Barely a week after the general election, Wes Streeting made his first official visit as Health and Social Care Secretary. He went not to a major acute hospital, but to a GP practice, where he pledged a shift in resources to primary and community care, in order to “fix the front door to the NHS”[1] and restore a system he’d previously described as “going through the worst crisis it’s ever been through”[2].
This pledge reinforces a way of making changes different to those experienced before and implies that leaders across systems will be held to account for making this happen. What we’ve learnt in our work in the Leadership Centre with primary care, in Devon and elsewhere, may be helpful and we think there are some lessons and pointers to how the NHS approaches this shift.
Devon has a combination of issues facing many Integrated Care Systems around the country. It faces a combination of complex, interwoven issues include: acute trusts and an ICB in deficit; experiencing prolonged and significant churn of personnel; and needing to meet the needs of an increasingly ageing population, with limited improvement in healthy life expectancy seen over the last decade. In his latest report, the Devon Director of Public Health called for increasing emphasis on prevention and on early intervention for key health conditions, both associated with primary care[3].
Our insights came from working with two distinct but linked groups. We worked with members of a nascent Primary Care Collaborative Board, made up of GPs and Managers from four different locality boards and representatives from Community Pharmacy – in other words, people who had volunteered to step up and put their heads above the parapet. In parallel, we worked with GPs, Clinical Directors, Primary Care Network (PCN) Managers and Pharmacists across all four localities.
One of our roles was to connect people to each other and support them in leading without formal authority. Both groups made the case that, in the words of one primary care representative on the ICB, “Primary Care is not the problem; Primary Care is the solution.” Both found it hard to get the message across. In part, this is because primary care operates very differently from the secondary sector and the NHS at national level.
Emma Richardson, GP Partner in Devon, said,“In general practice, we are lucky to have more autonomy, different to the hospital system. But it’s difficult to maintain the standard of patient care when the rest of the system is very challenged…you put your energy into where it can really make a difference, and that matters…You can’t make the hospital waiting times less, but you can support your patients.”
Primary care is mostly made up of independent small organisations, often competing for business and resources, with an understandable focus on hyper-local issues and often struggling to gain good positive relationships with their Devon secondary care providers.
Richard Ward, Digital and Transformation Lead for Mid Devon Primary Care Network, said, “Sometimes within the system we are competing when we should be co-operating…general practice is very diverse in the way it approaches things – there should be consistency across the system, but that isn’t how it currently works…we can’t expect people to know how to interact with us when it is all run so differently from practice to practice.”
This hyper-local focus could be an advantage: it was noticeable, for example, how immediately PCNs and community pharmacies came together at locality level to identify and try out new ways of joint working, for example pharmacy consultations helping to reduce demand on GP services.
Hannah Doidge, Operational Manager at Barnstaple Alliance Primary Care Network said, “I understand there are a lot of ways we can be more efficient by working at scale…but it’s getting that balance right, so we can get the benefits of working at scale without losing that important ‘teamwork feeling’ we have at practice or PCN level. The people and support network around you can be the reason you don’t become overwhelmed – and to lose that would be quite scary.”
Challenges arose when local representatives tried to present a Devon-wide front in a Collaborative Board: history and ‘baggage’ got in the way, necessitating an initial emphasis on reciprocal behaviours to help people make progress. Because primary care is made up of many independent businesses rather than predominantly large-scale, hierarchical and statutory public bodies, primary care leaders have to rely on carrot rather than stick: they have no recourse to the sanctions that can be applied in other parts of the system. Behaviours – especially diplomacy, persuasion and the time and willingness to build common understanding – are crucial. At the same time, leaders need to navigate the potentially contested territory that comes with bodies that do have that statutory responsibility: the Local Medical Committee and the Local Pharmaceutical Committee.
Emma Richardson said, “I think it’s achievable for primary care to come together as a collaborative, but it needs an ethos change higher up – there’s no point giving targets and setting up funding streams which cause rivalry; we’re never going to come together when there’s rivalry over the funding. For example, general practice gets a lot of funding from flu jabs and then pharmacists also get funding from the flu jabs and there’s only a certain number that be given out… The new initiatives in pharmacy around checking blood pressure – they’re being paid per item which was got rid of in general practice 15 years ago. That something we just do anyway – whether or not it’s right, it does create a rivalry and affects the relationship between GPs and pharmacists. The funding in general practice has in, real terms, really dropped. It’s having a personal hit on partners because of the enforced pay rises without the increase in the global sum to support those, so it’s a really sensitive area, which can be really personal as well. It’s difficult. A more collaborative approach is definitely possible, but it needs something different.”
And they do this with one hand tied behind their back. Primary care is facing all the same challenges as the rest of the public sector: increasing demand, cost inflation, and recruitment and retention. However, resourcing has not increased at the same levels as other parts of the NHS, and GPs are leaving the profession or retiring early. In Devon, as elsewhere, practices and pharmacies are struggling to meet higher costs and closing, with subsequent impact on local – especially rural – populations; on the morale of people working in primary care; and on demand for care in the secondary sector. Emma shared that, “A lot of policies are created with a London-centric idea and when they filter down to rural practices in Devon, sometimes don’t work as well. For example, Pharmacy First works really well in inner cities where there are pharmacies which are well-staffed on every corner, but it’s completely different in Devon where there may be a single-handed pharmacy that’s already struggling to keep up with their dispensing.”
