Primary care integration

A number of reviews pointed out the complexity of primary care services, which rely on a mixture of independent, public and private contractors, with a multitude of different professionals, often working in relative isolation. There was a lot of evidence that this fragmentation has got worse over time, and has been adversely affected by changes in the health service, and the contracting out of some segments of health care:

“The GPs later explained, as part of this review, that they no longer have the same contact or alignment with Health Visitors as in previous years, where they would have regularly met with Health Visitors assigned to the practice.”

The fragmented nature of primary care, with GPs working as independent practitioners, but nevertheless as part of a multi-disciplinary team including practice staff, health visitors, midwives and school nurses, many of whom would be located elsewhere and under different employment structures, brings substantial challenges to effective

safeguarding practice. This has the potential for both duplication of and gaps in service provision. This was reflected, for example in a recommendation in one SCR to review the provision of midwifery support to pregnant teenagers:

“Currently there is only one part time Specialist midwife providing tailored support to a proportion of these clients in one half of the Trust’s catchment area. Alongside this and on both sides of the district there is an increasing development of the Family Nurse Partnership. There is significant overlap of the responsibilities of each role and the services they offer. This introduces a risk of both duplication of, and gaps in, provision.”

Recognising that there are inevitable transitions inherent within primary care services, such as those between midwifery and health visiting, and between health visiting and school nursing, local teams need to ensure that there are appropriate structures in place for smooth transition, ensuring that information is recorded and passed on, and that any transition, particularly for a vulnerable family, is planned so that appropriate support is maintained:

“The midwifery service continued to support the family appropriately until the health visitor had taken on the care of the family and this is good practice although there is no evidence of earlier communication between the two services which would have been expected in a high risk family. This is presumably due to the lateness of the booking although this should have increased the need for communication between the two services.”

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The fact that general practitioners are essentially autonomous independent practitioners causes a lot of concern among safeguarding professionals. This, combined with the huge remit of general practice, means that there are inevitably wide variations in the degree of engagement by GPs in safeguarding processes. As highlighted in this SCR, this places responsibility on the commissioners of GP services to be clear how they will support GPs in their safeguarding role and ensure that expectations may be met:

“GPs have no ‘senior managers’ and are essentially autonomous. Wide variations in levels of awareness of and involvement in safeguarding seen within this serious case review pose issues for commissioners of GP services about how expectations may be defined, monitored and (if unfulfilled) responded to.”

General Practitioners play a crucial central role in relation to early services for children and families, given that all children are, or should be, registered with a GP. They potentially provide a central repository of information, and a bridge between community services and secondary/tertiary care. This responsibility was identified in a case involving a 17-year-old who died as a result of his underlying chronic health problems, and was related to Care Quality Commission findings in relation to the Peter Connelly Inquiry:

“The GP was not as effective as would be expected in ensuring that children’s social care were aware of those involved with [the young person], or at informing staff from the hospital that children’s social care were involved. As stated by the GP agency author ‘following the death of Peter Connelly in 2008 the Care Quality Commission clarified that GPs are seen as the central medical record holder and should be able to identify trends in patients’ care. I don’t believe that in this case the GP practice saw itself as the service that was pulling all the information regarding [the young person] together in order to consider what extra support this young man needed to manage his diabetes’. The reviewer agrees that the GP was essential in this case in ensuring that [the young person] received the health care he needed, but they were not adequately aware of, and therefore were not undertaking, this important role.”

However, it is important that this role isn’t accorded undue weight, or that unrealistic expectations are placed on GPs in this regard. In the following case, the impossibility of a GP being able to keep tabs on all vulnerable children was highlighted in relation to those children who are not brought to appointments:

“Although there are procedures in place… relating to children not taken to appointments these did not make a difference in this case. Volume may be an issue as in relation to the follow up appointment made by the regional hospital this was an error made within the context of approximately 8-12% (2000) appointments a year not being kept… Discussions with hospital practitioners suggested that there can be a reliance on GPs to identify where follow up has not taken place although it is hard to know how the GP would realise that this had

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happened, particularly in the case of the second episode of vomiting when the GP was not informed of the failed appointment until four months later.”

This would suggest there is a need for a deeper consultation at local levels between GPs, their commissioners, secondary health services and other agencies as to what expectations can realistically be placed on GPs as central repositories and coordinators of care, and how any expectations can be effectively supported by robust structures and processes. This is something that LSCBs could usefully take a lead on, in partnership with their local health commissioners and providers.

Learning Points

 The increasing fragmentation of primary care services requires creative discussion at a local level to identify processes and structures to enable effective sharing of information and transition between different providers of care

 LSCBs could work with GPs, their commissioners and other stakeholders to realistically review what can reasonably be expected of GPs as repositories and coordinators of care, and how such expectations can be supported