17

Integration of Primary and Community Care Committee

Corrected oral evidence: The integration of primary and community care

Monday 6 March 2023

3.05 pm

Watch the meeting

https://parliamentlive.tv/event/index/5eff2d21-43ee-4f34-8b75-2a1e9c2ec566

Members present: Baroness Pitkeathley (The Chair); Lord Altrincham; Baroness Armstrong of Hill Top; Baroness Barker; Baroness Finlay of Llandaff; Lord Kakkar; Baroness Osamor; Baroness Redfern; Baroness Shephard of Northwold; Baroness Tyler of Enfield; Baroness Wyld.

Evidence Session No. 1              Heard in Public              Questions 1 - 12

Witnesses

I: Professor John Campbell, Professor of General Practice and Primary Care, University of Exeter Medical School; Professor Kate Walters, Clinical Professor of Primary Care and Epidemiology, University College London; Professor Hazel Everitt, Professor of Primary Care Research, University of Southampton.

Examination of witnesses

Professor John Campbell, Professor Kate Walters and Professor Hazel Everitt.

Q1                The Chair: Welcome, Professor Campbell, Professor Walters and Professor Everitt. As you know, we will all ask you questions—I think you have had advance notice of some of them—but the session may or may not go according to plan, depending on what we hear from you and what my colleagues want to come in with.

I will start with the first question, as is customary. What are the most significant challenges facing primary care at present? If you do not mind, Professor Everitt, I will ask you to answer first.

Professor Hazel Everitt: The key challenge, which everybody is well aware of, is the workforce. We have a workforce that is severely under strain, and to be able to think about improving integration and maximising the benefit from the system we need to value our workforce and give it sufficient training and time to have the opportunity to do the work that is needed to put innovation and integration into the system.

Professor Kate Walters: Along with that is that there is insufficient time to be anticipatory. Because of the demand and the needs, a lot of care is reactive to problems that arise right there in front of you. So there is insufficient capacity in the system to be able to plan the care in a more anticipatory way.

The Chair: Perhaps you could also mention the barriers that you see to making progress in these areas.

Professor John Campbell: Three areas will need attention over the next few years. We need efficiency in service provision; systems are not designed to function and cannot function if they are perpetually operating at 98% capacity. That just does not work and leads on to the problems that we are seeing with recruitment and retention in the primary care and community care workforce. We need stability in the structures. We have the potential for great progress in anticipation of the work of the integrated care systems, but we need stability over the next few years rather than change.

There is also a real issue with efficiency, stability and equity—the latter in relation to primary and community care. It may not be seen as attractive when compared to the fantastic interventional work that is offered in the acute sector, which is astounding given the advance of science and the availability of new treatments. However, the community is where most of the work takes place and where most issues are resolved, and we need equity of status for primary and community health services.

The Chair: Hazel and Kate, if I may use your first names, do you agree with John about those barriers and that most of the work is done in the community? You used quite a memorable phrase there, John.

Professor Hazel Everitt: Absolutely. It is very well recognised that most patients are seen in the community. In fact, most healthcare happens in the home, with self-care by carers and patients themselves. There is also an interface between self-care and community and primary care. It is important where that lies, and that it is managed. Obviously 90% of care happens in the community. Those people in the community hold a huge amount of risk and manage a huge amount of illness, which helps the system to function. If more people came through and that risk was not managed and dealt with in the community, it would overwhelm the whole system.

Professor Kate Walters: Indeed. Also, primary and community care are taking on more and more from secondary care, so, if anything, with time even more is being taken on by our sector. I agree completely with Professor Campbell and his points.

Q2                Baroness Armstrong of Hill Top: I have a quick question for Professor Campbell. How do you reconcile keeping the system the same for the next few years, and equity? I hail from County Durham. I said five years ago in this place that the GP system was broken, because at that stage my GP practice was not offering anything for five sessions a week, and there was no community care within 12 miles. In London, where I now spend more time and access care, I can always get at least a telephone call with the GP, and very good community care is available—physio, nutritionist, and all the rest of it. That sort of inequity is absolutely running the system at the moment, in my view, and I do not see how keeping the system stable will improve that level of inequity.

