In this blog, our Head of Strategic Operations Dr Sean Clarkson reflects on a recent project with the Care Quality Commission and explores how primary care is tackling inequalities within local communities, what the key enablers are and their future role.
The challenges which communities and health systems face as a result of health inequalities are stark and ever-increasing: the COVID-19 pandemic is a testament to the devastating inequalities in health outcomes and access to healthcare services across England. Health inequalities and how the system can continue tackling them is a growing narrative across all areas of the system. The 2022/23 NHS Priorities and Operational Planning Guidance and the NHS Long Term Plan both place health inequalities and prevention as a high priority, with initiatives such as Core20PLUS5 further underlining the system’s commitment to this important agenda. Tackling health inequalities isn’t the responsibility of just one area of the system, it requires the whole system working together, with primary care being one of many key players within local geographies. Ostensibly, primary care has a huge opportunity to contribute to reducing health inequalities and firmly embedding the prevention agenda. In this blog I’ll explore some of the ways primary care is already tackling inequalities within local communities, what their future role should be in tackling inequalities as part of a wider connected system, and importantly, what are the key enablers in realising the potential which primary care holds.
How primary care is already contributing to the health inequality challenge
In collaboration with the Care Quality Commission (CQC) we recently delivered a project to better understand how the CQC’s regulatory process could better capture, consider, and encourage innovation in primary care to tackle health inequalities. As part of this project, we undertook a series of fieldwork activities to gather examples of best practice through existing projects within GP practices to tackle inequalities. Through this work we captured numerous examples, including: implementing ‘at home’ services to reach frail/vulnerable patients, developing culturally focussed education material to improve health outcomes in BAME communities, and workplace exchange programmes to provide better joined-up patient care to name but a few.
Whilst these projects were all having significant impact within their local communities, many of them were being led by individual practices themselves with very limited resource and capacity – some being undertaken by GPs within their own time – meaning their potential impact and scale was naturally constrained. Similarly, whilst there were examples of great work taking place across Primary Care Networks (PCNs) which demonstrated how partners could come together to increase impact and scale, there were few examples of true system-wide working at Integrated Care System (ICS) level, with all partners coming together at place to understand how to better adapt services to meet the needs of their communities.
The future role of primary care in tackling health inequalities
The recently published Fuller Stocktake reviewed the integration of primary care with the wider system, citing the need for a more joined-up approach to prevention and making greater use of PCNs via neighbourhood teams: focussing upon meeting the demands of the communities who need care the most. This clearly points towards the need for more joined-up thinking, coordination, and leadership of interventions to tackle inequalities at ICS level: delivering against one of the ‘Triple Aims’ in the Health and Care Bill, focussed on providing “Better health and wellbeing for everyone”. Through the endorsement of Fuller’s recommendations from all ICS chief executive designates and the demands being placed on ICS leadership from the centre around prevention and addressing inequalities, it is clear that inequalities will be at the heart of many Integrated Care Systems emerging strategic plans.
The role of primary care in tackling health inequalities is therefore clear. Primary care and PCNs need to work in close partnership with other NHS partners at ICS level, utilising their collective data and intelligence on the needs of the local community, and delivering Fuller’s vision for a better joined-up local service provision which provides care to people who need it, when they need it, and how they need it. Whilst there are many facets to this work, there is a clear role for innovation adoption as a means of tackling inequalities e.g. offering new services which better meet the needs of specific patient groups. Doing this at scale across an ICS footprint and ensuring integration and buy-in from the rest of the system has many clear benefits around improving outcomes for patients and ensuring equity across a locality.
The recently published ‘Plan for Digital Health and Social Care’ provides a useful challenge for primary care and system partners to focus their immediate system-level working upon, both in terms of tackling inequalities but also improving patient care more broadly. In doing this, ICSs will need to retain focus on mitigating the risks of digital exclusion (one of their 5 key priorities), as this is understandably high amongst communities who already face inequality challenges and have difficulties accessing traditional health and care services.
How primary care needs to be supported to realise their potential
Primary care and GP practices are just one part of the complex system of stakeholders which constitutes an ICS, all of whom need to be supported to realise their opportunity to tackle health inequalities. The lynchpin to Fuller’s vision for greater integration of primary care and ICSs playing more of a driving role when it comes to prevention and tackling inequalities fundamentally comes down to strong ICS leadership and culture. ICSs and their leaders need to be firmly focussed upon: joined up working, putting the differing needs of the communities they serve at the heart of everything they do, and ensuring focus remains on prevention as well as acute care.
It’s important this system level coordination of health inequality interventions and ownership of innovation adoption doesn’t stifle innovation within GP practices themselves. Instead, the system should nurture and encourage this work, subsequently spreading it at scale across PCNs or ICS footprints if appropriate. The report summarising our recent work with the CQC builds upon this, citing how practices often struggle to recognise innovation themselves, and what is business as usual in one area may be highly innovative in another: firmly pointing towards how effective integration and joined-up working at ICS level could address some of these challenges.
However, the responsibility and drive towards tackling inequalities can’t just rest with local leadership, there needs to be a sustained push from the centre. This doesn’t just mean reinforcing the need through policy, it also requires creation of the conditions to allow change to happen at a local level e.g. through dedicated funding initiatives.
It’s clear that primary care – like many other ICS system partners – have a significant role to play in the drive towards preventative health and the increasing focus on tackling health inequalities. This role shouldn’t be underestimated. Not just because primary care is already delivering numerous projects and initiatives having high impact upon inequalities, but because they are often the main link between the system and the wider population, particularly when it comes to topics such as prevention and wellbeing. Through their work they are also close to the needs of specific communities and patient groups, valuable intelligence which they are well placed to feed into system-level thinking about adapting services to meet the needs of the populations they serve.
ICSs and their leadership are the key to much of this, ensuring whole systems come together at place, and fostering a culture which focusses upon tackling local challenges, delivering against the centre’s ambitions, and fundamentally working together for the benefit of local communities: playing to the strengths and opportunities offered by each partner. National initiatives such as Core20PLUS5 are helpful in channelling and enabling this local activity, however, this doesn’t mitigate the need for continued central funding commitments to create the capacity and capability needed to focus on these important agendas within already crowded systems.