Brendan Martin, Dr Niamh Lennox-Chhugani and Dr Sebastien Moine.

Q213 The Chair: Welcome to this session of the Integration of Primary and Community Care Committee. We are grateful to our witnesses for joining us. We have with us Mr Brendan Martin, founder and managing director at Buurtzorg Britain and Ireland; Dr Niamh Lennox-Chhugani, chief executive and director of research at the International Foundation for Integrated Care; and Dr Sebastien Moine, visiting research fellow at the Primary Palliative Care Research Group at the University of Edinburgh.

I welcome you all; thank you for sparing the time to answer our questions. As you know, we will take turns to ask you questions, but I warn you that today is a voting day in the House of Lords, and we are liable to be interrupted by a loud bell. You will not be able to miss it, but I will take over the session if that happens.

Let us start in the hope that we can continue. I ask everyone, but principally Mr Martin: what is the Buurtzorg model, and how does it facilitate integrated working and overcoming barriers to integration?

Brendan Martin: Thank you for having me. It is a pleasure to be here. The Buurtzorg model is based on supporting people to live their lives with as much meaning, autonomy and warm social interaction as possible, no matter their circumstances, whether that be someone needing support while recovering from hospital care or someone coming to the end of their life. The purpose I described applies across the board.

On the relationship between primary and community care, what has been important for Buurtzorg in the Netherlands—I will come on to what this means in a second—has been enabling people to support people in the way they need, with clinical and personal care when needed, in an holistic way. Our model is based on supporting people to care for themselves as well as possible, drawing upon and strengthening their own assets, if you like, and the assets around them—in their families, among their neighbours and in their local communities. Indeed, Buurtzorg is the Dutch for neighbourhood care, and we take just as seriously the idea and practice of supporting and strengthening neighbourhoods’ capacity and capability to care for themselves as we do supporting individuals to do so. So integration of health and care is at the heart of our model.

Another characteristic of the model, one necessarily based on what might be called our relational care approach, is that we start by finding out what is important to our clients and their goals, and we explore with them what is needed to achieve those goals, drawing on their strengths and the assets around them, as I said.

Working in that co-creative way means that our professionals themselves need to work with a very high level of professional freedom and responsibility. We work in self-managed neighbourhood teams. Although the teams have, in some respects, a hierarchy within them—in the sense that some team members are better qualified than others and might be highly specialist in their training, while others may be nurse assistants—they nevertheless operate as a self-managed non-hierarchical team, doing what is needed when it is needed and learning, experimenting and changing as they go.

They do this on the basis of a framework of normative standards, which is important. The normative standards cover the quality of care, the quality of the working relationships, and the way in which resources are used, since we would not be able to sustain our model unless resources are used effectively. However, within those parameters, teams and the professionals within them are free to find their own solutions. We believe that that self-management is crucial to the relational care at the heart of our model.

Finally, we support all that with coaching when needed. The coaching’s purpose is to support the teams themselves to find their own solutions, but sometimes, like anyone, they get stuck and need a little external support, so coaches are available to support them when needed. They also have the support of digital and back-office services whose culture is to serve and support the front-line professionals, similarly to how the culture of the professionals themselves is to serve and support their clients.

So the way in which we organise as an organisation, as well as the care itself, is a continuity of logic, from the heart of it—the relationship between the professional and the person needing support—right through to how the organisation supports those professionals, aiming to build strong relationships, try things out, learn and build trust as we go. That is how I would briefly express what the Buurtzorg model is about.

The Chair: That was a comprehensive answer. Thank you.

Q214 Baroness Wyld: Opening the discussion out, could the witnesses say, from their experience of international research and practice, what the current strengths and weaknesses of the English approach are to integrating primary and community care?

Dr Niamh Lennox-Chhugani: From the point of view of the research that we have collated over the last couple of decades, the first thing to say is that, internationally, there are different definitions of scope related to primary care and community care and what is being integrated.

