A National Clinical Strategy for Scotland

3. Primary and Community Care

The majority of healthcare is delivered within the primary care setting, with the provision of around 25 million face-to-face consultations in GP practices each year. Across the world it has been shown that effective primary care, with universal coverage, can significantly improve outcomes for patients, and deliver the most cost-effective healthcare system. The integration of health and social care from April 2016, and the development of a new GP contract by 2017, offer an opportunity to modernise primary care. Primary care includes four professional groups of independent sub-contractors - medicine, pharmacy, dentistry and optometry and all need to work in close association with community care for the benefit of the whole population.

The current arrangement of universal registration of the population with a particular general medical practice, and the maintenance of the practice as the local point of access for most care will remain a key element of an effective primary care system. The similar approach in terms of NHS dentistry will also continue. This approach enables the provision of local healthcare, with a personalised and incremental approach to investigation and referral, based on assessment of need, and helps to stream people into the most appropriate services.

It is essential to recognise the importance of long-term relationships between patients and small teams within primary general medical and dental practices. These long-term relationships allow for the delivery of more person centred care that is holistic and less focussed on task delivery. The long-term relationships allow for supported self-management in a context that is most appropriate to the person's preferences and needs, across the full range of health problems - primary care is the last home of true generalists, and is able to address health needs in a model that combines a bio-medical approach within a psycho-social context.

General practitioner recruitment is challenging at the present, and will be for the next 5-10 years, with GPs known to be due to retire within that timescale. In addition to seeking to attract doctors into general practice, expansion of capacity in primary care is required. Other professionals have shown that, with appropriate training, they can more appropriately deliver many of the roles within traditional general practice, and provide service of equal or improved quality. The rise in the number of practice nurses in the last ten years has shown that they are able to take on a great deal of care and treatment, with particular benefit to people requiring ongoing management of long-term conditions. Advanced nurse practitioners have also been recruited to practices (and other primary care settings, such as Out of Hours Services), and have shown that they are very able to deal with a wide range of presentations in general practice, and are able to treat most presentations with clinical autonomy. More recently, pharmacists have been shown to have a useful role in providing excellent pharmaceutical care, especially in patients on complex combinations of medications.

Substantial contributions are made to the primary healthcare of people by a wide range of healthcare professionals - district nurses, health visitors, midwives, community mental health teams, counsellors, social workers, link workers and benefits advisors. This is not a comprehensive list of professionals that are found in practices, or associated with practices, across the country - what it does demonstrate however is the emergence of teams, with a wide range of professionals, each contributing their unique skills to managing care and improving outcomes.

Within general practice there will be a significant shift in roles in the future. Firstly, there must be increasing emphasis on prevention, self-management and individual responsibility. The aim of primary care must be to support people to maintain the maximum level of health they can achieve, but in a way that encourages independence and self-management and reduces dependency on the healthcare system. This will require the provision of information and training to people so that they can manage their own health problems - often with motivational interview techniques. The general practice of the future will have stronger links with social care support - via local government and the third sector - directing people to services and community assets that can improve health, increase resilience, and add purpose to lives. For many, self-management is a difficult challenge if their lives are ruled by more immediate concerns relating to day to day life - benefits issues, housing problems, family stresses, unemployment etc. The aim must be to support people to access the services and organisations that can most appropriately help them to address these problems, so that proportionate self-management of illness can become a reality for all patients.