Professor John Campbell: My point is that the issue is not about resorting to the past and staying with it. Primary care teams are hugely dynamic and highly efficient components of the healthcare organisation system, but they need time for things to settle down. Just now, we have primary care networks, as you will all be aware, which are essentially organisations or structures associated with 30,000 to 50,000 people. They are relatively new and are seen as being a potentially tremendous way forward, but they need time, to settle down as well as to be evaluated. There are so many new initiatives going on to address the kind of inequalities that you are talking about and we are all concerned about. I have spent my life working to provide evidence on those kinds of areas, but getting evidence, acquiring efficient data and delivering care all take time. The integration we aspire to in order to work more closely with community health colleagues will take time.

Over the last few years, we have seen primary care groups, primary care trusts, clinical commissioning groups, integrated systems and integrated boards. We now need time to allow these potentially highly attractive and efficient structures to settle down and to allow GPs, primary care teams and our community health colleagues to work on that and to address the inequities that currently exist in the system.

Q3                Lord Altrincham: Thank you, professors. We have an important question on integration. Improving integration between health services has been a long-held ambition of successive Governments. Can you provide the committee with a brief explanation of what integration between different parts of the health service is meant to achieve, and how well primary care services are currently integrated with community care, and provide examples of successful or innovative models of integration, either in the UK or elsewhere?

Professor Kate Walters: On the definition of integrated care in the healthcare context, the WHO definition is quite good: seamless, co-ordinated care but care orientated around the person themselves, and people working together collectively to organise care around that person and what they want and to create actions as a result.

A good example of successful integrated care is the crisis care models, which have a good evidence base for successful innovations to prevent people going into hospital at the point of crisis. There is a better evidence base for the cost-effectiveness of that kind of intervention, and they have been successfully implemented across a number of different contexts, so that is a good example.

Professor Hazel Everitt: It is really important that patients, and staff, know what care is out there and how to access it appropriately. At the moment, there are so many systems and points of access, and it is so complex, that it is really hard for patients, carers and staff to navigate the system. We cannot get an integrated system when we do not have good IT or good data sharing and when the staff and the patients do not understand the system well.

We really need to work on getting the system to fit together better. Our staff are an amazingly valuable asset. They are really innovative and keen and they have all sorts of ideas, but they do not have the head space to be able to implement those, and a lot of them have not had the training or the skills to enable them to implement them. It is amazing what has been happening with social prescribers and first-contact physios, and getting the pharmacists into primary care, but the communication needs to be there; it will not happen without good systems and good communication.

Professor John Campbell: I think the challenge is respecting and honouring the range of professional backgrounds that are represented in this agenda. Primary care is no longer just GPs, by any means. GPs bring one particular set of skills to the table, but we work closely with nurses, reception staff, administrators—complex teams—in our practice. We also have pharmacists and physios, first-contact physiotherapy. It offers tremendous potential, but it needs to be exploited. That means honouring the fact that not everybody does the same thing; people are working together effectively in teams.

Health visiting—I know you will be hearing from nursing and health-visiting colleagues later—has been hugely valued by GPs and their teams, but it is now no longer really part of general practice. Sadly, we have lost so many health visitors that we do not know who these people are or where they are. They provide a hugely valuable service, safeguarding and supporting families and people with long-term conditions—to give a specific example.

Lord Altrincham: Clearly we will be looking for examples of excellence for our report. Are you suggesting that we will be looking for multiple different models, rather than some overarching model, for how this could work better?

Professor Kate Walters: Yes, multiple models.

Professor Hazel Everitt: Yes.

Professor John Campbell: Multiple models in an existing structure. I think GPs generally feel positive about the potential of primary care networks. Intuitively, they have the sort of size that means that management and vision can be retained locally and yet services delivered effectively.

Certainly it cannot just be every flower in the field flourishing. I will give a specific example from my own patch in north Devon. The integrated care system (OneDevon) has already been working with colleagues in north Devon to establish what is called High Flow, which is an impressive coming together of council services, ambulance services, mental health services, primary care and GP-based community services to target and support the 20 highest-intensity users of health services in north Devon. It is quite a niche and focused activity, yet it is bringing together these agencies to work effectively together. That kind of approach offers great potential.

Q4                Lord Kakkar: I declare my interests as chairman of the King’s Fund and the King’s Health Partners.