That is one of the challenges of making comparisons. The organising models are very different, which makes direct comparisons also quite challenging. Some international systems include social care in their model of primary care. Some include it in their model of community care. Some include community care itself in their model of primary care—they have a much broader scope in what they mean by primary care and what is included in that. Others separate out social care completely under the welfare system, away from the health and care system. So that is the first thing to say about trying to make international comparisons.

We also know from research that there are four—

The Chair: I am sorry, Dr Lennox-Chhugani, but you can probably hear the Division Bell. My colleagues need to go to vote now, so I must suspend the session, with apologies.

The committee suspended for a Division in the House.

On resuming—

The Chair: I am sorry about that. We were in the middle of Dr Lennox-Chhugani’s answer to Lady Wyld’s question.

Dr Niamh Lennox-Chhugani: I will pick up where I left off. I was talking about some of the challenges in making international comparisons. In our evidence review, we look at four core elements of integrated primary and community care, but also system-wide. They are care co-ordination, care continuity, person-centredness and community-centredness. This is what we tend to compare, rather than models themselves.

On the strengths and weaknesses, recent research comparing different models of integrated care over the past 20 years showed that some of the strengths of the English approach were about having a clear national policy. The Five Year Forward View, published in 2014, set out very clearly the direction of travel and the ambition for care integration and population health. That was consistent right through until probably 2019-20. With that came consistent funding for relatively large-scale testing of different models of care integration through the new care models programme. Embedded within that was evaluation. So it was very much an evidence-based, evidence-informed approach to looking at what worked in care integration across not just primary and community care but also secondary care.

One of the limitations that we have seen from the evidence emerging over the last two to three years is that, over time, there has been an inconsistency in the purpose or shared vision, or goals, in some of these models of care, and that the ambition set out in the 2014 policy has not been sustained over time. Increasingly, there is a narrow focus on avoidable admissions: avoiding admissions into hospitals has been one of the main goals of a lot of models of integrated care now emerging in England. That is a significant dilution of the original policy that was set out in 2014.

The other limitation in the English experience of integrating primary and community care, and integration more widely, is an overreliance on structures and contracting, particularly in relation to the inclusion of primary care as it is scoped within the English system and as it is currently practised. That is probably in some ways a limiting factor to the progress that has been made in integrating primary care with community care in the English context.

The Chair: Forgive me, we have another Division. You can probably hear the Division Bell. I will have to suspend the session again; I am so sorry.

The committee suspended for a Division in the House.

On resuming—

The Chair: Not all my colleagues are back, but we are quorate again, so we will proceed. Again, I cannot apologise enough. Perhaps I might go directly now to Dr Moine, with thanks to him for joining us, and put Baroness Wyld’s question, which has just been comprehensively answered by his colleague. From your experience, Dr Moine, what are the strengths and weaknesses of the English approach to integrating primary and community care?

Dr Sebastien Moine: Thank you very much for having me here—I am very happy to participate in this discussion. I will first issue a caveat: I worked as a GP in France for 13 years and I moved to the UK six years ago. It was first for research purposes, but I have continued working here as a GP as well. I work in Scotland and do not know the English situation very well, although I know that there are some similarities between NHS England and NHS Scotland. That would be my point of view. Also, the amount of evidence will be limited. This is more about my personal experience.

What really struck me when I started working in the UK, in NHS Scotland, was how we as GPs—maybe my colleagues do not pay the attention I do to the same phenomenon—have the sensation of being part of a whole system, including at the primary care level. That may not be the same situation in France. For example, we can spend hours here in meetings with policymakers discussing primary care. It is not a notion that we tend to use that much in France. That is probably because the French and British systems have very specific structures and histories. I would not be able to tell you which one is best; there are advantages and inconveniences to both systems.

In France, for example, we have three different actors involved in funding healthcare, paying for care, planning care and delivering care. The three actors are our Ministry of Health, which is a very central actor, the original health authorities, and the national health insurance. Sometimes these actors may have different interests, which is not the case working in the UK, where we have the same organisation, the NHS, which is funding care, training professionals and planning healthcare at the same time.