General dental practices will continue to be the main providers of NHS dental care, with the increasing development of new roles to meet population needs - increased input from dental nurses, hygienists and dental therapists. These developments will mirror the broadened range of clinicians in general medical practice. Primary care dentistry is provided, in the main, by independent practices or the public dental service, and accounts for over 4 million courses of treatment per annum and provides most of the dental care for the population. The capacity of the service has increased substantially over the last decade and now there is an average of 90% of children and over 80% of adults registered with a dentist. There is a reduction in registration as the patient ages and this highlights a significant issue in years to come with an increasingly ageing, frail, dentate population. There have never been so many older people who have retained their own teeth and the demand on the service is expected to rise steadily. The skills required to treat this often vulnerable group vary from those required to provide routine preventive care to complex restorative or surgical procedures. There is an opportunity for dental care professionals (therapists, hygienists, dental nurses and clinical dental technicians) to contribute to the oral health of this population and at the other end of the clinical spectrum enhanced skills will be required of the dentists. The service which was developed in the early days of the NHS had a history of supporting restorative care (fillings etc.) and now there is a need to focus more on the preventive element in conjunction with the older person's carers. Similarly younger adults are expected to need a preventive approach to maintaining oral health and for both groups the system will have to adapt. A revision of the system for the remuneration of general dental practitioners will take place, with a view to developing a contract that rewards a more preventive approach to treatment.

While the basis of primary care will continue to be universal registration with general medical practices, there is a need for very significant change in order to ensure that there is effective integrated working across health, social care, third sector organisations and communities to improve health, healthcare and wellbeing. The challenge for primary care will be to integrate the wider health and social workforce into small, relatively autonomous, multidisciplinary teams that are able to flexibly deliver a broad range of personalised services - ensuring that health and social care needs are addressed in a personalised way to support the ambitions laid out clearly in the 2020 vision:

'Everyone is able to live longer healthier lives at home or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management.'

All members of the wider primary and community care team must have a focus on a philosophy that, as well as providing conventional evidence-based healthcare, aims to^[8]:

• Change the balance of power: Co-produce health and wellbeing in partnership with individuals, families, and communities.
• Customise to the individual: Contextualize care to an individual's needs, values, and preferences, guided by an understanding of what matters to the person in addition to "What's the matter?"
• Promote wellbeing: Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require healthcare or medication.
• Make it easy: Continually reduce waste and all non-value-added requirements and activities for individuals, families, and clinicians. This requires an appreciation of the "treatment burden" that some people may experience for example in terms of complex medication regimes, and frequent and multidisciplinary review appointments, as well as a need to reduce bureaucracy for clinicians as much as possible. It also requires improved access for patients to a much wider range of appropriate health and social care professionals, across the statutory and third sectors - possibly by further developing doctor telephone triage systems or even electronic access to information, advice and, where appropriate, online consultations.
• Assume abundance: Use all the assets that can help to optimize the social, economic, and physical environment, especially those brought by individuals, families, and communities. This helps move away from a strictly medical model of health and wellbeing, and recognises the importance of optimising life circumstances. This is not the sole responsibility of health services - and requires primary care services to work in an imaginative way to use community supports to optimise wellbeing. This links to the point above, and enables and supports self-management.
• Collaborate and cooperate: Recognize that the health and social care system is embedded in a network that extends beyond traditional boundaries. Eliminate siloes and dismantle self-protective institutional or professional boundaries that impede flow and responsiveness.
• Support Self-Management: Using the benefits of longer-term relationships with people, encourage patients to move from being dependent recipients of healthcare, to informed individuals, better able to understand and manage their conditions. This will include a greater use of social support approaches and greater use of evidence-based psychological therapies. The drive to support self-management will understand the patient's personal needs, wishes, values and capacity for change - aiming to promote systematic standardised treatment, but avoiding undue burdens or unrealistic expectations for patients and their carers.
• Anticipate: Work to develop more comprehensive anticipatory care plans with higher risk patients, to understand their preferences and to plan for challenges that might otherwise result in undesired and avoidable hospital admissions.
• Use technology to the full: While there is currently insufficient evidence to support the widespread use of telemonitoring people's health, there is evidence that simple telecare can support patients to manage and remain at home, and appropriate use of technology can help overcome social isolation in house bound patients.

The Health Foundation, among many others, argues the case for self-management. This approach is supported by their review of 550 pieces of high-quality research, which evidence the effectiveness of self-management.

The authors of this review state:

'Hundreds of systematic reviews, randomised controlled trials and large observational studies have examined the impact of supporting self-management for people with long-term conditions. Whilst the findings of individual studies are mixed, the totality of evidence suggests that supporting self-management can have benefits for people's attitudes and behaviours, quality of life, clinical symptoms and use of healthcare resources.'