With so many different professional groups, how do you think professional leadership can be provided across that broad spectrum?

Professor Hazel Everitt: It is really important that we build leaders for the future. It has been a really underfunded, underrepresented area, particularly with regard to allied health professionals getting good training in leadership, implementation and research. You will get those changes coming through the system only if you get good representation of all the allied health professionals—nurses, physios, pharmacists, health visitors as well as GPs—with all being able to put their voice and help to build this for the future.

That is really important, so they need training and opportunities to build their skills. That should be part of the job. Within Primary and Community care there is no research and leadership role automatically within posts. Consultants are meant to have that in secondary care, but even in secondary care it has been squeezed out because of the workforce pressures. However, it is not even part of the remit at the moment for primary and community care. It needs to be there.

Q5                Baroness Redfern: To follow on from Lord Kakkar’s question, are you saying that we lack better dynamic leadership to move things forward?

Professor Hazel Everitt: We need to harness a lot of the stuff that is out there. There are lots of dynamic people working locally, but at the moment we do not have the resources to fully evaluate the wonderful innovation that is happening out there and then to share best practice.

Integrating complex interventions into a complex system does not happen by diffusion. It is a really complicated thing that needs time, energy, money, people who know how to implement, and we need a culture of research and academic excellence where evidence-based practice gets spread and can be implemented. We have done a lot of science on the barriers to implementing evidence into practice and primary care. The research is out there on the ways it can be done well and the barriers to it, and we need the workforce to understand that and then to work with that to spread good practice.

Baroness Redfern: Who is going to monitor this to move things forward much more quickly? We have heard a lot about barriers, but we want to move forward.

Professor Hazel Everitt: As a clinical academic community, we are doing a lot in primary care already with the National Institute of Health Research School for Primary Care to do research in order to get good evidence into practice. That could be built on significantly to help to evaluate all the local initiatives that are so promising and to spread them more widely out into the community.

We know that research gives very good value: for every £1 that goes into research, a lot of money comes back into the economy, and the benefit to patients is considerable. That could be expanded.

Baroness Redfern: Sorry to interrupt, but who will actually monitor progress?

Professor Hazel Everitt: Obviously the integrated care systems could monitor that. That would be an option. At the moment, it is not being evaluated. Most of these systems are not being looked at, which is a big problem: we do not have the data to be able to inform so that we can make good decisions. Data sharing is an issue, and I know there will be questions on that later.

The Chair: Yes, there will. Let us move on to our next question. PCNs and ICSs have already been mentioned.

Q6                Baroness Armstrong of Hill Top: Indeed. I want to ask about the structural changes that came through the Act last year. Some of the changes were in place before the Act went through, which was a bit of an issue for us. Have you been able to evaluate the strengths yet, and the weaknesses—things that might be perverse outcomes? Have you seen anything that you think is working well or not working well that you think we should look at?

Professor Kate Walters: It is interesting. We put some thought into this. There is a lot of good case study evidence from the vanguard sites, but it is quite hard to generalise across, as I am sure you will find. People are not necessarily measuring the outcomes in the same way, so it is hard to make comparisons across different cases. It is still early days, but an important priority will be that people measure things in the same way so that we can get learning across different cases. There is obviously flexibility in the way the ICSs deliver things, and we need to understand what is working better and what is working less well. We cannot do that if people are doing things in a very different way.

The Chair: John, you mentioned the question of time earlier. What is your view on this?

Professor John Campbell: It is too early to pronounce on the efficiencies of the ICSs, but these have great potential to truly integrate services in a way that is meaningful for patients.

There are predictable things. A key issue for my ICS colleagues—I know, because I have spoken to them in the last 24 hours—is that we can have this pastiche, if you like, of primary care networks and places associated with that, but if the digital boundaries differ for health visiting, community nursing, district nursing and practices, and if the technologies that are being applied—SystmOne and EMIS are common IT systems in general practice—differ from what is going on in community health services, we immediately hit a barrier and lose the potential to share information effectively across boundaries and to work together. So there are simple things that could be done.

