Department of primary care health sciences, University of Oxford: winner, service delivery innovation award

Daniel Lasserson, senior clinical researcher, and Maggie Webb, unit manager, in the emergency multidisciplinary unit.

An emergency unit designed exclusively for old and frail patients is keeping them out of acute hospital and helping to prevent bed-blocking.

The emergency multidisciplinary unit (EMU) established at Abingdon community hospital in Oxfordshire is hoped to become the national model for the future of emergency care for older people.

Patients can be referred to the EMU, which is seen as an alternative to an acute hospital A&E, by either their own GP, a community nurse or ambulance paramedic.

The unit, which is open seven days a week from 8am-8pm on weekdays and 10am-4pm on weekends, is not available for patients who have suffered a stroke or a heart attack, who would still be taken to the local acute hospital's A&E. The majority of the 5,500 patients it has seen arrive with chest or bladder infection or heart failure. The average patient age is 89.

Staffed by elderly care physicians, GPs, nurses, healthcare assistants, therapists and social workers, the unit can quickly assess a patient. It has point of care blood testing with rapid results and X-ray facilities so the unit can guarantee speedy diagnosis.

The EMU has five hospital beds available for patients who may need to be kept in for a maximum 72 hours. A "hospital at home" nursing team is also available to provide support to patients who are sent home to recover.

"I would say that the EMU is more than just a casualty for older frail patients – it's more intensive because we aim to provide care for the episode at the time or for a number of days," says Dr Daniel Lasserson, a GP and senior clinical researcher at the department of primary care health sciences, University of Oxford, who helped design this new model of care.

Lasserson adds: "Its aims to deliver an acute care pathway for frail older patients that does not rely on bed-based care, yet can still provide appropriate medical, nursing and therapist treatments within an individually tailored care plan as close to the patient's home as possible.

"It was designed to challenge the existing urgent care pathway of admission to an acute hospital with its associated harms of unfamiliar and physically challenging environment and loss of independence."

The EMU, he says, addresses the dilemmas of how to best care for a growing elderly population with complex needs and multiple chronic conditions and to provide an alternative to "office hours" general practice or acute hospital bed-based care.

According to the EMU audit, 65% of patients who are assessed by the unit are able to stay in their own home – only 17% of patients need acute hospital care.

Lasserson says this new way of working, known as "interface medicine", is challenging the traditional medical training and care. Oxford has created an Interface Medicines Fellowship and is in discussions with Health Education England about how it can be developed nationally.

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Primary care is at crisis point and under pressure to change

The short term crisis in A&E and the long term need to move care out of hospitals are two pressures facing primary care. Photograph: David Levene for the Guardian

Primary care is about to be seized by a degree of turbulence and change that will make the acute sector look ordered and calm.

The pressures for change are coming from every direction: the short-term crisis in A&E, the long-term need to move care out of hospitals, the need to improve access to GPs while reducing their workload, the tightening economics of general practice and the need to improve clinical quality.

Looming over all this is the determination of Jeremy Hunt, the health secretary, to claim the government has "sorted out primary care". His speech to the King's Fund last week made plain his game: having decided that the Labour's 2004 GP contract is the source of problems ranging from poor care of older people to A&E pressures, he is going to rewrite it by next April, sweeping away bureaucracy and securing a "dramatic simplification" of targets and incentives.

The demands for higher clinical standards and a wider range of community services are combining with the need for GPs to cut costs to eradicate singlehanded practices slowly. While GP federations and networks are growing, others are taking a more radical approach.

The Vitality Partnership in Birmingham, one of the models debated at the King's Fund primary care conference, is standardising procedures, has clinical peer review backed up by its own turnaround team, runs an effective patient records system which is gradually reaching local hospitals and has centralised, low-cost administration. It is now a major provider of services such as rheumatology and dermatology.

GP culture can often present itself as conservative, suspicious, even cynical, but the reaction of groups such as Vitality to the threats and opportunities shows the passionate and entrepreneurial side of primary care. It is also striking how leading players are not waiting for the local area team or clinical commissioning group to tell them what to do; they are leading change themselves.

