'Learning together': sharing international experience on new models of primary care.

Recent editorials in the SJPHC have highlighted some of the challenges facing general practice (GP) and primary care across Europe (such as multimorbidity and widening health inequalities) [1], as well as possible solutions (such as task shifting and strengthening primary care research) [2-4]. Such proposed solutions have been called ‘New Models of Primary Care’ [5] and include better integration between primary care and secondary care and between health care and social care; development of more multidisciplinary teams (MDTs); and GP practices working collaboratively in clusters. This represents a major cultural shift.

This editorial presents the Edinburgh Consensus Statement on new models of primary care (Box), distilled from discussions at an international workshop hosted in Edinburgh, Scotland on 17 May 2017 by the Scottish School of Primary Care (SSPC). External speakers included academic and primary care leaders from Australia, Canada, Denmark, Finland, the Netherlands, Norway and Wales. There were remarkable similarities between countries not only on the common challenges faced (ageing populations, health inequalities, multimorbidity and escalating healthcare costs) but also in the proposed solutions that are currently being enacted or suggested by Governments and healthcare systems.

Edinburgh Consensus Statement

‘The population challenges facing primary care in Scotland and other countries will require leaders who take a collaborative approach, and who are proactive in wider roles, such as advocacy and social activism. General practitioners will work closely with other health and social care professionals in MDTs where roles and contributions are understood and respected. Patients’ goals and preferences elicited through shared decision-making will guide the direction and amount of their healthcare. The resourcing of primary care will reflect the growing needs of older people and those with premature multimorbidity in deprived communities. These represent major cultural shifts. As new models of primary care develop and evolve, retaining and building on core values, such as mutuality, respect and compassion, will be essential to staff and patients alike. A strong focus on developing and maintaining trust among all involved is essential, and consideration for staff wellbeing must be evident. Generalism will remain at the heart of primary care. Rapid access to high-quality data to produce intelligence for transforming care will be essential. Collaboration between policymakers and academics in primary care research could quickly improve quality and value, achieving greater health gain for citizens, by filling in current evidence gaps and guiding the adoption and delivery of policy directives.’

Here, we summarize the five key themes that emerged from the presentations and discussions: leadership; values; roles, relationships and ways of working; data and IT systems; and research and evaluation.

First, regarding leadership, the population challenges facing primary care require leaders who take a collaborative and collective approach, and who are willing to be proactive in terms of wider roles, such as advocacy and social activism [6].

Second, as new models of primary care develop and evolve, retaining and building on core values of GP [7], such as mutuality, respect and compassion, is essential to staff and patients alike.

Third, there is a need for new ways of working. Government policies and resource allocation should tackle the imbalance between secondary care and primary care (and the inverse care law [8] within primary care, where resources are not matched to need [9]) to better meet the needs of patients, not just for person-centered care but also for prevention and health promotion. As new models progress with the ambition to achieve better integration, there is a clear need to build and develop a different culture and new trusting relationships, as championed by Don Berwick’s ‘Era 3’ of health care [10]. Trusting relationships, based on collaboration and not competition, are required between the different GP practices within GP clusters; between different disciplines in MDTs; between health care, social care and the third sector and at interfaces between primary care and secondary care. All of these require strong commitment by many different stakeholders including politicians, policy makers and those charged with the planning and provision of services.

Fourth, new models of working will need substantial local and central support to deliver high quality integrated primary care. Primary care should have easy access to secondary care data and vice versa. This needs good national and local health service infrastructure and training and support for all clinicians and support staff. Better and quicker linking of data from ‘big data’ sources to primary care data is urgently required. In Scotland, for example, data derived from the Scottish Primary Care Information Resource (SPIRE) will be essential to the development of new models of primary care.

Finally, there is great scope for the development of ‘Evidence-based Realistic Medicine’ in primary care [11]; pragmatic, co-designed interventions and service evaluations that facilitate the translation of evidence for ‘realistic medicine’ into practice [12]. There are numerous evidence gaps in areas such as multimorbidity, polypharmacy, use of digital health, treatment burden and the early detection of cancer. Addressing these gaps will require innovative ‘middle ground’ research methods [11]. International research collaboration would be a useful way to pool resources to answer the ‘big’ issues in primary care transformation, producing findings that are robust within a shorter timeframe than usual.

We would welcome feedback from SJPHC readers on the above. We firmly believe that collaboration is better than competition when it comes to developing new models of primary care, and we need it now more than ever.