To go back to the earlier question about who is going to monitor that, we have efficient, big organisations in NHSX and NHS Digital, which are there to help with supporting those kinds of areas. We have just finished and reported a piece of work to NIHR on what we have called digital facilitation, which is about supporting the public and users in optimising the use of primary care technologies—online services. They are not going to happen by magic; they need to be planned and implemented effectively, and that is a potential shortcoming. We would love to work with the integrated care systems in an effective way as academics, and it may be appropriate for ICSs to hold some elements of research funding so that they can work with us in evaluating what is going on in their patches.

Q7                Baroness Barker: Who is responsible for technology in community care?

Professor John Campbell: Currently, there are six main systems working in the general practice environment, two of which are predominant in English healthcare delivery and that together probably account for 75% to 80% of practice uptake. I have absolutely no idea who supports district nursing, or the technology and records system associated with it. I can say that, because that represents exactly the problem: that we need to have seamless systems that are co-ordinated. I am sure that is being worked on, but it will need intensive effort to bring in the many community health service providers. Beyond nursing, health visiting, pharmacy—the big professions—there are many others where information needs to be shared.

Baroness Barker: Who is responsible for the fact that the technology does not work?

Professor John Campbell: At the risk of going on about this—we should not underestimate this—I have not used paper records in my practice for 20 years. It is monitored carefully on a day-to-day basis at local level, working in conjunction with providers. However, in terms of the efficiency of the service, we have the most technologically advanced system and a huge amount of data in the NHS. The sad thing is that, because of governance issues such as data availability, it is very hard to exploit that for the benefit of the wider public and researchers.

So in terms of monitoring it is a challenge, but good systems—certainly primary care systems; as I say, I cannot comment on community health systems—are in place to support that.

Baroness Barker: How many times do patients get asked the same question?

Professor Hazel Everitt: They get asked the same question an awful lot, because the systems do not talk to each other. Sometimes it is important to ask questions repeatedly because people are coming at it from different aspects, but it is frustrating for patients and for clinicians. A core basis of data should be available to everybody. Obviously, that needs proper data protection and it has to have good access, and the patients should have access to that too so that they can see what is being held about them.

However, technology goes beyond that. We have a huge opportunity with all the health apps and all the other options for help that are also potentially available. However, at the moment the systems are not there for making them available, for telling people which ones are well researched and which have a good evidence base. It is really tricky. It will always be important that patients not only do things digitally, but that there is a human person they can speak to to help them navigate the system. When you are ill, it is really hard to navigate even a simple system, and this is not a simple system.

Baroness Barker: Is there any primary care network or any ICS for whom this is anything more than a pipe dream? Is it near to being a reality for anybody anywhere?

Professor Hazel Everitt: I do not think that anywhere is doing it particularly well at the moment.

Professor Kate Walters: Data is a priority in many ICSs, but people are not necessarily coming up with the solutions, so it is not an easy nut to crack. I am not aware of any area that has some kind of seamless co-ordination across the community sector and primary care.

The Chair: What about the area that you mentioned earlier? Have they cracked the nut of technology there?

Professor John Campbell: The specific example of High Flow in north Devon has demonstrated that it is possible to work across boundaries. I was interested to hear a bit about it, because it has a strong theoretical basis; it has been carefully put together using existing theory to help to support the service delivery. That is an impressive achievement.

As regards the technology supporting it, I do not know. In our recent work for NIHR, we were not able to identify many gold-standard examples of where the facilitation and support for the public in making data, allowing them to use digital systems, and then making the data available have been delivered effectively. But there are some tremendous places. I have heard that one practice in Frome in Somerset is delivering high-quality digital innovation at the front end of the health service. But we were not able to identify specific examples that would be applicable more widely or that should be rolled out. These need evaluating carefully.

Q8                Lord Kakkar: I should declare specifically on this point that I am chairman of UK Biobank.

I was very interested by the comments of Professor Campbell and other members of the panel about the research opportunity that is apparently being squandered at the moment. On the general data protection regulations, where should the role of the data controller for the community in primary care lie as regards the bulk of data—with the individual general practitioner or somewhere else more broadly across the system?

Professor John Campbell: I imagine that it needs to be external to the practices, but it is surely not beyond the wit of man, the NHS or healthcare more widely to deliver efficient systems that can integrate the data that we are collecting from hospitals, labs and the genetic profiling of individuals, which is now easily available within a very short time, right through to all the data on clinical care, prescribing and general practice. The fact that we have not been able to do so at this point is shocking.