At the same time, primary care’s dispersed management infrastructure, in comparison to NHS Trusts and other public bodies, puts it at a real disadvantage in system-wide working. Decision-making in the NHS commonly happens in a plethora of long meetings, accompanies by lobbying and influencing, conducted mainly by full-time senior managers. By contrast, primary care leaders have far more limited capacity, and it’s impossible for senior clinical leaders to be “in the room where it happens” for enough of the time. One leader from the Devon system said, “All of the managers in NHSE are trained in the old system, and this is a new world. The skills and behaviours required are different.”
As a result, primary care loses out in the battle for visibility, resources and prioritisation, particularly in systems – like Devon – with big performance challenges.
If we want the future to be different, we need to do things differently. Here’s some of what we’ve learned:
- The system needs to re-frame working with primary care as a privilege: primary care is uniquely placed to know local needs, raise the voice of the patient in the system, bring a different voice and demonstrate joined-up care in action.
- Understand that working with primary care is very different to working with other parts of the NHS: take the time to learn, and ask questions rather than making assumptions
One leader shared that, “Primary care is different to the rest of the system – it is a complex, adaptive system and it is constantly changing. You have to be able to function at scale at the top, but not lose the benefits of the agility at the bottom. It is important that GPs come together quite quickly – they are too small otherwise to influence. The whole of primary care share that issue – you will go bust and have to hand back contracts – and that means you think differently and behave differently. If you’re a hospital your salary isn’t dependent on your profits.”
Hannah Doidge also told us, “The ICB want us to get to a particular level of collaboration, but I feel there is very little support around the investment needed… to help make that happen. I think primary care can get forgotten about in that respect…”
- ICBs and other system partners will be more effective if they work “with the grain” of primary care, rather than assuming it’s the NHS in miniature
Another leader in Devon said, “They’re trying to change the culture at the top, but the culture throughout must change along with it. For me, it’s about building trusting relationships with the right people over difficult issues, and learning how to compromise. There are now green shoots, although there’s still quite some way to go.”
- Acknowledge that senior primary care leaders have to operate simultaneously as front-line managers of small (in NHS terms) operational units that cumulatively act on a large scale, and strategic system leaders. Bringing primary care together at system level, to have greater impact, requires high-level leadership skills
Hannah Doidge explained, “We acknowledge that there needs to be a collaborative voice for us to be heard. If we can align our communication, then it’s more powerful”.
- Start with making connections and building relationships: this builds trust that can lead to positive outcomes even when resources are constrained
- Enable people across the whole system to connect better with each other: this produces more harmonious relationships and better patient/community outcomes Richard Ward said, “We’re in the age of the system – it’s no longer about how the individual operates, it’s how the system does.”
- Garner opportunities and innovations that are happening both in your patch and elsewhere in the country, to broaden knowledge and skills, and to try out new ways of working at local and system level
Neil Parsons, Business Transformation Manager for Mewstone PCN, said: “We’re very lucky in our PCN as we have an amazing community pharmacy lead and we’ve built a really exciting relationship and we’re really starting to see the benefits of that and the fruits of our labour – we’re seeing service lines where we’re working together to best meet patient needs and it’s really exciting. People keep saying to us, ‘your numbers are incredible, how have you achieved this?’ and the reason is that we’ve taken time to sit down together and work through our common challenges. We just need to expand that approach.”
- Show how stepping up beyond the day job and into system leadership can lead to improved outcomes as well as interesting opportunities for career development, not least for experienced clinicians.
We are currently preparing a learning review of our support in Devon, with examples of learning and change as part of our work in places around the country. As elsewhere, we have focused on practical work, signposting good practice and influencing towards positive change and improvement. We have looked to assist people working at different levels and help them face into the future. And we have already seen change happen. Primary care in Devon is achieving much with limited resources, and it could achieve more still with continued emphasis on relationship-building, networking and testing/redrawing the boundaries within the system.
A leader within the Devon system, said, “We need to take a step-by-step approach to reaching a primary care collaborative whilst also getting to it as soon as possible. That means getting a GP collaborative together as soon as possible – 118 practices, 4 localities – you need to get engagement and involvement, a year of doing that and having a voice at the table will hopefully get people to realise that this is a far better way of working.”
So the stakes are high. There is a real opportunity here to engage with primary care in the process of change, using its strengths in, and understanding of, local places and communities. If we can do this, not only will we ‘fix the front door of the NHS’; we can help to repair the whole of the health and care system. One of those who took part in the work in Devon shared his thoughts, “There are enough people who can see that things could be a lot better and the prize for primary care collaboration is significant. We have to move to a social model of care, not the medical model we are stuck in. It’s about building communities, building the benefits of integration with local populations and intergenerational support. The opportunity is there, that’s why I’m involved.”
Debbie Sorkin, John Wilderspin and Tim Whitworth, The Leadership Centre
For more about this work, please contact Debbie.sorkin@leadershipcentre.org.uk
[1] As reported, for instance, in The Guardian, 9th July 2024: “Labour to ‘fix front door’ of NHS by diverting billions to local surgeries”: Wes Streeting pledges billions to GPs in order to ‘fix front door’ of NHS | NHS | The Guardian
[2] Interview between Wes Streeting and GP Online, July 2024: https://sphinx.acast.com/p/open/s/61308bc46789b8001a82ac6e/e/667d4c91482fca9c1bfba1ae/media.mp3
from GP Online https://www.gponline.com/new-health-social-care-secretary-wes-streeting/article/1879772
[3] Devon Annual Public Health Report 2023-24: https://www.devonhealthandwellbeing.org.uk/aphr/2023-24/