Integrating primary care: an inside perspective on the Fuller Stocktake

ABSTRACT

In November 2021 Claire Fuller led a national piece of work looking at primary care within integrated care systems (ICSs) to identify what was working well and why. The published report from this piece of work became known as the Fuller Stocktake.¹ In this interview, Professor Fuller sets out the process and principles behind the Stocktake.

Introduction

In November 2021 Claire Fuller was invited by NHS England chief executive Amanda Pritchard to lead a national piece of work looking at primary care within integrated care systems (ICSs) to identify what was working well and why. The published report from this piece of work became known as the Fuller Stocktake¹ and was co-signed by all 42 ICS chief executives, who committed to the recommendations.

Professor Fuller is a practising GP and chief executive of the Surrey Heartlands ICS, which came into effect formally on 1 July 2022. Box 1 sets out more about her background and why she was invited to carry out the Stocktake.

Box 1.

Claire Fuller's background

Claire champions true citizen and professional engagement (of the broadest remit) and believes in a population health management approach to improving patient outcomes. She is also a firm advocate of the need to join up the public sector to ensure involvement of the wider determinants of health in reducing health inequalities for the people that live in Surrey.

Claire has been a practising GP since 1995, spending most of her career in Surrey, with a spell in Northumberland, where she worked in a single-handed rural practice.

Claire regularly speaks nationally about the importance of multi-professional leadership, integrated care and population health, as well as the impact and implementation of the Fuller Stocktake. She has been HSJ Clinical Leader of the Year and is regularly named in the HSJ list of most influential people in the NHS. She is a member of the NHS Assembly.

Claire has also been appointed as visiting professor in the Faculty of Health and Medical Science at Surrey University for the period April 2021 to April 2024. Most recently, on behalf of the NHS Assembly, Claire has been supporting a series of conversations with system leaders, staff, stakeholders and the public to reflect on how far the NHS has come since it was established in 1948, and what its priorities should be for the future which has contributed to their report The NHS in England at 75.

The following article is based on an interview between Claire Fuller and Imran Rafi in July 2023. The remit of the Fuller Stocktake was the integrated care system in England; Box 2 and Box 3 provide a background on the current picture in Northern Ireland and Scotland.

Box 2.

The integrated care system in Northern Ireland

As the Fuller Stocktake was being published in May 2022, the political institutions in Northern Ireland (NI) were set on a path to continued suspension following the Assembly elections and previous February 2022 collapse. The failure to re-instate the NI Assembly and NI Executive continues to have a far-reaching impact on the much needed transformation of our Health and Social Care Service.

The strategic direction was set in March 2016 with the publication of Health and Wellbeing 2026: Delivering Together and the articulation of the need to empower local providers and communities to plan integrated continuous care based on the needs of their population. In October 2020, a programme of work was approved by the then health minister Robin Swann to develop an ICS model for NI to enable improved integration, partnership working and collaboration both within and outside traditional health and social care boundaries, with the aim of tackling the wider determinants of health and wellbeing and delivering care on a population needs-based approach but with the person at the centre of the model.

What is different in Northern Ireland's journey to an integrated care system is that for the last 50 years we have had integrated health and social care. One might argue that based on outcomes, such an integration has not sufficiently delivered improvements at a population level; however, throughout that time various restructuring exercises and changes in legislation have not veered from this integrated approach but sought to further collaborate with agencies such as the Public Health Agency NI to commission services to promote health and wellbeing.

Of note, and in contrast to the approach outlined in the Fuller Stocktake, has been the less obvious emphasis historically, on the role of primary care and how such a vision for integrating care and improving access, experience and outcomes will impact on our communities.

That said, it is on this strong foundation of integration that the fledgling ICS NI will sit. Encompassing a single system and model working together, ICS NI will function at three levels, the heart of which is the area level (comparable to ‘place’ in England). Bringing together within five Area Integrated Partnership Boards (AIPBs) representatives from health and social care and wider partners in local councils, voluntary and community sectors, service uses and carers will plan and manage care and services based on the identified needs of the local population. AIPBs will be co-chaired by a GP, with additional general practice and primary care representation.

Area level will be supported by a locality level, best placed to deliver changes, alongside being a critical source of population needs and intelligence.

It is at the regional level that all parts of the system will come together with oversight and co-ordination.

The target launch for ICS NI is April 2024, but without the changes in legislation to allow the formation of Area Integrated Partnership Boards, this date is likely to slip. What has not stalled is the commencement of a pilot test AIPB site and ongoing plans to roll this testing out further across the region with the aim of achieving operational learning and refinement while awaiting the green light.