Some studies included in the review argue that supporting self-management reduces the use and costs of health services. It has been suggested that self-management support programmes may reduce visits to health services by up to 80%.

Other findings suggest it is more likely that patterns of service use change, rather than reduce overall. For example, people may engage more frequently with a practice nurse, telephone coach or with peers, but less with hospital services. The aim is not to reduce contact overall, but rather to support a different pattern of contact which may lead to fewer crises and inpatient admissions.

de Silva, D. Helping people help themselves: A review of the evidence considering whether it is worthwhile to support self-management; 2011

The proposal that GPs become more involved in complex care and system-wide quality improvement activities will require a refocusing of GP activity. It is expected that GPs will be less involved in the more routine tasks and provide an opportunity for other health professions in the practice and the wider community team to work to the "top of their licence" i.e. taking on roles that their professional training has prepared them for. To achieve this, the training needs of GPs, members of the wider practice healthcare team, and the other professionals working across primary care, will need to be considered, and where necessary developed and met.

There will be challenges in managing the successful transition of care from provision by an individual GP or a small team, to care that is delivered by a much broader team. The aim will be to provide people with appropriate clinicians to support their needs, but to ensure that complexity is minimised, duplication avoided, and professional boundaries blurred. This will require considerable leadership - which may not always come from the GP - but must aim to provide continuity and holistic care to all patients without providing an episodic, impersonalised task-focused service. It has been shown that experienced nurses, often with years of clinical experience in hospital settings, can be trained readily to take on substantial roles within practices. There will likely be a need to look at the capacity for nurse training. There is a current opportunity to reshape roles with the negotiation of a new contract for GPs. A re-defining of the role must develop for GPs so that they can use their skills to the maximum. It is proposed that there will be a revised role for the GP from 2017, with the GP as the senior clinical decision maker in the community, who will focus on:

• complex care in the community
• undifferentiated presentations (i.e. first presentations of illness), and
• whole system quality improvement and clinical leadership.

The new GP contract will not include the current Quality & Outcomes Framework (QoF) which the Cabinet Secretary has confirmed will be phased out from April 2016. This will move practice funding from a significant Payment for Performance scheme which relied on incentivising increased activity in practices. It is anticipated that the negotiation of the new GMS contract for Scotland will see the development of recognition of, and payment for, "values based quality". This approach recognises that the contribution of general practice to individuals and communities is more than the sum of bio-medical management of illness, and relates also to issues such as access, continuity, relationship forming over many years, and a holistic approach to all issues impacting on physical, mental and social health. A similar revision of the remuneration of general dental practitioners will take place, with a review of the payment scheme and the possible replacement with a contract that rewards a more conservative approach to treatment.

Although co-location per se will not necessarily lead to the required increase in joint working, it is nonetheless recognised that it can significantly support it. For that reason it should be an objective to increasingly arrange for co-location of primary and community care services, in a way that enables them to work as manageably sized, close-knit teams with excellent inter-professional communication, and "one-stop" access for people. This will probably only be achievable over time due to the obvious constraints of premises development - but the benefit of co-location and team building in taking joint responsibility for patient care must not be overlooked. Some practice premises are currently used in the evenings and at weekends by community groups - this should be encouraged so that these valuable assets can maximally contribute to communities.

The contribution of pharmacists can be considerably enhanced, with their expertise ensuring that people with complex medication regimes have their care optimised, and the potential for side effects or harmful interactions reduced. It is likely that they would have particular benefit in care home settings where polypharmacy is a significant problem, as well as reconciling people's medications on discharge from hospital.

