What exactly is the Fuller stocktake?
NHS England commissioned GP Dr Claire Fuller, who is also the chief executive of Surrey Heartlands Integrated Care System (ICS), to review the current state of primary care across England and make recommendations on how to accelerate integration.
The idea behind the report was to give England's 42 ICSs, which will take over from CCGs on 1 July, a clear picture of steps they could take to drive forward integration and the support that primary care networks in particular would need to do this.
All 42 ICS chief executives have signed up to the recommendations in the report.
What is the aim of integrating primary care?
The report says that integrating primary care will help to improve 'access, experience and outcomes' for local communities. This centres around three key things:
- Streamlining access to care and advice for people who get ill but only use health services infrequently
- Providing more proactive, personalised care from a multidisciplinary team to people with more complex needs
- Helping people stay well for longer as part of a joined-up approach to prevention.
According to the report all ICS chief executives believe that achieving these aims will only be possible if they support and develop a 'thriving integrated primary care system'.
What does the report mean for primary care networks?
The report effectively sets out the next stage of development for primary care networks. It says that PCNs across England should evolve into 'integrated neighbourhood teams' bringing community providers across local areas together and working closely with acute and mental health teams.
Dr Fuller says these teams should be 'rooted in a sense of shared ownership for improving the health and wellbeing of the population'. In some ways this is very much back to the initial idea of what primary care networks were supposed to be for.
In order to achieve this, Dr Fuller says PCNs will need additional support from ICSs. This includes 'full alignment' of clinical and operational workforce from community health providers to neighbourhood footprints. The report also calls for PCNs to have access to 'back office and transformation functions' from their ICS, including support with HR, quality improvement, organisational development, data and analytics and finance.
The report says there needs to be a shared approach to estates, with organisations (including secondary care) co-locating teams in the community.
It adds that all of this work will involve a 'realignment' of the wider health and care system to a population-based approach to health, which could involve aligning secondary care specialists to neighbourhood teams.
Dr Fuller says that PCN clinical directors will need more support and there needs to be protected time for team development in order to make this work.
When is all this due to happen?
The report says that these neighbourhood teams should be up and running in the most deprived areas by April 2023 and cover all parts of the country by April 2024 at the latest.
What does the report say about access?
As mentioned above, the report says that people who prioritise quick access to care have different needs than those who value continuity of care. The report sets out a vision of how to improve same-day access to urgent care.
It says that the current system is 'not fit for purpose' and that primary care needs to move towards a 'streamlined and integrated urgent care system'. This would involve every 'neighbourhood' (PCN area) creating a single urgent care team and offering patients the 'care appropriate to them' when they contact the team.
These teams would connect into the wider urgent care system and bring together GP in-hours, extended hours teams, urgent treatment centres, out-of-hours, NHS 111 and others. The report says this new system should be for all patients assessed as 'requiring urgent care, where continuity from the same team is not a priority'.
It adds: 'Same-day access for urgent care would involve care from the most clinically appropriate local service and professional and the most appropriate modality, whether a remote consultation or face to face.'
So this is very specifically not talking about access to a same-day GP appointment, unless that is deemed to be the most appropriate professional the patient needs.
What does it say about prevention and health inequalities?
The report makes repeated mentions of ICSs using the Core20PLUS5 approach. This involves identifying the 20% of the population in England that is most deprived and other groups identified by data as well as five clinical priorities to reduce inequalities.
One interesting aspect of the report is that Dr Fuller says that it is 'generally accepted' that distribution of primary care funding is not always well aligned to population need. She argues that ICS leaders should review discretionary investment and attempt to address this problem.
The report also highlights that there are too many 'small pots' of development money that are ringfenced for specific purposes and a more useful approach would be for NHS England to combine these and allow ICSs to decide how best to spend the money to meet the needs of local people.
How will all this be achieved?
Dr Fuller acknowledges that 'very little of what is outlined in this stocktake is easy to deliver'. She says that tackling issues around workforce, estates and data will be key to delivering the vision for integrated primary care. The report says that 'the right approach' in these three areas will make the biggest impact for helping local areas succeed.
The report sets out a series of recommendations, some aimed at ICSs and others for the government and NHS England to take on board, which broadly fall into these three areas.
In terms of workforce it says that the primary care workforce must be an 'an integral part of system thinking, planning and delivery' and a focus of the upcoming national workforce strategy. Tackling the GP shortage is 'essential and urgent', it adds, although it includes little detail on how to do this.
The report says NHS England should consider further flexibilities to the Additional Roles Reimbursement Scheme (ARRS) and also look at how the scheme will operate after 2024. It also recommends that improving supervision, development and career progression for these staff will also be crucial in order to retain them.
On premises it says ICSs need to develop system-wide estate plans that maximise the use of community spaces. The report talks about ICSs looking at innovative approaches, such as making use of space in hospitals and local authority premises in order to create opportunities to co-locate teams. It also says the government needs to put the primary care estate at the heart of its next Health Infrastructure Plan and that capital funding for developments need to come into primary care.
Among the other recommendations are that primary care must be represented on all 'place-based' (normally local authority level) boards and that ICSs must work alongside local people and communities to deliver the ambitions sset out in the report.
What have people said about the report?
Health and social care secretary Sajid Javid said that the report's recommendations would 'improve patients’ access to services, including those with the most complex needs, and help people live well for longer'.
RCGP chair Professor Martin Marshall said the report was 'appropriately ambitious given the scale of the crisis in general practice'. He added: 'It shares a number of key aspirations with the college about the future of general practice, and how general practice fits within the new ICS structures and the wider NHS.'
While positive about the fact the report recognised and championed the vital role of GP practices, the BMA raised concerns about some of the challenges ahead. England GP committee chair Dr Farah Jameel said: 'There is much to welcome in this report, but we cannot shy away from the challenges facing us. [Recent] figures reveal that we’ve lost the equivalent of almost 400 full-time, fully-qualified GPs in England in the last year, and we face sky-high demand as practices attempt to address a vast amount of unmet need in the community two years into a pandemic - often in completely inadequate surgery buildings.'