A very obvious example for me is the IT system in primary care. In Scotland and in the UK you have very good connections with secondary care, for example, because each GP is involved in referring patients to different services and you can keep track of all these referrals via your IT system, which is amazing. We do not have such tools in France. French GPs just write a few sentences on a piece of paper for a referral and give it to the patient, who can then see a specialist. So this integration of the IT system is very important.

Secondly, and this is the case in primary care in Scotland, one part of the general practice medical record can be uploaded and shared with emergency departments and out-of-hours services, as is proving the case in England as well. We have this key information summary for people with very complex or multiple chronic conditions, and when they have complex needs we can share this part of the medical records with out-of-hours services so that we can allow for some continuity, regardless of when the patients have to call.

I heard what Dr Lennox-Chhugani said about patient-centredness. One of the main threats to the main role of primary care, which is to have a holistic approach to the care of patients, is to become overly specialised. The obstacle, or the threat, to that is to have a revisionist approach and continue to cut people into tiny bits of specialties. In order to make sure that we have this continuity and whole-person approach, being able to share information about the person as a whole is very important in our daily practice.

The Chair: Thank you very much, Dr Moine. We went on in your absence. Does Mr Martin have any brief comment to make on that question about the strengths and weaknesses?

Brendan Martin: The only addition to what the other witnesses have said is that we find that the preoccupation in relation to integration in England tends to be with the institutional and organisational arrangements rather than starting with the person needing support at the heart and building around that. We believe that the success of Buurtzorg in the Netherlands has been because we have been able to start in an holistic way with the needs of people needing support and to create the organisational and institutional environments in which the professionals are able to make the relationships with each other that are needed to provide the support that individuals need.

We tend to find here that the approach to integration starts, if you like, at the other end—we would say at the wrong end—in trying to integrate organisations and institutional arrangements rather than creating an environment where the professionals can find their relationships with each other and, of course, with the people they serve. That is so important to us in what is a very highly complex environment, where to cut through the complexity you need the professionals to be able to exercise greater freedom and responsibility.

Q215 The Chair: Thank you very much. You can hear the bell again, but I will not adjourn the session because, as I understand it, we remain quorate. When the bell stops, I will put another question to you.

Thank you very much for your answers to that. In the absence of Lord Altrincham, I will put a specific question to Dr Lennox-Chhugani about the physical estate. We have heard that the physical estate used for primary care and a lack of data sharing are two things that can make integration very difficult. Has Scotland specifically faced similar problems, and is it overcoming them?

Dr Niamh Lennox-Chhugani: I consulted colleagues in Scotland in order to answer this question, and I think the consensus was that this is still work in progress in Scotland. Back in 2018, a new national code of practice for GP premises was agreed as part of the GP contract in Scotland. That involved a move toward GP practices no longer having to provide their own premises. This is a 25-year programme, however, and although it has been slow in progress, according to some of the experts I have consulted in the last week, there is a sense that at least a policy direction has been set and a commitment made to this.

I think there is a view that this will help with some of the fragmentation that is experienced in primary care, particularly in relation to developing the initiative around multidisciplinary teams, because that is also a policy focus for performance improvement to primary care in Scotland. That has probably been the biggest focus of changes in the Scottish system in primary care since that contract was agreed. So it is more a case of the estates limiting the ability to deliver on some of the other, enabling aspects of interdisciplinary or multidisciplinary work, particularly in relation to pharmacy and MSK—I understand that those two areas were a particular priority and focus in Scotland.

There is an issue with the lack of capital investment. None the less, I think the consensus is that there is a policy commitment over the long term in Scotland and that it will happen despite progress being slow.

Dr Sebastien Moine: Once again, I am not familiar with the technicalities of the new Scottish GP contract, but I have been able to witness this in a few surgeries where I have worked. There is a policy focus on increasing the skill needs at the very level of the GP surgeries; obviously, we can have physiotherapists and community pharmacists as well. One other major actor in our surgery that tends somehow to turn into some sort of hub, trying to strengthen the links with the local community, is the link worker, who is able to join the dots between the health approach that we try to initiate on the medical ground but also on the more social and community ground.