Internationally, we are perhaps squandering a tremendous opportunity. Maybe there are concerns about commercial exploitation—there are certainly big issues to do with data protection and confidentiality—but those are manageable. If my smartphone allows the routine end-to-end encrypting of messages, it must be possible to do this effectively for the benefit of the public and the well-being of the NHS itself.

Professor Hazel Everitt: I think patients are very willing to be in a research trial and have their data shared if they have a cancer diagnosis and go into cancer trials. We need to have a culture of data sharing and research in primary and community care to be able to harness that data. A lot of patients come into trials very willingly. We do an awful lot of big clinical research trials where they share lots of their data. We need to work with patients in the community to embed research, innovation and improving evidence-based practice as a norm in primary and community care. It is not there as a norm, but it needs funding, resources and expertise across all the people in primary and community care. That needs to be built up through the workforce, as well as having the digital side.

We are starting to build primary care data science groups in some of the universities where we are trying to integrate the social care data with the primary care and hospital data. That takes, time, energy, money and expertise, but it will be very well invested money if we go down that route.

Baroness Barker: I asked my questions in the way I did, because there is a fundamental problem, certainly from a patient perspective. Why would I share highly sensitive data with an organisation that cannot organise itself properly to share very basic data? That is one problem. As regards technology, patients in some cases are very much ahead. We discovered during lockdown that they did not mind doing a lot of telemedicine, but the NHS is not equipped to do video conferencing, for example.

Professor Hazel Everitt: It is interesting. We have done quite a lot of research that looked at patients’ preferences for mode of consultation, and obviously we have more opportunities now: we have telephone, video and face to face. The research has shown that the telephone is useful for some people for some transactions, but video does not add much; it has limitations on being able to see and examine people and does not add much more than telephone. So although the technology has been problematic for video, we are not using it partly because clinicians and patients find that if you get to that stage, you want to see people face to face. In fact, it is really important to see people face to face; there are hidden agendas and vulnerable people in the community who need that. So there needs to be a suite of offers, of choice, so that the right type of consultation can be done for the right patient.

Baroness Barker: Thank you very much. I go back to my initial question: whose responsibility is it, and why does it not all happen? I think we have established that you cannot answer that, but that seems to me to be the fundamental question that we need to answer before we talk about building new systems in the future.

The Chair: There is another question, is there not? I say this from personal experience this week. It is one thing to provide and share all the data, but quite another to ensure that staff who are looking at it actually read it and use it. Maybe that comes back to your leadership and training question. My personal example is someone who was admitted to an orthopaedic ward with a suspected broken femur. He was about to be discharged because he did not have a broken femur, but he had a severe advanced cancer diagnosis which the staff on the orthopaedic ward had not even seen. How does that happen, we ask ourselves?

Professor Kate Walters: One aspect of data sharing is people’s histories—their stories and health problems. Another is care planning and the person themselves sharing what they hope to happen with their families and between professionals. Care planning is not done in a very co-ordinated way across primary and community care, and one person might have multiple care plans that do not talk to each other.

Baroness Armstrong of Hill Top: That is what we are really struggling with. Individual patients will have to take individual decisions about things. I am now signed into so many trials and whatever, and it is ridiculous, because once I have signed to say, “Yes, I’ll do it”, the NHS then contacts you for everything. The fact is that primary care is largely still a private enterprise and has different systems from those of acute care, and different systems again from community care, so care planning becomes very difficult.

We need reassurance that people in primary care understand that that is now a real issue; people will get to a diagnosis and maybe into acute care, but the systems are still not talking, so, as the Chair is saying, one hand does not know what the other has been doing. Are you seeing any real discussion of this in the primary care system so that they are able to help us all move to systems that will talk to each other?

Professor Kate Walters: Certainly those discussions are happening. Everybody is aware of the concept of multiple long-term conditions and the need to co-ordinate care better. In fact, people are trying to co-ordinate care plans better and look at automation. In my practice, for example, we have a single care plan that covers a person’s every health condition, which draws in data across all the different health conditions. We still have yet to make progress on co-ordinating what we do in primary care with the organisations outside it, and even in primary care across to community pharmacy and the other elements of primary care.

