The challenges facing primary care: Q&A with Dr Ollie Hart

Dr Ollie Hart is a GP partner at the Sloan Medical Centre in Sheffield. He is also the clinical lead for Sheffield’s person-centred care work stream, and an executive on the ‘Sheffield Move More’ board. We spoke to him about the challenges facing primary care and the realities of improving quality in the sector.

What’s the biggest challenge facing the primary care sector at the moment?

It has to be the massive increase in demand for our services. We’re managing increasingly complex cases within the community, but at the same time public demand on the health service is also changing. People are living longer, but it’s also like society’s got more health anxiety these days and people’s threshold for seeking help is lower.

So just managing demand and having the capacity to respond is really challenging and is sucking all of our energy at the moment. It means we don’t spend enough time planning the proactive care needed for people with long-term conditions, or people who are house-bound or vulnerable. Those people are being relatively abandoned because we’re so focused on dealing with the upfront demand.

Where do you think the biggest opportunities lie for improving care or even public health more widely?

There are massive opportunities... general practice has a big role to play in using person-centred approaches and trying to upskill people in how they deal with their own health. Going back to the messages in the Wanless report, there’s an economic argument to having a fully engaged population, as well as all the health and wellbeing reasons.

And then there’s all the wider stuff, like encouraging people to live healthier lives (I’m involved in a movement in Sheffield to get people to be more active). But it can’t be our job to do everything. One of the challenges for general practice is to know where you can deliver your best value.

I think one of the biggest opportunities is how we diversify within the primary care team. We’re having to redefine who does what. How do we decide if someone should see a GP or a nurse practitioner? Or a pharmacist, a health care assistant, a health coach, a life navigator? There’s a place for all these roles now. The opportunity is to work out how we distribute these resources so we function as a network. And that network has to include the public as well, because our patients need to understand that the paradigm of your GP doing everything for you has changed.

What support is there to encourage quality improvement (QI) in primary care?

I’m not sure that there is anything overarching really. CQC inspections lean towards making sure you have a development plan for your practice, and the GP Forward View talks about how practices need to develop improvement skills and use them to develop resilience and sustainability in practice... but organisational development and building specific skills for improvement in our workforce, that’s relatively new for general practice.

I’m not aware of that many clinical commissioning groups (CCGs) where QI is particularly high up the agenda, although there are pockets of it. I was involved in the Microsystems coaching in Sheffield last year, led by Sheffield Teaching Hospitals and funded by the Health Foundation. I think I was the first GP in the city to do that training. A couple of CCG chief executives now seem interested in adopting this approach in primary care. So people are starting to wake up to the fact that this is a big opportunity but it’s definitely in its early stages.

How have you used the skills you developed becoming a Microsystems Coach back in your own practice?

I encouraged my team to get involved in a project applying QI approaches to reshaping our maternity services. It allowed others to experience leading change. For me the most important difference has been having a shared framework with a clear plan for reflecting on measures of change.

What is the most challenging thing about trying to implement improvement in primary care?

One of the hardest things is that practitioners are quite independent. Although we’re working in partnerships, what happens in our consultations and the way we all practice is still quite variable. The challenge for QI can be to find a coordinated vision – the core values that we’re all working towards. For example, some GPs might really value safety and not missing problems, whereas others might really prioritise person-centred care, but be prepared to sacrifice a bit of safety in doing that. Different values and priorities can pull in different directions.

Where do you think primary care should be focusing QI energies in the future?

I think I’d come back to managing the flow of patients through the primary care system – applying a QI approach could really help. It would make sure the right kinds of patients were being seen at the right time, and it would free us up to help with the hot case management, where people with long-term conditions flare up and become genuinely unwell. From a CCG perspective, this is where much of the financial stress comes from as it leads to unplanned admissions. If we could address the flow aspects better, we’d have more resources available to help with managing these complex cases, an area where we can really add value.