General practice is the best job in the world, and one of the best things in the job is that most of the people we meet are not even patients but just people. We are involved in prevention, health promotion and so on, and we follow people’s life course and trajectory. That gives us the time to build confidence with them and to involve the assets present in the community. It takes time, and we need not only actors and professionals with a medical profile but community organisers, and so on. There are also a few places with social prescribing, such as in a couple of surgeries that I have been working in, and there is lots of focus on creating groups where you have a combination of patients and health professionals going out for a walk or taking care of a garden. I can see this sort of development at my very local level in general practice.

Q216 Baroness Barker: How do the outcomes and policies to promote integration of care in England compare with the systems that you are familiar with?

The Chair: Are you addressing anyone in particular?

Baroness Barker: No. Anybody can answer that one.

Baroness Finlay of Llandaff: Dr Moine would be interesting.

Dr Sebastien Moine: I have followed remotely the developments of your quality of outcomes framework in NHS England since the early 2000s, for example, and the changes. In France, this is a very specific topic and quite an issue. Doctors there have contracts with the national health insurance, but most of them are paid via a fee-for-service scheme. That means that they are paid if they see patients, and if they do not they are not paid. That is a huge obstacle to developing co-ordination, teamwork, and so on.

To be honest, a new generation of GPs tend to work increasingly within multi-professional group practices, which is a real opportunity to develop teamwork in primary care. Within these multi-professional group practices, the medical team can have a combination of different mechanisms of payments, so it can be a bit of fee for service, a bit of pay for performance, and capitation, as is the case in the UK. However, that is a new phenomenon and a new momentum in France.

The objectives and outcomes are decided with the French ministry of health and are passed on at the local level to the original health authorities after they have been validated by the national health insurance. That, as you can see, multiplies threefold the possible obstacles and difficulties in trying to achieve these goals and outcomes. However, it is moving forward.

Q217 Baroness Armstrong of Hill Top: Hello. I am sorry to have missed so much of your contributions, but I hope we will not vote for at least another half an hour.

I will address this question to Brendan Martin. I gather that you introduced your programme in West Sussex. Have you introduced it anywhere else, and what sort of barriers or difficulties did you experience when you first introduced it here? What learning about the English system, and about your model and where it comes from, have you gained from the experience in England of trying to implement it?

Brendan Martin: Thank you for that question. You are probably referring to West Suffolk rather than West Sussex.

Baroness Armstrong of Hill Top: You are absolutely right. Sorry about that.

Brendan Martin: Not at all. We have worked in around 40 different settings in Britain and Ireland since beginning our partnership with Buurtzorg in the Netherlands in 2017, and West Suffolk was one of those places. Those experiments have varied from introducing a brief and fairly basic understanding of the fundamentals of the model right through to supporting organisations in order to systematically, and indeed quite radically, change the way in which they function in order to support the front-line professionals who work in self-managed teams. So we have a lot of experience across that spectrum.

First, we do not encourage any organisations to try to implement our model. However, we encourage them to learn about and think about what has made it so successful in the Netherlands, where over the last 15 years—since Buurtzorg was founded—it has become the largest provider of community-based health and care services in the Netherlands. Fundamentally, that means starting with clarity of purpose and engaging with all the stakeholders to think about what that purpose means for the way in which the services are provided. Where we have had most success, perhaps paradoxically, has been where organisations, rather than trying to copy the practices that Buurtzorg has modelled in the Netherlands, have tried to command an understanding of the fundamentals of Buurtzorg’s purpose and approach.

We are finding some progress in a few places. We have worked for a long time now with Medway Community Healthcare, which I recommend to you as a body of experience. We are also, in a social care context, working with the Thistle Foundation in Scotland, and, again, I know that it will be willing to provide information.