The Chair: Of course, that is the nub of the work of this committee, which is why we are rather pressing you on this.

Q9                Baroness Finlay of Llandaff: Before I ask this question I should declare that I am a fellow of the Royal College of General Practitioners. How suitable is the current GP model, and to what extent can it enable effective integration between different services?

The Chair: Yes, is the model workable?

Professor John Campbell: To be honest, the potential value of general practice as a clinical discipline that protects the whole system cannot be overstated. As others have said, it is the jewel in the crown of the NHS. It deals with 90% of the contacts for 8%[1] of the financing of the NHS. That is a highly effective and efficient system, but one that is grossly under strain, with huge problems, which are well publicised, with the recruitment and retention of GPs.

I will give one example that you may be interested to hear of as a committee. You may be aware that we recently started, for the first time ever, to recruit 4,000 trainees into the English training system for general practice, which is a tremendous achievement on the part of Health Education England. However, there is a problem, because 47%—that is a figure from my colleague, Professor Simon Gregory (Health Education England)—are international medical graduates. That is a frightening figure. Without those people coming to support the delivery of general practice care, we will have major problems. We are recruiting these colleagues from countries where it is perhaps questionable to do so. They have their own health needs and we are taking some of their best people into the UK healthcare system. There is an ethical and moral question to be addressed on that issue, but we are glad to get them.

The flipside is that we have a major issue: why is general practice as a career now seen as unattractive to our UK graduates? That is the disaster of current times. We are tremendously grateful that we have international graduates, but if we did not have them, we would be in big trouble. That question has been addressed by Professor Wass in her report from three years ago, By Choice: Not By Chance. We need our best graduates to want to go into community care, and we have to ask why that is not happening.

In our own research a few years ago, we found that GPs were concerned about the risk associated with practice—the risk of being a partner. In the past year in Devon, we have had a 20% reduction in partnership compared to 4% just three years ago. This is not only about the attractiveness of general practice as a career, but about the willingness to go on to senior levels and to take on the responsibilities of partnership, which is seen as just too high-risk—on clinical accounts, on premises accounts, on financial accounts, and on personal risk accounts. That is one of the important factors that is driving many GPs into early retirement, or quitting the profession early, or reducing their commitment to day-to-day clinical practice. I could say more, but I will not.

Professor Kate Walters: In addition to the workforce issues that we have just been talking about, another key issue is estates. Under the current model, just under half of practices’ premises are owned by partnerships. If we are going to go for a real integrated model where we try to co-locate things in premises, the issue of estates under the current model will also have to be addressed.

Professor Hazel Everitt: I totally agree. Communication between professionals is enhanced if you are co-located, and the reports have all said that the estates are in the NHS, particularly in community care. So there is an opportunity there to co-locate, to build communication and to increase integration. However, general practices are already working hard to expand the multidisciplinary team in general practice. We have the advanced nurse practitioners, the pharmacists, the physios, the social prescribers and everybody else now working together, so it is happening, but it needs a workforce with the time, space and energy, and at the moment in general practice it is firefighting. It is really hard to get through the day job let alone to have the time, energy and resources to think about how to improve things and integrate. It needs more space to be able to do that.

The Chair: How do you propose to get it?

Professor Hazel Everitt: Obviously, we need to increase the numbers, which will slowly come through. We need to increase the multidisciplinary team and work more efficiently in that way as well as by being more efficient and spreading good practice. That is where the monitoring, the evaluation, the research and the implementation come in to spread good practice across the country. People in different communities need different stuff—you cannot have one size fits all. That is important. People in London need something different from people in rural communities, but they still need the services, which need to be appropriate for the setting they are in. That is why local is important, but you need the resources going in across the piece.

Q10          Baroness Tyler of Enfield: First, I declare an interest as a non-executive director of the Royal Free London NHS Foundation Trust.

I would like to pick up on the very interesting figures that you quoted, Professor Campbell—I hope I have got it right—when you said that general practice accounts for some 90% of contacts, but some 8% of the budget. Is one of the problems with general practice in certain parts of the country feeling like it is pretty much falling over—certainly there is great frustration on the part of patients at not being able to get appointments—just down to the fact that there is not enough money going into it? You have the envelope, and within it not enough is going into primary care—and, I would say, community care—because basically it is going into hospitals and acute care. Would that be your view at a simplistic level?

