcomes.
But there are many health and care related issues facing Greater Manchester that could be addressed by improvements both to primary care generally and to specific services, In particular by ensuring we all work together and make the most of every opportunity to give people the right support close to where they live.
As elsewhere, our population is ageing, with a predicted 29% increase in the proportion of people over 65 by 2032 and the proportion of over-85s expected to double. Increasing numbers of people have more than one long- term condition. This has led to increased complexity in the care provided to our populations within primary care. At the same time, we have higher than average numbers of children and younger adults, with under-19 year olds accounting for 24% of the Greater Manchester population.
Greater Manchester has suffered some of the poorest health in the country in the past. We still face significant health inequalities, with unfair differences in the health of groups of people, because of social, environmental and economic conditions that increase their risk of becoming ill and make it harder for them to stay healthy and get the right treatment when they need it.
For instance, national public health figures show higher levels of deprivation in parts of Greater Manchester than in other areas of England. Three local CCGs are in the bottom 10 nationally for healthy life expectancy at birth.
How people use – or do not use – primary care and other health services in Greater Manchester is a further indication of the scale of the challenge ahead, and where the whole range of primary care services could do more to benefit patients.
Thousands of people are treated in hospital when their needs could be better met in the community; care isn’t joined up between teams and not always of a consistent quality. In Greater Manchester people diagnosed with ‘ambulatory care sensitive’ conditions such as diabetes, asthma and hypertension, which can be actively managed, are more likely to be admitted to hospital as an emergency case when this could have been avoided.
General practices vary a lot, both across Greater Manchester and within localities. According to the 2015 national GP survey, nearly three quarters of Greater Manchester patients report a good overall experience of getting a GP appointment, but 12.5% were unable to make an appointment at some stage. Other research has found the proportion of patients who have a ‘poor’ experience of making an appointment varies significantly by locality.
Primary care, both in our region and nationally, faces a variety of challenges, with new ones emerging all the time.
Workforce capacity and capability
There is pressure on primary care from other parts of the health system, resulting in increased workload. According to one survey, nine in 10 GPs feel their heavy workload has a negative impact on the quality of care they give their patients.
Problems recruiting and retaining GPs create further workforce difficulties. Between 2002 and 2013, GP numbers only increased by 14%, compared with a 48% rise in hospital consultants. A third of GPs hope to retire within the next five years, and a fifth of current GP trainees plan to move abroad. Other parts of the primary care workforce face similar challenges, for example in practice nursing, over 64% of practice nurses are over 50, and only 3% are under 40.
This strategy recognises that there are a number of health care professionals e.g. pharmacists that could be better utilised to support these challenges. We will also expand on the traditional concept of primary care to foster a much wider primary care system including, for example; physiotherapy, midwifery, podiatry and social care along with voluntary organisations in order to enable people to access the most appropriate professional and service directly.
Sustainability and affordability
Investment had fallen from 10% of total NHS funding in 2010 to 7.9% in 2014/15. The financial constraints on the NHS are likely to continue and are another reason why primary and secondary care needs to change. In Greater Manchester, £6billion of health and social care expenditure accounts for nearly one third of total public sector spending.
Expectations and attitudes
There is rising demand for medical care and patients have increased expectations regarding the care offered to them. We need to manage demand effectively to deliver high-quality, sustainable care for Greater Manchester.
Primary care practitioners have a critical role to play in delivering short, medium and long- term interventions to improve the health of local people. Whether by finding and treating the right patients, building resilience and enabling recovery in particular patient groups, or enabling the best start in life for all, primary care must contribute to the reduction of preventable demand.
‘Organisational inertia’ can be a barrier to different ways of working to improve service delivery and the quality of care. So too can cultural and professional resistance to change. Leadership at all levels, throughout the system, is increasingly important in developing and implementing new approaches to primary care.
We have begun to address all these challenges but further transformation is necessary, including the effective integration of community, primary and secondary care.
Improving access
In 2014, as part of the Healthier Together programme, we said that: “By the end of 2015, everyone living in Greater Manchester who needs medical help will have same- day access to primary care services, supported by diagnostic tests, seven days a week.” We have built on the success of our demonstrators by opening
Setting higher standards
NHS England and the 12 CCGs of Greater Manchester have collaborated to develop nine Greater Manchester Primary Care Medical Standards, which will be implemented by December 2017 (see section 2 for details). These are based on the Bolton Quality Contract, which commenced in April 2015, covering aspects of service delivery such as appointments, prescriptions, vaccinations and mental health care.
We have worked with GP practice staff to develop best practice guidance for offering improved access; including managing demands for urgent care during practice opening hours and helping patients understand their electronic health record and online health services.