The experience we have developed boils down to three lessons. The first is that if you create conditions in which the health and care professionals are able to work with the level of freedom and responsibility that Buurtzorg professionals have, and if you give people the opportunity to do that if they want to, very good things happen. In other words, you do not have to be a Dutch nurse to work in the Buurtzorg way.

Secondly, as a result of that, we have seen very strong and positive changes in the quality and nature of the care that is being provided. One of my favourite examples comes from Guy’s and St Thomas’ NHS Foundation Trust, where we supported the development of a couple of teams, and now that is expanding. They found that the nature of the relational care that they were able to provide indeed involved a high level of investment of time in the relationship building up front, which many district nurses and homecare workers do not have time to do in the context in which they work. However, by having that time to build those relationships, the nurses at Guy’s and Tommy’s were able to get a return on that investment quite quickly, because they were able to support their clients to look after themselves more effectively. Indeed, Buurtzorg in the Netherlands has reduced by half the number of hours of professional input on average per client.

However, the third and equally consistent lesson in our experience has been that NHS and other organisations, with one or two exceptions, have found it very hard to make the kind of organisational changes that are required to go from what have been quite successful small-scale pilot projects to growing that approach to the norm. That requires quite substantial organisational change in the mindsets of organisational leaders, the culture within organisations and the way in which those organisations support their professionals. That, of course, is overlaid with the systemic challenges of the regulatory environment and the separation of health and care institutionally in Britain, none of which helps. Those organisational and institutional barriers have proved significant.

Q218 Baroness Finlay of Llandaff: I will ask you for one thing, and one thing only, that the UK Government could do to better integrate the health service in England.

Dr Niamh Lennox-Chhugani: I will be honest. It is really difficult to boil it down to one thing, because so many things in the health and care system are interdependent. However, if there was one thing that I would recommend the system policymakers in particular do at this stage it would be to look at the system of payments and contracting in the health and care system that disable or fragment it and do not enable care integration at this point in time. A lot of initiatives, particularly things like the better care fund, have gone a long way to enabling greater integration by pooling funding, but they are disabled in many of the current payment systems and contracting structures in place in the system today.

Dr Sebastien Moine: As a GP, I have a special interest in palliative care. We all know that the last year of care and end of life in patients can be fraught with suffering and can be quite harmful, not only for the patients but for their loved ones and family. It also entails a lot of cost at the global level—maybe around 10% of healthcare expenditure, depending on the studies. You cannot run the Tour de France with a single gear on your bicycle, and it should be the same in healthcare, so we probably need to identify the last couple of years before people might die not for prosaic reasons but to be able to better meet their needs.

That means the use of IT systems in general practice and maybe by using the same language. In NHS Lothian, for example—I think it is also the case in NHS England—we increasingly tend to use tools to identify deteriorating frailty in older people. There should be some sort of alert, and maybe the goal of care should be switched from wanting to fix everything to trying to take into account the preferences of people and their families and communities; otherwise, we might miss a lot of opportunities.

Baroness Finlay of Llandaff: Thank you. I should declare my interests in palliative care too. I do not want anyone to think that that was a set answer. Very briefly, Mr Martin, what is the one thing?

Brendan Martin: It would be to support, or if necessary to mandate, local authorities to make the people needing support more aware than they are of the possibility of direct payments being available to them. The use of direct payments is not nearly as widespread as it could be, and it needs to be more widespread if we are to get, within a clear framework of standards, a greater plurality of service provision. So the one thing we would welcome, if necessary through mandating, would be for direct payments to be offered as the default position. People can decline them if they wish to, but at least make local authorities more willing to make them available to people needing support.

The Chair: Thank you very much. I cannot apologise enough for the disjointed nature of this session; I am afraid we are not in control of the parliamentary business. Also, I cannot thank you enough for the wonderful insights that you have given us from your particular points of view. They have been extremely useful to the committee. As you know, this is a public session that will be put into a transcript, and you will have the opportunity to correct any errors. If there is anything else that you feel you would like to have said or any more examples that you would like to give us, the committee will be only too willing to hear them. In the meantime, I thank you very much on behalf of all the committee. Merci mille fois.