What ICS NI will not have is commissioning capabilities. These will continue to rest with the Department of Health through the Strategic Planning and Performance Group with a health minister and department setting the overarching strategic direction.

Meeting the future health and wellbeing needs of our population has never been more important, not least because the backdrop of widening inequalities here is so stark.

This fledgling integrated care system will continue to evolve but, as with many of the challenges within healthcare in NI, it is dependent on legislative change and ongoing political stability – something that none of us here currently have nor can ever take for granted.

Ursula Mason Chair, Royal College of General Practitioners Northern Ireland

Box 3.

The integrated care system in Scotland

Scotland has sought to increase integration of health and social care services since its Parliament was established in 1999, striving to improve outcomes for communities through the value of integration. The Public Bodies (Joint Working) (Scotland) Act 2014 delivered the arrangement in place today, requiring local authorities and health boards to work together to plan and deliver adult community health and social care services, with the option to include services for children, homelessness, and criminal justice.

Since the Act's implementation in 2016, Scotland has 31 integration authorities, or health and social care partnerships, mostly set up in a body corporate model, with functions delegated to a third body, the Integration Joint Board. NHS Highland is the only one using a lead agency model, delegating functions in house between the Health Board and local authority, to continue the radical partnership agreement it had already had in place since 2012.

Assessing the national impacts has proven difficult, and variation across the country and a lack of usable data has hindered evaluation of good practice and sharing learning. The context of workforce challenges, the lack of guidance to develop the cluster network, and the current constraints on the public purse have also likely had a stalling impact on steps towards integration. Most disappointing is the apparent failure to improve Scotland's record on health inequalities. Next on the reform agenda looks to be the National Care Service for Scotland. Belief in the principle of collaboration persists.

David Shackles Joint chair, Royal College of General Practitioners Scotland

What is the political and legal background that formed the context for the Stocktake?

In 2012, the Lansley reforms broke up the primary care trusts (PCTs) into clinical commissioning groups (CCGs), setting up a competitive market that fragmented the NHS into multiple organisations. Ever since then, either deliberately or by stealth, we've been joining it all back up again, and the Health and Care Act of 2022 formalised that joining-up. The 2022 Act goes some way to removing the commissioner/provider split introduced with the Lansley reforms and gives permission, and indeed the requirement, for health and care organisations to collaborate and work together.

What do integrated care systems, integrated care boards and integrated care partnerships do?

There are 42 integrated care systems around the country of varying sizes; the smallest one serves about 500,000 patients and the largest about 3.2 million patients. Integrated care systems have four aims: to improve health outcomes, to reduce health inequalities, to improve value for money and efficiency, and to develop the NHS involvement in social and economic development.

As part of the Stocktake, I talked to all 42 chief executives and found out more about why each ICS has a particular footprint that leads to this variability. There are basically two reasons for a footprint: either they are based geographically around a big county council (eg Hampshire or Kent), or all the patients in the ICS flow into a particular big teaching hospital. For example, in London there are five integrated care systems, based around the teaching hospitals.

Then, when you come out to the shires, two thirds of the country by geography are covered by county councils, yet they only cover one third of the population. So, where the footprint of the ICS is due to the local authority footprint, what they tend to have (generalising significantly) is smaller, scattered district general hospitals. What then happens within these footprints is really good collaboration between the hospitals and local people – so it works on the ‘place’ level – but the hospitals are isolated from each other. In the more urban areas, where you have big teaching hospitals, they have much more dense populations, often with more deprivation. These areas tend to have metropolitan boroughs or unitary councils whose footprints are well defined and work together, but are disconnected at the hospital level.

So it's partly true when people say ‘when you've seen one ICS, you've seen one ICS’. Yet it's not completely true because we all have the same four aims, but start from different aetiologies with different issues to work on. For example, in my ICS in Surrey, our ‘place’ working is really good but the hospitals are quite separate from each other. Whereas if you're in central London or Manchester, the hospitals can be more remote from primary care and neighbourhood working. You've got to do both the vertical joining up and the horizontal joining up. And then you can deliver the four aims. Everybody should end up in the same place.

One complication is the local authority element. This is because the NHS is a large, centralised organisation where, although we're all separate organisations, we're all linked into the centre; yet the local authority system is very much about local control. An integrated care system has got two ‘boards’: an integrated care board and an integrated care partnership committee. And although local authorities are members of the integrated care board, the board holds the accountability for the planning of the NHS spend. The integrated care partnership holds accountability for developing the system's strategy, which the integrated care board then needs to deliver. But because NHS England can't have accountability over local authorities, that bit therefore sits outside, which adds complexity and makes how we work less straightforward.

What approach did the Fuller Stocktake take? What did you find out about the facilitators and challenges to effective integrated working?

