In November 2021, NHS CEO Amanda Pritchard asked Dr Claire Fuller – a GP and CEO designate at the new Surrey Heartlands ICS (integrated care system) – to carry out a ‘stocktake’ of integrated primary care. Dr Fuller and her team were asked to look at what is working well and why, as well as how to accelerate care integration across systems.
The ‘Fuller Stocktake’ used workstreams, roundtables, one-to-one meetings and a dedicated online platform to garner feedback and suggestions on six themes: creating the right environment (for working together), people (workforce), access (physical and non-physical), working with communities, governance and data (for improving population health).
The resulting report, published at the end of May, showcases a new vision for integrating primary care centred around three essential offers:
- Streamlining access to care and advice for people who get ill but only use health services infrequently: providing them with more choice about how they access care and ensuring care is always available in their community when they need it
- Providing more proactive, personalised care with support from a multidisciplinary team of professionals to people with more complex needs, including, but not limited to, those with multiple long-term conditions
- Helping people to stay well for longer as part of a more ambitious and joined-up approach to prevention.
Role for pharmacy
“The two issues that have dominated the debate are the need for people to access same-day urgent care and the need for GPs to be able to provide continuity of care to those patients who need it most”, says Dr Fuller. “To get there, we are going to need to look beyond a traditional definition of primary care and understand that NHS urgent care is what patients access first in their community – typically from their home or high street and without needing a GP referral.”
So how do we get there? Dr Fuller says by enabling primary care in every neighbourhood to “create single urgent care teams and to offer their patients the care appropriate to them when they pop into their practice, contact the team or book an online appointment.”
Critically, she says, we need to connect up the wider urgent care system so that currently separate and siloed services are organised as “a single integrated urgent care pathway in the community that is reliable, streamlined and easier for patients to navigate”.
Dr Fuller also acknowledges that feedback showed that the wider primary care team could be “much more effectively harnessed, specifically the potential to increase the role of community pharmacy, dentistry, optometry and audiology in prevention, working together to hardwire the principles of ‘making every contact count’”.
One solution, she suggests, is for ICSs to “normalise this sort of interaction and subsequent intervention, rather than relying on individuals going the extra mile and stumbling across crucial insights”. She also pinpoints “scope for efficiencies in pharmacies being able to refer onward directly, e.g. to mental health or other neighbourhood services”.
A vital building block in this process is embedding primary care leadership across the four primary care professions and in the new governance arrangements they are designing. “This might be through the creation of a primary care forum or network with credibility and breadth of views to be able to advise the ICS,” says Dr Fuller, as well as “building relationships with existing local professional committees across all four pillars of primary care, such as local medical, pharmaceutical, dental and optical committees and primary care audiology, [which] will ensure the support and collaboration of key local leaders in improving access, experience and outcomes.”
The primary care representative bodies have been positive in their responses to Dr Fuller’s report and its recommendations. Matthew Taylor, chief executive of the NHS Confederation, called the Stocktake “a watershed moment for establishing primary care as an integral part of local systems, working across boundaries to deliver population-based care, and a demonstration of the benefits of the integration agenda.”
RPS England chair Thorrun Govind welcomed the review’s “constructive and inclusive engagement with the pharmacy profession”, but added that “to maximise the contribution of pharmacy teams, we will need to foster pharmacy leadership at system, place and neighbourhood level to ensure they are involved in decision-making.” And she added: “There needs to be a strong voice for primary care and pharmacy within new ICSs, supported by new ICS pharmacy leads working with pharmacy colleagues across the system [and] by investment in education and training, protected learning time, and the long-awaited roll-out of read/write access to patient records.”
Welcoming the report’s recognition of the potential of community pharmacy to play a greater role in prevention and urgent care, Malcolm Harrison, chief executive of the Company Chemists’ Association, said the CCA would have liked the report “to also recognise that the sector will only be able to deliver more in these areas if there is appropriate investment and funding to match”, and pinpointed some ongoing workforce challenges that need to be addressed.
“We are pleased to see that the report acknowledges the recruitment and retention challenges that community pharmacy faces”, said Mr Harrison. “However, it also commends the recruitment of roles into primary care networks (PCNs) without acknowledging that this is in part due to the direct recruitment of pharmacists from community settings.”
Meanwhile, with NHS England saying that the community pharmacy contractual framework will continue to be negotiated nationally with PSNC, but delegated commissioning and assurance of CPCF and local commissioning will all happen at the ICS level, PSNC’s director of contractor and LPC support James Wood, emphasised that: “This makes these emerging ICSs particularly important players for community pharmacy, so it is vital that the sector continues to do all that it can to fully engage with them.”
Mr Harrison added that the CCA is calling for the NHS to agree national standard specifications for services that ICSs can commission. “This will enable patients to understand what they can expect to get from their pharmacies and allow pharmacies to consistently deliver care, to reduce the prospect of regional variation in NHS care,” he said.
Back in March, the NPA arranged a roundtable for members of the Stocktake team to hear from pharmacy representatives about how community pharmacies can best be supported within ICSs to meet the health needs of people in their local areas, as well as real-world examples of what was working, and what wasn’t, for the sector.
After the event, NHS England & NHS Improvement director Gina Naguib-Roberts said: “We don’t want to leave it to chance that community pharmacy is in the right conversations within ICSs.” NPA local integration lead Michael Lennox added: “We ensured that community pharmacy voices were heard in the Stocktake process, and now that conversation needs to be amplified locally.”
These efforts seem to have paid off. Following the publication of the Stocktake report, NPA chief executive Mark Lyonette said: “The NPA is pleased to have worked with the Fuller team to ensure that the voice of community pharmacy was heard within this review…This document is a clear signal to ICSs to break through silos in primary care and to engage community pharmacy in a multidisciplinary push on prevention, urgent care and long-term conditions. This is an invitation to be active partners in integrated care and that means investing time and energy in building relationships to improve local services.”
With ICSs now formally established, the report’s recommendations could not be more timely and Dr Fuller is hopeful they can be achieved. “The truth is, we can create a much better offer for all our patients, but it requires effective collaboration across primary care and with the wider health system,” she says. “The ultimate arbiters of the success of this approach will be our patients. If patients are happier tomorrow than they are today because they are receiving more appropriate care when they need it, then we will be heading in the right direction.”
Next Steps for Integrating Primary Care: Fuller Stocktake report