Use of technology and IT will underpin these changes. Electronic information sharing will facilitate collaborative working across integrated health and social care teams to best support people's needs. People and their GPs will have access to electronic patient records and patient held information from medical devices and other consumer products to help them manage the individual's health and social care needs and agree outcomes which are then recorded in electronic anticipatory care plans. NHS approved web-based tailored information and telehealth/telecare will help people and their carers to self-manage at home. Clinical decision support and evidence-based knowledge hubs are being developed to support clinicians to have access to have the most up to date information when they need it about clinical risks and best practice. Visual tools are being considered to combine this with people's own data and information to allow informed decisions to be taken. Enhanced GP digital services will make it more efficient for people to book appointments and order repeat prescriptions and over time will provide greater choice for people who might prefer digital interaction and consultation with their primary care team, where that is appropriate. Virtual electronic medication records will ensure reconciliation of medicines between a hospital and primary care setting and will be accessible to community pharmacists to ensure safe medicine use.

The distribution of general practices across Scotland is determined largely by historical patterns of care and populations, and there is evidence that the allocation of resources does not always match need, particularly deprivation. In general there is evidence of fewer doctors working in smaller practices in the most deprived areas of Scotland. A recent survey by the Deep End GPs (a group of GPs who work in the 100 most deprived practices in Scotland) has shown that deprived areas generally have fewer doctors, and that the doctors there are more likely to be older and in single-handed or smaller practices. There was an ambition to address this inequitable distribution in the 2004 GMS contract and there is potential through the new 2017 GMS contract, and resource allocation by Integration Joint Boards to further address this issue either by redistributing existing resources, or ensuring that any additional resources improve the match with need.

Primary Care Out of Hours Services

A review of GP out of hours services, led by Sir Lewis Ritchie, has recently been completed and a report published. The report describes a need to have a broadened multi-professional team, working from a number of emergency hubs. There are suggestions to increase the input of GPs to the service, and development of a more integrated and responsive service capable of supporting alternative professionals. It will be essential to ensure that the service retains high effectiveness and has skills to effectively assess risk, and avoid admission to hospital as a "default" action where there is diagnostic or prognostic uncertainty. An over-reliance on admission to hospital has the potential to seriously strain hospital capacity in a way that may not always bring benefit to the patient or carer. Reducing avoidable admissions is an important system wide objective that can improve overall care for the population. A national implementation plan, including an outline of investment to support delivery, will follow in spring 2016.

Community services

Community services will significantly change over the next few years as a result of integration between health and social care. This offers significant opportunities to support people better at home, using integrated and co-ordinated services.

The experience of Torbay is relevant here.

Torbay was an early example of integration of health and social care services (in 2004) and the progress made was written up in a report in 2011^[9]. Integration there led to significant system wide change, leading to the development of a wider range of intermediate care services, working closely with general practice to provide care to older people in need, supporting them to live independently in the community. Importantly the support included the development of care planning for the most vulnerable, and the provision of rapidly responsive services for crisis management of problems which was overseen by health and social care co-ordinators. The culture developed across the integrated organisation was based on a common understanding of the need to develop responsive services for a fictitious elderly "Mrs Smith", and strong leadership. The results were a reduction in the use of hospital beds, low rates of admission for people over 65, minimal delayed discharges, reduced use of residential and nursing homes (balanced by an increase in home care services).

One of the assets of high functioning teams (such as GP practices or clusters) is the ability to work to a degree of autonomy, and develop a flexible range of solutions to meet people's needs. They are driven by professional standards and often work best with small teams able to manage their own workload, and to have minimal bureaucracy. This has been the philosophy behind the Buurtzorg nursing teams in the Netherlands.

In 2006, community nurses started a new concept in the Netherlands: Buurtzorg, which in English means "neighbourhood care". It is a not-for-profit provider of care through care homes and in community settings. The experience of Buurtzorg shows how understanding demand in human terms and supporting self-help are fundamental prudent improvement principles.

Most traditional home care in the Netherlands has been based on an approach similar to that in the UK. This model views home care as a product that can be delivered most efficiently when divided up into separate component processes. These processes can then be delivered by different individual specialists, for example, those who administer pills and injections, those who dress wounds and others with more specialist skills who, for example can connect morphine drips.

