Preliminary Findings From the Guidelines in Practice Survey on the NHS Reorganisation Reveal Your Hopes For Its Potential to Improve Patient Care—Provided Obstacles to Implementation Are Overcome
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The NHS in England is undergoing a restructure that has the potential to transform primary care: connections between local health and care services will be enhanced, and services tailored to local population health needs. However, simultaneously, the NHS is experiencing the worst pressure in its 73-year history, coping with patients who have COVID-19, long COVID, and physical and mental health conditions exacerbated by lockdown, and facing a backlog of care delayed by the pandemic.
Last month, Guidelines in Practice conducted a survey to gauge healthcare professionals’ opinions on this reorganisation of the NHS (see Box 1 for a breakdown of the respondents). We asked for your views on the impact of the changes: will patient care improve, and how much influence will primary care have in integrated care systems (ICSs), which have taken on the core functions of CCGs? Is the reorganisation feasible in the aftermath of COVID-19, and has sufficient funding been made available? Your answers reveal that you are hopeful of the benefits that the restructure will bring, but wary of the many obstacles to progress that remain.
|Box 1: Breakdown of the Survey Respondents by Sector and Role|
Of 270 healthcare professionals who responded to the survey:
Of the healthcare professionals surveyed:
Impacts on Healthcare Professionals and Patients
Under the plans outlined in Integrating care—next steps to building strong and effective integrated care systems across England,1 primary care networks (PCNs) are tasked with expanding the general practice workforce and generating multidisciplinary primary care teams. In all, 65% (176 of 270 respondents) agree that a wider skill mix in primary care will lead to more comprehensive care for patients; 9% (24) disagree, and the remaining 27% (73) are unsure. Efforts to meet this target are already underway, with survey participants indicating that 75% (202) of practices have appointed clinical pharmacists, 57% (155) have appointed social prescribing link workers, and 48% (129) have appointed physiotherapists. Some of the other practice roles are community paramedic (29%; 78), pharmacy technician (29%; 77), and physician associate (26%; 70).
Impacts on Practice
These data are supported by 50% of respondents (136), who state that they are already enjoying a better skill mix within teams, and 39% (105) say that the restructure has led to improved communication with community care. However, fewer than one-third of the participants feel that the changes have freed up GP time (31%; 84), a stated aim of the reforms,2 and even fewer (26%; 71) think that GP workload has reduced as a result (see Figure 1).
Among the other issues raised are that there has been no visible difference to respondents’ practice, that the restructure is a ‘false economy’ that has increased bureaucracy, that it is poorly organised and managed, and that the blurring of job roles has led to confusion.
Impacts on Patient Care
Some of the expected benefits for patient care appear to have filtered through: respondents have observed improved communication between different healthcare professionals (43%; 116), the ability to adapt care to suit patients’ individual needs (37%; 99), faster access to the appropriate healthcare professional (36%; 96), and smoother transition for their patients between care teams (30%; 80).
In addition, 25% (68) identify other benefits for patients, including improved access to different services and increased patient satisfaction. However, many survey participants report negative consequences—such as ‘more disjointed care for patients with a lack of continuity’ and ‘substandard care … [creates] more queries and return visits’ —and some suggest that the situation is now worse than it was before the restructure.
Identifying Obstacles to Implementing the Changes
Integrating care—next steps to building strong and effective integrated care systems across England emphasises the importance of strong local partnerships, with primary care playing a central role in providing joined-up care.1 For 17% of respondents (45), this is a very feasible objective; 61% (165) state that it is possible, whereas only 22% (60) regard it as unrealistic. With readers optimistic about the potential for partnership working, Guidelines in Practice sought to identify other potential barriers to implementation of the changes.
Primary care budgets, formerly administered by CCGs, are now the responsibility of ICSs.1 Crucially, more than half of those surveyed feel that funding is insufficient to support the development of a multidisciplinary workforce, with a further 22% (59) expressing uncertainty (see Figure 2).
Primary care is well placed to shape the new care pathways forming within each ICS, but to achieve this it will need to be represented at all levels of the ICS. However, this is not reflected in respondents’ observations, with the majority (93%; 252) disagreeing with the statement that PCNs and ICSs have equal weight (see Figure 3). Although a small number feel that PCNs and ICSs are working well together, half of the survey participants (135) think that ICSs exert top-down control over PCNs, and a considerable number believe that PCNs are not adequately represented in ICSs.
Can the Restructure Succeed in the Context of COVID-19?
Although the COVID-19 pandemic has underscored the need for a health improvement agenda—which aligns with the stated aims of the reorganisation1,2 —the backlog of work it has created may be an impediment. Healthcare professionals face the competing priorities of addressing long waiting lists and implementing new service specifications, coupled with workforce burnout and staff shortages. Against this backdrop, three-quarters of respondents (75%; 202) lack confidence that the restructure will improve patient care; 41% (111) think that it will make no difference, and 34% (91) say that it should be reconsidered. Only one-quarter (25%; 68) believe that it will help patients.
The reasons for this are varied (see Box 2). Many respondents are critical of the time, staff, and funding available to implement the restructure. Others suggest the timing is wrong because it is difficult to predict the ‘new normal’. Some survey participants anticipate increased bureaucracy and government interference, and there are concerns that entrenched views will prevent real change. A more positive view is that, despite the inevitable upheaval, the restructure will resolve difficulties with the previous model and improve care delivery. Many report that practices are already working in successful local partnerships and that, with appropriate funding and close collaboration, barriers between care providers can be broken down, quality and efficiency can be maximised, and variations in care can be reduced.
|Box 2: Reasons Given by Respondents for Positive or Negative Attitudes Towards the Restructure|
Although some GPs, nurses, and pharmacists recognise the potential of the restructure to enable more seamless care for patients, many are dismayed about the limited time and resources available to implement the changes. The healthcare professionals who responded to the survey expressed scepticism that primary care would have enough of a voice in ICSs, and many are concerned that the reorganisation will not deliver the anticipated improvements for patients or healthcare professionals. It is clear that additional funding and support is needed if primary care is to harness the potential benefits of the new NHS model.
Nina Buchan, PhD
Features Editor, Guidelines in Practice
Commenting on the survey’s findings, Dr Anthony Cunliffe, Joint National Lead Macmillan GP Adviser; Macmillan GP Adviser London; Joint Clinical Chair, South East London Cancer Alliance; and Editorial Advisory Consultant for Guidelines in Practice, said:
The winner of a £100 Amazon voucher for participating in our survey is:
Dr Rachel Clark
GP, Greater Manchester
Keen to learn more?
Read Dr Karen Kirkham’s article on the new NHS model to understand the role of general practice in realising the objectives of the NHS long term plan, how primary care network (PCN) service specifications contribute to the delivery of place-based care, and the relationship between GP practices, PCNs, and integrated care systems in the changing NHS.