Reflection on primary care conference Nov 2017 – Felix Gradinger

Session 3: Organisational support for person centred approaches and scaling up.

“System change – working with multiple local initiatives and top down policy dictats: Exploring context and capabilities for Integrating Care”

This workshop entailed the beautiful and relevant and experiment to get a diverse set of stakeholders that mostly did not know each other to take a comprehensive system-wide look and work through their individual experiences using an evidence-based framework around the capacity to implement integrated working (

The participants were a good balance of people from various regions across Devon, Plymouth and Cornwall. We also saw a good mix of 2 provider representatives (CPT, Livewell), 2 commissioners (Devon NEW, SDT) and 4 GP practices including managers, clinicians and service users. There also was a good mix of backgrounds from academia (2 Profs), nursing professions (4 incl academia/commissioning functions), one representative from Academic Health Sciences Network and one pharmacist.

So far so abstract, as the first part entailed a hefty discussion and in some cases outright refusal by participants to engage with the framework – an overall sense that this was too complex and that people preferred to work more from the bottom up, i.e. starting from their own experience.

Question/insight number one: do academic approaches to comprehensive understanding adequately match the particular type of operational and experiential knowledge used on the ground in driving system change?

There was a general sense that the framework itself would not be helpful for frontline managers as views and access to overall context from each diverse perspective represented in the room diverge so much, i.e. implementers may not be used to thinking about implementation in context, or they might not be able to see the context they operate in while they are in the middle of it.  There was also an issue about the vocabulary and language available to capture system dynamics, and the discrepancies of academic and operational worlds.

Question/insight number two: how to match the focus on ‘implementation in context’ and normative agenda of PCCC endorsed by researchers and framework with tailored insight that matches

Specific insights gleamed from plenary and group working on the various domains in the framework comprised (beside more obvious barriers around top-down dictats, money/politics, leadership, workforce, information governance, shared records and safety/indemnity):

  1. an animated discussion around form vs. function; and consensus that integration is too often caught up in historical forms, and top-down dictats that predetermine forms– whereas the integrated, person-centered, idealised function is deemed to be wrapped around person and communities is often secondary to the above.
  2. Stakeholders describe an opportunity for primary care through formal or informal federating and to champion the local patient perspective to increase the power of the voice of both, and share how this has potential for impact at system level (needs to be resourced).
  3. IT shared records and systems: this is key for integration and the most obvious thing is read/write access for all; General Data Protection Regulation (GDPR) coming in next year is seen as threatening and it is deplored that information governance is often used as an excuse not to change comprehensively.
  4. Person-centeredness and Culture change: conference presentations and case studies really chimed with people and enthused to use clinicians as key change agents for integrated working with their service users (and outcome-based commissioning).

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