The Dutch organisation found any savings made in cost per hour from specialisation were lost when the cost of managing a complex and fragmented process was also factored in. A better system, one that put people's needs at the centre of care, was needed. Buurtzorg decided to revitalise the district nurse role. The care provided by its generalist district nurses is to build a relationship with the client, solving problems and rebuilding their self-confidence as part of recovery. The organisation has shown that a single, unhurried visit by a highly-trained district nurse is more effective than several visits by specialised care workers, each performing their allotted tasks.

This way of working has increased the unit cost of interventions but this is compensated for by a 50% reduction in total demand. Nurses serve neighbourhoods of 10,000 people in self-managing teams of ten. Working with GPs, they see themselves as community builders, developing neighbourhood-level support for their clients from friends, families and volunteers and they even have a weekly slot on local radio they can use to advertise events and services, provide advice and put people in touch with one another.

Preliminary findings show that Buurtzorg's patients use 40% of the care they are entitled to. Half of people receiving care do so for less than three months and patient satisfaction scores are now 30% higher than the national average. With no managers, communication lines are short and employees report greater work satisfaction. In 2011, Buurtzorg was chosen as the Dutch employer of the year.

The learning from this powerful example is that post-integration structures must not be afraid to experiment with quite devolved structures for professional teams, with a minimum of bureaucracy, but based upon clinically relevant shared objectives. Above all their success relates to taking ownership of people's problems and feeling empowered to address the problems using locally available resources with flexibility. Technology also played a key role in supporting the devolved structure by providing electronic access to client information at the point of care. There is potential here for reductions in management spend, as well as better overall outcomes. There is already considerable interest in the Buurtzog model and how it could be tested in Scotland.

From April 2016, the Integration Joint Boards will be responsible for planning local services including those that are at the interface between primary and secondary care. There should be a continued emphasis on identifying those people most at risk of avoidable admission, providing adequate support for them. The aim should be for joint development of anticipatory care plans for crisis points, provision of rapidly responsive services that can provide an alternative to hospital admission, and support for rapid discharge, with continuation of rehabilitation in the community if required. All of this must be supported by robust IT services to ensure that data can be captured and analysed in real time to support service planning, home monitoring technology to support people who are at risk, digitised case notes and electronic information sharing to support secure rapid exchange of up to date information between services, and mobile access to information to support community working.

Reduction of Avoidable Admission

It will be an essential objective for Integration Joint Boards to support people to manage at home, through a range of local initiatives. The ability of innovations to reduce avoidable unscheduled admissions to acute care is variable. The King's Fund review of factors which reduce avoidable admissions to hospital concluded that there was evidence to believe that the following reduce avoidable unscheduled care admissions. However, further evaluation is required.

Approaches that reduce avoidable admissions:

• Continuity of care from being able to see the same family GP
• Integration of primary and secondary care
• Self-management in patients with COPD and asthma
• Tele-monitoring in heart-failure
• Assertive case management in mental health
• Senior clinician review in A&E
• Multidisciplinary interventions
• Comprehensive geriatric review.

Approaches that reduce avoidable re-admissions:

• Structured discharge planning
• Personalised healthcare programmes.

There is also modest evidence that a proactive approach to anticipatory care and case management can reduce avoidable admissions. Primary care and community teams should combine to identify those at greatest risk of avoidable admission to hospital, and ensure that a proactive approach is adopted to reduce the risks of exacerbations of illness, and to prepare effective support should deterioration develop.

Anticipatory Care Planning

A study was undertaken in 2010 to evaluate the impact of introducing Anticipatory Care Plans (ACP) for a cohort of people from a general practice in Nairn, Scotland, that were considered to be at high risk of experiencing a hospital admission (identified using the Scottish Patients at Risk of Readmission and Admission tool). A group of individuals with a similar SPARRA score were also identified but ACPs not introduced to compare the two sets of results. When comparing the 12 months preceding the introduction of ACPs to the 12 months following (for those that were still alive in the second 12 months), the group of individuals for which ACPs were introduced saw a 52% reduction in the number of days spent in hospital. The study also found that for those who died during the second 12 month period, individuals with an ACP were more likely to be able to die at home.