Amanda Pritchard called me when I was coming out of my interview to be chief executive of Surrey Heartlands and asked me if I would like to do this piece of work looking at how primary care works in systems – and I said yes, of course! I wasn't sure what to do or where to start at first. Amanda had said this was a document for the 42 integrated care systems. Over the course of the next few days, I spoke to every single integrated care system and asked the chief executives what they thought about primary care and systems and what they thought should be done differently.

What was really interesting was both the differences and the things that were the same. There's only one other chief executive who has been a GP, but they're all really, really proud of what they do in general practice and in primary care within their systems. In terms of the issues that they wanted help with, there were two key themes: access and continuity. We've got to make access better; we've got to make it easier for people to be seen, when they need to be seen. Then there are all the findings from the British Social Attitudes Survey.² As professionals, we know what it's like now when patients come in and they say things like, ‘I've been waiting so long’, ‘I've been round the houses trying to see someone’. The system has got to be easier: it will make our job better and it will make it better for people.

The other theme, of continuity, was the thing that interested me the most. When I started in general practice, we didn't have everything we have now. I remember the computers arriving in my practice. I can remember when we got our first mobile phones. When we used to do our own on-call, you'd go to somebody's house, and you'd have to use their phone to check back. But you knew everyone, there was absolute continuity of care and that is what made the job what it was. It's not that job anymore, and we've lost something in losing that continuity. And the problem is that some of the patients are waiting to see who they think of as their doctor. For example, my parents are still alive, but increasingly frail. They'll wait, and by waiting, they may end up in hospital, because they've waited too long, while the younger generation tend not to care who they see and so get seen much more quickly.

One of the elements that emerged strongly was that we do need to carry out risk stratification, particularly for our most complex people, to make sure they've got the right team of people around them and there is continuity for them. We have to make sure that our practices are protected from work that they don't need to be doing and shouldn't be doing – the more transactional business and then, at the other end of the scale, the really complex work – to make sure we can provide as much of that continuity as possible, and get on and deliver the day job.

How can we achieve the release of time needed to achieve continuity of care?

There is great work going on in this space, particularly on taking demand out of the system. For example, in East Surrey, one of the places in Surrey Heartlands, we have a population of about 250,000. They used the Johns Hopkins methodology to identify those people most at risk of admission. They identified 60,000 people of moderate high risk and then looked in detail at the top 1% of that – around 600 people – noting the number of contacts they had had over the last year. Altogether, these 600 people had had 1,800 A&E attendances, 450 outpatient appointments and 400 inpatient admissions. But astonishingly, these 600 people had had 54,000 GP contacts. That sounds very high, but it equates to two appointments per week – no GP will find it hard to think of people that come in twice a week.

The team then identified who those 600 people were and divided them up between the PCNs, with each practice, depending on its size, having about 200 people. They then put a multidisciplinary team in around them, with impressive results. Looking in more detail at the 600, 80% of them were over 85, 10% of them were children with complex needs and 10% of them were people with mental health issues experiencing real social issues and chaotic lives. Starting with the 80%, they ensured they were managed through their frailty hubs, where they have community services, the voluntary sector, a community geriatrician, and now a GP there too. The care becomes about phoning people proactively and asking, ‘What matters to you? Do you really want to go to six outpatient appointments, what might be better?’ By doing this they have managed to reduce the number of hospital admissions and A&E attendances by 12%, and GP contacts by 20–30%, so it's having a significant impact.

In another local primary care network they have found similar numbers, driving out 37% of activity for that cohort. Evidence that it works to do real anticipatory care for this cohort of people. But you have to first identify them and that means giving up looking after these patients in the more traditional way. You can then take out the transactional stuff – using triage to take out 20–30% – without going near a clinician.

Can this model of care easily be translated across the country?

All 42 ICSs wrote a letter committing to implementing the recommendations of the Stocktake; they've now all done their baseline assessments setting out what they've done and where they've got to in terms of implementation. The model of care has three lenses: how you join up on-the-day urgent access, how you look after your most complex patients, and how you look at inequalities with local communities to reduce future demand – building on the work we all did during COVID vaccinating communities and populations that are often missed.

How can we ensure we have the workforce to implement the Fuller Stocktake?

We now have the NHS Long-term Workforce Plan³ that has set out a commitment on behalf of the NHS to create a bigger, future workforce, with the necessary training that underpins it. But the places that are already doing this successfully have done this by using their Additional Roles Reimbursement Scheme (ARRS roles) differently. Instead of having two hours of a paramedic here, and two hours of a pharmacist there, they've put them together to work as one team. Then you have the workforce from the hospital and community services reorganised around that footprint, and that's the commitment they make. So it isn't an extra workforce, it's people you already have but working in a different and more efficient way. For example, you reduce a lot of the demand by joining up the care, by eliminating multiple visits, referral paperwork and handovers. To do this, you need a single record that everybody can see, you have to get all your data joined up, and you still need the right estate – somewhere for them to sit physically together to have those conversations.

