Fuller Stocktake: No shortage of ambition

Perhaps one of the most important documents in recent health service history, the Fuller Stocktake: Next Steps for Integrating Primary Care throws down highly ambitious plans to improve population health by streamlining access to care and advice

The Fuller Stocktake Report, Next Steps for Integrating Primary Care, landed in late May to a fairly warm reception. Commissioned by NHS England and NHS Improvement with the aim to find out what is working well in integrated primary care, why it is working, and how implementation of integrated primary care can be accelerated, it provides recommendations for how the newly formed Integrated Care Systems (ICS) can support integrating primary care with a focus on local population-based care. Dr Claire Fuller, who is herself the chief executive of an ICS in Surrey, and a GP, engaged with around 1000 people across the health sector. The ‘new vision’ is built around three main offers: to streamline access for people who get ill but use health services infrequently, providing them with more choice and ensuring care is always available when needed; to provide proactive and personalised care from multidisciplinary teams for people with complex needs; and to help people stay well for longer with an ambitious and joined-up approach to prevention.

ICBs - an opportunity
It’s fair to say the report landed at a highly challenging time. With significant backlogs of care, major workforce challenges, rapidly rising demand and a tight financial settlement, it can be difficult to envisage how most of the stocktake’s recommendations can be addressed without a different kind of stocktake. However, the document acknowledges this and does well to articulate the collaborative processes and neighbourhood level integrations that have given rise to its recommendations. The report states that ICBs have an opportunity to use their scale and combined power to develop relationships between sectors, but that integrated working needs to be “rooted in a sense of shared ownership for improving the health and wellbeing of the population. They should promote a culture of collaboration and pride and build relationships and trust between primary care and other system partners and communities.”
Set out in four main sections, building integrated teams in every neighbourhood; improving same-day access for urgent care; creating the national environment to support locally driven change; and hard-wiring the system to support change, it concludes with a framework of 15 actions by which to track progress, with most of the detail to be thrashed out by the 42 ICBs as they come online on July 1st.

Avoiding perverse incentives
On publication, Professor Martin Marshall, chair of the Royal College of GPs, said: “We need further detail about the proposals around streamlining urgent access. Any new metrics will need to be thought through carefully so they have a positive impact on patient care, and avoid any duplication or perverse incentives across the system. Addressing workforce and workload pressures, improving staff morale and investing in support for change will be particularly key to achieving the report’s aspirations.”

Professor David Colin-Thomé OBE, chair of PCC and formerly a GP for 36 years: “When I read this stocktake admittedly rapidly, I thought a ‘same old’ NHS document in which as usual primary care must be subsumed into a faceless big is beautiful bureaucracy. On a more thorough read, I was wrong and feel it a positive contribution respecting what primary care has achieved, and the opportunity for it to be a real leader in improving the ailing NHS.”

“The stocktake is just that, a taking of stock, but the message is clear as to me it always has been – do not abdicate sole responsibility to government and then complain about the ensuing policy. It is up to all of us to be the policy developers by utilising the vehicle of change being offered. The Fuller stocktake is of great value but only if it ensures the commitment that is seemingly promised, of ‘buy in’ by current senior leaders and thereby enabling local services to have a locus of control. The best leaders keep control by letting go.”

The stocktake was accompanied on publication by The King’s Fund report Levers for change in primary care: a review of the literature, which, near conclusion, makes a general point about NHS reform: “While the delivery models in primary care have only changed in a limited way since the creation of the NHS, structural change in the commissioning and oversight of primary care has been a constant theme. There is limited research evaluating the precise effects of the various structural reforms to the NHS over the last decade in terms of their effects on change and improvement in primary care.”