How we work

Fundamentally, the Greater Manchester model is based on developing integrated neighbourhoods at place level to improve the health and wellbeing of their 30-50,000 populations. These units are of a size small enough to have a comprehensive understanding and connection to their communities, while being large enough to support functioning multidisciplinary team working. Critically, therefore, they are large enough to help colleagues support each other to be resilient and meet local demands and testing out new ways of working with a wider set of partners to address the causes of poor health.

Primary care is at the heart of these models of proactive, integrated neighbourhood care. Through Greater Manchester’s 65 Primary Care Networks (PCNs), practices and community pharmacy come together locally and integrate with community services, social care and other providers of health and care services to create more seamless services for the local population, improve quality of care and support the sustainability of general practice. It also enables more person-centred care.

Operating in a multidisciplinary way through Integrated Neighbourhood Teams (INTs), primary care facilitates the provision of, and access to, place-based care, with local services responding to local need.

A common aim being, where possible, people will be treated and cared for closer to home and will only access hospital-based care when necessary. General practice is organised to cover every neighbourhood, pioneering a networked approach through all 65 PCNs in Greater Manchester, with a dedicated community pharmacy link for every neighbourhood.

Anticipatory care

We will do this with greater consistency through models of proactive anticipatory care by seeking out those more at risk, and through developing enhanced relationships with specialists at the intermediate tier level to enable conditions to be managed at home and in the community. Through integrated and partnership working with (for example) crisis response, social and community care, anticipating early intervention and prevention, primary care will be more responsive to what people need, whether they require urgent care, have a long-term condition or complex needs requiring a focused package of care and support.

We will do this through facilitating the development of new models of proactive anticipatory care to identify those groups which are seldom heard. We already have a few examples in Greater Manchester, such as high impact care, extensive care or focused care type approaches. These approaches will encourage community providers to develop levels of enhanced intermediate tier services, step up, step down, discharge to assess facilities to blend the gap between secondary, community and primary care to further integrate at place.

Using neighbourhood profiles and risk stratification to gain a better understanding of populations at place and neighbourhood level, GP practice multidisciplinary teams will be able to identify regular users of unplanned attendances through case finding approaches. Here, support solutions can be sought to prevent further admissions and maintain independence at home or in the community. We will enable remote monitoring at home and facilitate digital connectivity through patient held record into Greater Manchester Care Record care plans. To date, this way of working has enabled the more mature of these teams to become self-directing in the design and development of services which are responsive and effective in meeting the needs of the local population.

People and communities

Our people and communities are wrapped around this. Each bringing their own personal attributes and strengths. Our communities, across 10 places (boroughs) and 65 neighbourhoods, offer a broad menu of community assets and opportunities. We are looking to scale and spread the work of the People and Communities programme across primary care through the resource available through the additional roles reimbursement scheme (ARRS). We are seeking greater flexibility in additional roles employable under ARRS to assist with data, digital and a population health approach.

As a mature infrastructure in Greater Manchester, through the PCB, its sub-boards and its delivery team, there is strong representation and involvement in all reform programmes and strategic development, ensuring primary care is considered and forging lasting relationships across sectors. This includes active involvement in transformation and recovery programmes such as elective, urgent emergency care, cancer, community centres and other reform programmes.

Digital maturity has the potential to significantly enhance integrated place-based working. For example, with advanced telephony comes call shifting and the flexibility through our many ARRS staff working across PCNs, linking to EMIS and taking and making telephone enquiries and referrals. The Greater Manchester Care Record is a key enabler to integrate across all primary care. This way of working will become even more important as we continue to develop our model of place-based partnerships.

In Greater Manchester, we are already several years in on our journey of developing partnerships at place through our Local Care Organisations (LCOs), of which our integrated neighbourhoods and PCNs are the very cornerstone. LCOs bring together key partners such as acute and community care, social care, mental health, primary care and the voluntary, community and social enterprise sector (VCSE).

People will access most of the health and care services they use in the place in which they live, including advice and support to stay well and access to joined-up treatment when they need it. As such, primary care plays a pivotal role within the development and delivery of care through place-based partnership working aiming to improve health and wellbeing outcomes for the population, prevent ill health and address health inequalities.

The types of activities and approaches place-based partnership will be responsible for include service delivery and transformation; population health management; connecting support in the community. All these activities are critically dependent on primary care, PCNs and particularly general practice working collaboratively with partners to identify those most at risk, understand their population health needs, coordinate care for people, promote health and wellbeing; work with a wide range of community partners to leverage and invest in community assets and support for improved wellbeing, for example, through social prescribing link workers. Through the Greater Manchester LCO board, a single Greater Manchester framework has been adopted which creates a standardised approach to developing integrated care at place. This describes a set of key characteristics of integrated place-based working and sets an expectation, or maturity for the ambition of the care model for Greater Manchester.

Our staff are our greatest asset. We saw during the Covid-19 pandemic how staff went above and beyond to meet the challenges put before them, including increased demand, higher acuity, staffing issues and difficulties posed by access. And this continues as we tackle recovery. Now, more than ever, we need to look after our staff and their health and wellbeing. Many of whom have experienced personal loss, stresses and exhaustion, even at times, abuse.

Through our established health and wellbeing programme, we are connecting with frontline staff from across all four primary care disciplines, with an excellent and varied offer of support. This includes establishing wellbeing leads, training and support, apps, signposting and working to establish outreach to frontline staff across all primary care disciplines.  In addition, we are working collaboratively with GMICP and the Training Hub, playing an important role in advising, supporting and bringing together workforce opportunities for primary care. 

We know, as amplified and accelerated through the pandemic, that digitally enabled primary care can support a proactive approach to managing population health and better identify those who would benefit from more targeted support, including dedicated support to care home residents.

Remote monitoring and online services can help people to manage their health and wellbeing needs; online booking systems, referral systems and consultations, backed up by face-to-face care when needed can improve access to primary care professionals and staff; while digital solutions can promote healthy living and self-management.

However, these solutions must be deployed in a way that is easy to understand and navigate and that follows correct standard approaches, for example, in relation to accessibility, thus reducing variation and poor patient satisfaction when people interact with digital or online systems.

The Greater Manchester Integrated Care Partnership is coordinating a regional Digital First programme to support primary care on a journey of digital transformation. The £4 million programme is in partnership with Health Innovation Manchester and Greater Manchester Primary Care Provider Board (PCB), one of the first primary care collaboratives in England.

The programme has specifically been examining health inequalities resulting from difficulties in accessing primary care. GP providers, clinical colleagues and digital teams are currently working together to design digitally inclusive GP services for citizens and to support general practice to meet increasing demand.

Supporting quality improvement of providers, and in turn improving patient outcomes is at the core of the PCB’s work.

GP Excellence and Primary Care Excellence

Mostly developed for general practice and in a partnership with the Royal College of GPs, GP Excellence is an academy for general practice, offering practice level quality improvement support, CQC readiness, resilience support and collaboration with the Clinical Research Network to provide research opportunities to create research-active primary care. Building on the success of GP Excellence over the last five years, excellence programmes are now in development for optometry, dentistry and community pharmacy, focusing on development and recovery work and opportunities for collaboration across the primary care disciplines. This infrastructure provides training and development programmes for primary care.

Primary Care Network Development Programme

A wide-reaching development and network programme for PCNs which includes regular connection to all PCNs, understanding issues and solutioning together (for example this has been an active network for the delivery of the vaccination programme). In addition, we provide development programmes to PCNs, including health inequalities at PCN level, anticipatory care and using digital for the purpose of case finding.