Some have suggested that training times should be reduced in length to increase workforce numbers, but I'd go the other way. I think we come out of training too soon and that's why we lose people. There's an extraordinary difference between being a trainee under supervision within general practice and working in a non-protected environment. I would add another 2 years, working independently but with supervision in a protected environment and with the opportunity to develop an extra skills, such as leadership, or Child and Adolescent Mental Health Services (CAMHS), endoscopy or frailty; this is a great opportunity to plug specific skills gaps locally.

What was the initial response to the Fuller Stocktake and how is implementation going so far?

When the report came out, I came off all social media and went away on holiday for a week as I really didn't know what to expect. But then I came back and was surprised to find that it had been well received. Somebody gave me some very wise advice the week before the report was due to be published; they said, this has your name on it, so make sure you are genuinely happy with it before it's published. It's just as well because I've had to talk about it so much since then.

Since then, I've visited around half the systems across the country. They all have their ‘Fuller boards’ and plans and I'm still slightly overwhelmed at the impact that it's had. I was in Manchester a couple of weeks ago and their very excellent strategy for the Greater Manchester primary care service describes implementation of the Fuller Stocktake.

While it was my name on the report, my views were formed from the number of people that I talked to. We had 12,000 people put information in via the website. I spoke to each of the ICS chief executives several times and we had monthly one-to-ones. I also spoke to several hundred people individually and through round table events, and there were one and a half million hits on Twitter. It was huge, and the views I formed were consensus views. I didn't start off with this as a plan at all. But two things just kept coming up, access and continuity. It was a real iterative process and I think that's why it stuck because people could see it evolving as it went on, and hopefully, they felt heard, particularly around continuity which was so important to everyone.

How can the Stocktake's recommendations be applied to multimorbidity, complex conditions or adults and children with disabilities?

The report is a blueprint; it comes down to the importance of ICSs understanding the population they serve and who your most vulnerable people are. Once you've identified that, it's then about putting in place the right multidisciplinary team and doing real anticipatory care. Bob Klaber from Imperial has been doing this for years in paediatrics in London; doing the connecting care piece where he goes out and sees children and sees their families. It's included in his job plan as a paediatrician, it's not a separate service. His job is to go out and see complex children, where they live with their families, and he continues to do it because he gets so much more information from seeing people outside of the hospital setting.

If you identify your most complex patients, I think there are different things you can do around long term condition management which we haven't done yet; some of that is about how we review people holistically rather than looking at single diseases. It comes back to building up the team around people. You know somebody's got heart failure. You want to increase the diuretic, but that's going to impact their renal function. So you need access to the right ‘ologist’ that can give you the opinion you need at the time. It's about having that multidisciplinary team with the patient and everybody present, then you can bring in the specialist input instead of people waiting to go to outpatients. It ties in with how we transform outpatients.

Is the information technology required to support implementation in place?

It's a requirement for all integrated care systems to have a single record that everybody can see. But there are different ways systems are doing this. Nearly all our GP practices locally are on the EMIS system. Our Surrey Care Record receives data from the GP record, some from secondary care, mental health, community and more recently the local authority. In time we should all be on one record, but we're not there yet.

The recent primary care access recovery plan talks about every ICS creating a secondary/primary care interface to discuss issues such as ‘Why are you asking for these blood tests?’, ‘Why are you not doing it?’ or ‘Why is this discharge summary coming?’ We need to set up a forum to talk through difficulties, because it is clear to me that the gulf between primary and secondary care is bigger now than it has ever been in my career.

What are the reasons for the gulf between primary and secondary care?

I think there are multiple reasons. Partly it's because we are all exhausted, and we've got too much work to do. There's an element of personal burnout and stress. But I also think, fundamentally, the Lansley reforms made things more difficult with CCG boards of GPs, and trusts working under Payment by Results (PBR), creating an antagonism. We stopped learning together and meeting regularly. Back in the day, you used to have the phone numbers of the hospital consultants. It doesn't happen like that now and that's partly because we don't know each other anymore. One of the real positive elements about the neighbourhood teams and the multidisciplinary approach is that if you can create a relationship between the secondary care consultant and a local geography, it will give us that ownership back, which will start to help. When doctors talk about patient care, there's no gulf.

Note

The interview on which this article was based took place in July 2023, before Professor Fuller was appointed as medical director of primary care at NHS England. The views given are her own and should not be taken to reflect NHS England policy.