(Anticipatory Care Planning and Integration: a primary care pilot study aimed at reducing unplanned hospitalisation: British Journal of General Practice, February 2012)

A similar study of Anticipatory Care Plans was undertaken in a care home in NHS Lanarkshire in 2009. Evaluation of the study found that when comparing the six month periods prior to and following implementation of the ACPs, there was a 34% reduction in the number of inpatient admissions and over 50% reduction in the number of hospital bed days (NHS Lanarkshire, Long-term Conditions Team, Anticipatory Care Plans in Lanarkshire Evaluation, April 2010).

Future development of electronic patient information summaries (building on the current Key Information Summary) should be based on Anticipatory Care Plans to enable a coordinated, person-centred approach across the health service.

Mental health

Mental illness is one of the top public health challenges in Europe. It has a significant impact on the overall health of the population, and on health inequalities. Overall, mental illness is the most prevalent of the longer term conditions as measured by burden of disease and disability. Estimates vary, but there is evidence that mental illness affects up to one third of the population every year^[10]. Psychotic illnesses affect around 1-2% of the adult population, with substance abuse including alcohol excess impacting on 5% of men and over 1% of women. Mental illness has a significant correlation with deprivation, and around 40% of those adults in receipt of welfare benefits and disability payments suffer from mental ill health. Patients with persisting mental health problems have increased rates of long-term conditions, particularly cardiovascular disease, cancer and diabetes, and have a life expectancy that is typically 10 years less than the least deprived and healthiest in our communities. Long-term conditions also bring challenges to mental wellbeing, and as a result, high rates of depression are found in association with long-term conditions, and contribute to the burden of these diseases. For this reason Scotland has improved access to clinical health psychologists, as recommended in SIGN guidelines on cardiovascular disease, diabetes and stroke.

Rates of dementia and cognitive impairment increase with age. Scotland has a good record in initiatives to identify and support patients and families to manage this illness. However in the elderly, depression is considerably more common, and is particularly associated with social isolation and loss of independence. Depression may be harder to recognise in the elderly and medication tends to cause more side effects, including falls and confusion.

It is important to recognise the significant changes that have occurred in mental health services over the last 15 years - changes which have considerable relevance to the changing shape of services in other specialties. Specialist mental health services have moved from being primarily a hospital based service to being a more community-based service, centred on multidisciplinary community mental health teams that work closely with practices and with local social work services. They have developed increased interaction with voluntary and third sectors to support their patients, and have increasingly recognised the importance of non-medication approaches to treatment, with particular emphasis on "the talking therapies" and the potential benefit of exercise. All general practices across Scotland now have access to counselling services for their patients, and waiting times for psychology services continue to fall, allowing more rapid access to alternatives to medication, and support that can impact on patients motivation and management of other long-term conditions.

Mental health services have moved to encompass a paradigm that has a strong focus on reablement and recovery, with anticipation and prevention of crises a strong feature. Supported self-management is the aim, with increased input from voluntary and third sector organisations to support patients to have a better experience of illness than would be achieved by a purely health-focussed approach, and to help reintegrate patients into employment, where possible, and into communities. Principles of risk assessment and management, in a way that is least restrictive to the patient, and proportionate to their needs, are well developed.

An enhanced approach to the management of behavioural issues in childhood and adolescence, and increased input from multidisciplinary Child and Adolescent Mental Health Services, results in a reduction in longer-term behavioural and personality issues, helping prevent life-long problems from developing.

There is scope to further develop use of IT to deliver mental health. Health Boards and NHS 24 have developed computer based Cognitive Behavioural Therapy packages for patients as well as telephone supported guidance. Patients are able to access a range of online and written support for mild to moderate mental health issues, and can be signposted to local community resources.