Professor John Campbell: Ultimately, sadly, probably not enough is going into the healthcare system more widely. Work in the last two weeks, possibly from the King’s Fund or maybe from NuffieldLancet Commission on the Future of the NHS identified that increases in NHS expenditure of an additional 4% per annum is required over the next five to six years to begin to address the gaps in the system.[2]

As regards primary care, money is only one issue. It is an important issue, but it is also about the perceived status of the work that GPs do. GPs provide care that is continuous, and continuity of care is seen by patients as desirable, but it has fallen from 50% just three or five years ago to about 38%.[3]

I think the public generally want and GPs would like to provide continuity of care, but it is a complex environment and that question cannot be addressed overnight. Continuity and co-ordinated care are important, as we have talked about—working across this complex environment of community care, primary care, acute care and mental health care. These are complex areas to be operating and providing co-ordinated care at the interface of.

Then there is the provision of comprehensive care. We think back to Dr Finlay of many years ago, who worked in isolation but provided care to the same people over a period of time. GPs aspire to that in their practices and their teams, but they do not want to work in isolation—we do not have we do not have the skills for this complex environment of care. We have great skills, but they are not all-encompassing. So it is about working with others, with first-contact physios and with pharmacists, who are now working in our practices and as part of the team—some are now partners in the practice in various settings—and with our nursing colleagues and the many community interest organisations that exist. We operate in a complex environment, but more resource is certainly necessary.

Q11          Baroness Finlay of Llandaff: I was listening to this and wondering about the multidisciplinary team meetings that have developed in big hospital specialties to deal with complex problems. You are talking about having everyone together, possibly in the same building and in a much better building, you still need to make the teamwork happen. It does not happen just because they are in the same building.

How could that be driven forwards, and how will the demands out of hours be met? Some 75% of the week seems to be out of hours, so we have a mismatch between when people are there and potentially available and when far fewer people are there.

Professor Hazel Everitt: The potential to have more multidisciplinary meetings would be great. It is really important to have that. We are already liaising with different groups in primary care, and that could be enhanced significantly. However, by harnessing the potential for primary care and community care to do preventive work and pick up things earlier, we will reduce the emergency care needed out of hours. So investing time and energy in in-hours general practice will help to reduce the potential need for some of the out-of-hours stuff. It is important to consider that.

Professor Kate Walters: There are definitely a lot of good examples of multidisciplinary team working in primary care now. Certainly in my own practice we already have team meetings with mental health, paediatrics, palliative care, and community frailty team meetings. However, it is not consistent across practices—different areas have operationalised things in different ways—and it is a big investment of staff time. In fact, one of the benefits of Covid has been that our meetings have all switched to remote and become much more efficient as a result, as people are quite geographically dispersed.

Q12          Lord Kakkar: What do each of you believe to be the most powerful intervention that might be applied to ensure effective delivery of truly integrated primary and community care?

Professor John Campbell: The most powerful interventions would be a commitment to stabilising the structures over five years to allow things to embed, a commitment from government and from the NHS itself to allow the current structures to embed to allow evaluation of the important range of new initiatives that are springing up, and a commitment to implement these more widely where appropriate or to discard them if the evidence is not there to support their use.

Professor Kate Walters: In addition, I would say investment in local leadership and pathways to local leadership, and future leaders, so that it is sustained over time, and a commitment to evaluate effectively so that we can learn as we go along, and more than we have done thus far.

Professor Hazel Everitt: Our staff are our biggest asset. They are highly trained and very committed, and they need to be valued and given the training, support and resources to be able to do their job to the best of their ability. At the moment, they are struggling with a system that is not fit for purpose. If we can data-share properly, use the technology and involve staff and patients in developing systems that are fit for purpose, that will make a huge difference going forward, but the staff are key; if we lose them, we will have a problem.

The Chair: Admirably succinct. On behalf of the committee, I thank you very much for your thoughts and your wisdom. Please do not think that this is the end of our engagement with you. If there is anything more you wish to tell us, I expect we will consult you more and come to you with questions. We hope to be further in contact with you in the future, but for the moment, thank you very much.