Utilising community pharmacy
In response to the 2014 national Improving care through community pharmacy call to action, the Greater Manchester Pharmacy Local Professional Network (LPN) engaged with healthcare professionals and the public to explore the best way to use what community pharmacy has to offer.
The network has revised its strategy in response and developed a six-point transformation plan that recognises how pharmacy can contribute to transforming health and social care services. With every local person visiting a pharmacy on average five times each year, there are real opportunities to deliver healthcare messages to the public directly.
Medicines-related problems contribute to demand for acute and emergency care, with around 6.5 per cent of hospital admissions associated with adverse drug reactions and significantly more resulting from exacerbations of conditions due to medicines not being used as recommended or sub-optimal prescribing. For example, 30% and 50% of people aged over 65 and 80 years respectively suffer a fall at least once a year and these episodes are often related to the medication that they are taking and/or symptoms of their long term condition. In a recent study, patients on four or more medicines bene ted from a reduction in risk of having a fall due to the intervention of a community pharmacist.
Pharmacists already help patients get the most from their treatment. Further joint working across health and social care will ensure that all patients on long-term medication have the chance to discuss their medication with a pharmacist and set their own targets.
Tackling oral health in children
The Greater Manchester Dental Local Professional Network’s Baby teeth DO matter campaign to encourage oral hygiene routine in under-fives, has led to better quality, more easily accessed preventive primary dental care.
Oral health improvement teams, local school nurses and safeguarding teams are working together as part of the ‘buddy practice’ scheme, currently operating in one Greater Manchester locality. This has increased access, identified unmet need and delivered signifantly improved outcomes for a number of vulnerable children.
Reducing the risk of sight loss
The Local Eye Health Network has collaborated with Health Education England (HEE) to develop the first, funded, non-medical prescribers programme for optometrists to enable them to better manage minor eye conditions in the community. To encourage care closer to home, the network has agreed a common pathway for glaucoma- related and cataract referrals. Implementation of these schemes and similar community eye care initiatives at scale across Greater Manchester would significantly reduce unnecessary referrals to hospital.
Innovative models of shared care for patients with long-term eye conditions are being developed. Greater integration of primary care optometry and hospital eye services would offer elderly patients in particular, timely care closer to home. These patients require a lot of follow-up care, so developing this at scale across Greater Manchester will significantly reduce demand for hospital eye services and help prioritise specialist care.
This transformation will help make high street opticians – which are increasingly open in the evenings and at weekends – people’s first port of call for eye care problems, especially minor ones, relieving pressure on both A&Es and general practice.
We want to encourage a population based approach to improving health and care through the delivery of place based care. This would include the alignment with the other public services e.g. housing and the police, in order to address the wider social determinants of physical and mental health. By removing silos of provision, we will incentivise providers over health outcomes not levels of activity, working together in an integrated delivery model.
Reducing silo networks and systems will enable people and information to flow across Greater Manchester. We will develop and upskill a sustainable primary care workforce with a focus on wellbeing, prevention and restorative health, whilst empowering our patients, carers and communities to take greater responsibility in their health and wellbeing. The development of robust systems will support the primary care workforce to deliver consistently high quality care, assured against evidence based standards.
We want to deliver ‘place-based’ care by moving to a neighbourhood model. This will see multi-disciplinary teams serving natural populations of around 30,000-50,000 people, and making the most of ‘community assets’ such as voluntary and community groups within neighbourhoods.
We plan to increase early detection of disease and find the thousands of local people with a condition that has not yet been diagnosed. We will use integrated patient information to identify those with patterns of symptoms or at particularly high risk of developing conditions, who will benefit from follow-up, lifestyle intervention or screening.
We want a system that understands the relationship between health and the wider determinants of health, ensuring access to support to address issues such as employment, fuel poverty and social isolation are as embedded as writing a prescription or making a referral to secondary care.
Key principles
We want a system that understands the relationship between health and the wider determinants of health, ensuring access to support to address issues such as employment, fuel poverty and social isolation are as embedded as writing a prescription or making a referral to secondary care. Our plans for transforming primary care are rooted in doing things differently and based on two key principles.
The first is that improvements are most likely to be successful when led by people themselves. We have described this as ‘People-powered change’ and we must make sure our public receive the right support to take more control of their own health and behaviours.
The second is that changes must be delivered to meet local needs and make the best possible use of what resources are available not just across Greater Manchester but within its different localities and neighbourhoods; we have described this as: Care delivered by population – based models.
The nine Greater Manchester Primary Care Medical Standards are:
- Improving access to general practice
- Improving health outcomes for patients with mental illness
- Improving cancer survival rates and earlier diagnosis
- Ensuring a proactive approach to health improvement and early detection
- Improving the health and wellbeing of carers
- Improving outcomes for people with long-term conditions
- Embedding a culture of medication safety
- Improving outcomes in childhood asthma
- Proactive disease management to improve outcomes