These organisations are a long way from the public's traditional perceptions of the family doctor. They are increasingly large, multidisciplinary teams with efficient, benchmarked systems run across several sites. Against this background, the independent contractor model for general practice looks archaic. Professor Clare Gerada – soon to begin her part-time role for NHS England as clinical chair for primary care transformation in London – is already preparing us for its demise.

On top of all this, everyone, from NHS England to clinical commissioning groups, now recognises that shunting primary care commissioning to NHS England's local area teams was a bad idea. It will fail to align primary services with the groups' wider goals and it will not deal effectively with substandard doctors.

Involving groups in primary commissioning means solving the issue of GP commissioners facing a conflict of interest. One solution could be for councils' health and wellbeing boards to play a role in awarding primary care contracts, such as overseeing the governance.

With all this change, it is difficult to see how the GP workload is going to fall. The widely claimed 14-hour days are simply unsafe. As the Care Quality Commission's new chief inspector for primary care, professor Steve Field, begins work, there is a risk of GP services becoming the next part of the NHS to be accused of serious failings.

Hunt has promised more primary care funding, and Health Education England has been charged with getting many more GPs into the system, but even the minister admits existing plans may be inadequate. And beneath these national numbers many areas with the worst health are desperately short of GPs.

Overall, significant parts of the primary care system are unsustainable financially and clinically, but elsewhere GPs are building new, integrated care systems in the community which hold out the prospect of reducing emergencies, shifting treatment away from hospitals and improving access. This is a cause for optimism, but it needs more money and more staff. Funding has to be moved from acute to primary care, which means shutting some hospital services.

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Primary care can ease pressure on hospitals

Primary care should be recognised as critical to finding a solution, rather than part of the problem, say James Kingsland and Graham Roberts. Photograph: Getty

Inadequate staffing levels and limited provision during the weekend are thought to have led to a rise in mortality rates in hospitals across the country. As a result, we need to refocus on the role that primary care can play in relieving the pressure on secondary care. It may be over-simplifying, but improved access to GP and other services in the community will reduce the burden on hospitals, particularly if there is an increased focus on preventative care. Primary care should be recognised as critical to rectifying this situation as opposed to being part of the problem.

We are seeing an ever-increasing demand on public services, with an expectation for immediate access to everything from our bank balance to consumer goods and not least to healthcare. Waiting lists and pre-booking appointments do not fit well with improving response times and rapid access. Too many people now prefer to seek help for a range of non-urgent health needs from an accident and emergency (A&E) department. While they can at least guarantee that they will be seen on the day, they can wait for up to four hours (or more, when the national waiting time target is breached) for what may not be the right care.

This means that the distinction between serious illnesses requiring urgent attention and those that would be better scheduled through an appointment system are blurred, and hospital staff are put under a greater strain than is necessary.

Many blame this "crisis" on poor access to general practice and the consequences of the 2004 GP contract, which saw most GPs opt out of out-of-hours care. However, this only identifies one small part of the bigger picture of increasing demand but poorer management of this, demographic changes, societal expectation and technological advances (to name but a few). Since 2004 there has been an eight-fold increase in out-of-hours activity in some areas, which suggests that there are other issues that need to be addressed aside from an alteration in working hours.

A significant problem is that many GPs do not have the facilities to enable them to increase provision and extend care facilities. Too many practices are still based in cramped converted dwellings, and while often in residential areas this actually adds to the restriction on the extension of services.

Expanding and equipping our GP surgeries to provide services that may have traditionally rested within hospitals is a major step in solving the current plight of the NHS. Integrated primary, community and social care centres with room for third-sector services and which also house diagnostic facilities and minor surgery suites, that serve a registered population, must be the future of primary care if we are to continue to enjoy an NHS free at the point of delivery. International evidence consistently demonstrates that a strong, well-resourced system of primary care reduces the risk of hospitalisation. The good news is that this vision already exists, but still reflects a minority of general practices.