Mental health services have worked on developing outcome measures which are holistic and take account of patients' social and physical wellbeing, as well as more readily measured clinical parameters. The description of the transformation of mental health services that has occurred in the last 15 years is important. In many ways, the development of services mirrors some of the developments that are proposed in other areas, namely:

• Supported self-management from multidisciplinary teams, accessed where possible in communities
• Reduced reliance on hospital admission, helped by community mental health and social work teams working locally, and supported by consultant specialists who have a more focussed role managing the most complex patients
• An approach that is anticipatory, plans for crises, and uses voluntary and third sector input to develop the support and social integration that helps improve the experience of illness, and improve outcomes
• Greater understanding and measurement of outcomes that are more holistic in their approach, to drive improvements that matter most to patients, associated with reduced use of medications where appropriate
• Exploration of the role of IT in helping patients manage their own conditions
• Greater liaison between acute hospital services and mental health services, with stronger appreciation of the interplay between physical, mental and social wellbeing.

Summary

In summary, the integration of health and socialcare for adults in April 2016, and the development of a new GP contract by 2017 offer an opportunity to modernise primary care. Primary care will continue to be based on general practices with universal registration of the population. The traditional primary care team will expand with greater roles being played by many other professionals working in autonomous teams. Continuity, and the building of therapeutic relationships will continue to be preserved in primary care. Expanded teams will need to ensure that the services they deliver are person, and not task, orientated.

Supported self-management and motivational encouragement will continue to develop significantly, especially for those with long-term conditions. This will match an increased emphasis on recovery and reablement, supported both by community rehabilitation teams, and the use of third sector and voluntary organisations. Increasingly services will be co-located, supporting better joint working and enabling people to access a wider range of services across health and social care settings. Health centres may become health and care centres, and premises may be used for wider community benefit outside normal working hours.

Increased investment in primary care will ensure the sustainability of secondary care services by allowing an increasingly elderly population with multi-morbidity to be treated more appropriately in primary care. GPs will have a leadership role, and will focus their skills on more complex cases making best use of their experience. Focused attention on the most complex cases, including those at highest risk of avoidable admission should enable patients to safely and appropriately be cared for more at home, or in a homely setting. Pro-active planning for crisis will clarify responses required in advance, based on people's expressed preferences. More input to care and nursing homes will support them to respond to people's acute healthcare needs without the need to default to hospital admission. GPs will have protected time for roles that require leadership, teaching, training and redesign of services to support improved outcomes. Balancing medical and social care will be important: patients with multiple long-term conditions and resultant loss of independence may benefit from increased social care, rather than more than medical intervention. The balance of care that is required is often best ascertained by comprehensive geriatric assessment carried out by community facing geriatricians.

Local development of intermediate care services to support care at home will be developed. They must be properly evaluated so that evidence of what works most effectively can be determined and shared. The role of community hospitals in the local delivery of intermediate care needs to be considered, ensuring that they can be supported to provide cost-effective and high quality care. It may be more appropriate to temporarily use care home and nursing home resources for some patients.

Expanding the range of online services and information for patients will encourage self-management and co-production as well as more efficiently direct people to the right primary care professional, relieving pressure on GPs. The way in which primary care will be delivered for certain types of patients will be transformed through increasing use of online consultations, remote monitoring and non-medicine prescribing. IT will be a crucial enabler for new models of coordinated, person-centred care delivered by community care teams and will increasingly support decision making and service delivery across primary and community care.

Rural practices will need particular support. This may be from expanded multidisciplinary roles, but will also require better phone coverage, and internet connectivity, along with decision support from remote clinicians with greater expertise. Recruitment to rural practices will in the future be improved if more support is given to training doctors in rural settings, and encouraging schools to prepare children for entry to medical schools. Strategic development of mental health services will be set out in the new Mental Health Strategy to be published in 2016, but much of the transformational change in mental health services, moving from an institution based service, to a multidisciplinary, integrated community-based service, with strong emphasis on supported self-management using voluntary and third sector resources, provides an example of successful, patient-focused, service evolution that outlines principles that could be considered more widely.