The NHS, now 65 years old, is continuing to develop and grow. We would be naïve not to build on the best of what we have already. The less well-informed response to the healthcare crisis is to create alternative, poorly evaluated services. This is not the answer, as was the case with the walk-in centres and NHS 111, which have risked fragmenting precious available resources and often provide questionable value for money.

Ultimately, in order to increase efficiency in the NHS and meet the public's top priorities of waiting and access, GPs need to be resourced and equipped to do more. They also need to build teams to perform and complete more episodes of care in their primary care setting in modern, purpose-built 21st-century facilities. It is extremely difficult to change the expectations of the general population, but what we can do is ensure that healthcare practitioners are working in the right environment to respond to the demands effectively.

Dr James Kingsland is national clinical lead for NHS clinical commissioning and Graham Roberts is chief executive of Assura Group

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We need to engage GPs in developing primary care

A distinctive feature of CCGs is that they harness the clinical expertise of their GP members. Photograph: Hongqi Zhang /Alamy

The creation of clinical commissioning groups (CCGs) is at the heart of the government's reforms to health and social care in England. On 1 April 2013, these newly formed, clinically led groups were handed control of around two-thirds of the English NHS budget, and responsibility for commissioning secondary and community care services for their local population. Much attention has been given to their commissioning role, but CCGs have another distinct role to play in supporting quality improvement in general practice. CCGs are in the unique position of being membership organisations, which presents an opportunity for GPs to be more closely involved in transforming primary care.

Will CCGs be able to influence changes needed in primary care when they do not oversee the NHS contracts for primary care? Success here will be dependent on strong engagement with GP members.

The King's Fund and The Nuffield Trust have been working together to study six CCG case study sites, focusing on governance processes and structures as well as emerging relationships. A distinctive feature of CCGs is that they harness the clinical expertise of their GP members. Our research explores how this is being done in practice – how members are involved in their CCGs, what influence they have over commissioning decisions and how leaders and members are working together to develop primary care locally. Findings from the first year of the research reveal the opportunities that CCGs have and challenges they face.

Our research suggests a great deal of enthusiasm at grassroots level, with GPs generally wanting CCGs to succeed, and a lot of energy and enthusiasm among leaders. CCGs have brought local clinicians together, in many cases formalising and building on collaborations between practices that existed more loosely under practice-based commissioning; but in other cases through the creation of new networks and relationships. We heard from GPs who felt positive about being in it together.

More than two-fifths of general practice respondents to our survey felt they could influence the work of their CCG – far higher than the number who thought they could have influenced primary care trusts (PCT) in the past system. Interviews suggested that the GP voice is better represented in CCGs than it was in PCTs.

Importantly, the majority of GPs believed that CCGs have a legitimate role in influencing their members in terms of referrals, prescribing, and other issues – although some felt wary about the form that this involvement could take. There was concern that the financial environment that the NHS is facing, with significant savings needed over the coming years, may lead to CCGs performing a rationing function that could damage GP-patient relationships.

Reconciling this role with the need to maintain clinical engagement and member ownership will therefore be a delicate balance for CCG leaders to strike. Most CCGs are emphasising their intention to take a supportive approach, particularly through provision of comparative performance data to member practices, and by facilitating various forms of peer-to-peer dialogue.

Our survey also highlighted that engagement – awareness, support and involvement – among CCG members is not universal. Nearly half of our survey respondents without a formal role in the CCG feel disengaged in its work – lack of time and capacity being the most frequently cited reasons. CCG members are also less likely than leaders to believe the CCG is owned by its members. Low GP engagement was a major barrier to the success of previous models of clinical commissioning. It is therefore critical that CCGs continue and build momentum on engaging GP members. Driving service changes that will win the support of the clinical community may be important here.

Over the next two years, our case study sites will shed further light on whether and how CCGs are building on the enthusiasm at grassroots level and harnessing the support of their GP members in order to develop and change primary care.

Shilpa Ross is a researcher for the King's Fund and Dr Louise Marshall is specialty registrar of public health for the Nuffield Trust

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