Paul Thomas: COIN Co-Chair 

November 2023 COIN meeting discussed platforms to help people appreciate that Community-Oriented Integrated Practice (COIP) needs to be part of the UK NHS. Video of the meeting can be seen at https://www.youtube.com/watch?v=NRZp04LDv4U. This is a summary of that meeting.

Drawing on the Complete Care Community Programme, James Kingsland presented the potential of Primary Care Networks to be platforms; John Spicer presented the potential of conferences, e.g. RCGP City Health Conferences & WONCA.

The Complete Care Community Programme (CCCP)

CCCP includes 65 Primary Care Networks that serve a population of 3 million. They are expected to address complex care issues in our communities, particularly health inequalities, requiring them to understanding the paradigm debate inherent to COIP.

Why does the NHS need COIP?

General practice and other healthcare units need multidisciplinary teams to function, but the science of developing multidisciplinary teamworking throughout whole systems is largely unknown. Traditional, linear thinking in the NHS, and much of UK society, encourages an engineering image of the world - it expects change to come from a direct relationship between cause-and-effect. This encourages silo-operating, hierarchy and competition that are unable to address complex issues. Conversely, COIP can address complex issues because it complements the traditional paradigm with an organic image of the world that expects change to come from complex co-adaptation. This encourages cross-boundary collaboration, Healthy Communities, Self-Care and Shared-Care. With traditional approaches, COIP can contain NHS costs (by reducing specialist care), improve inequities (by empowering people), and improve job satisfaction (through better understanding generalist/specialist interfaces).

Healthcare is at a pivotal moment. The NHS needs to lead this paradigm debate in order to address complex issues, contain costs, improve inequities and ensure job satisfaction. 

Infrastructure that nurtures COIP

• Geographic areas with cycles of collective reflection and coordinated change to develop multi-disciplinary working and healthy communities.

• Relationship-based care that develops trust, equality, sees bigger pictures and promotes health of communities & families as well as individuals.

• Infrastructure - Training, support, evaluation, leadership, role modelling, removal of bureaucratic obstacles like barriers to GP registration.

Obstacles to achieving COIP

• Traditional, linear thinking is very appealing.  Kierkegaard’s assertion 200 years ago is still true – most people mistake the certainty seen in hindsight for the emergent order that frames living forward. So most people cannot engage in this paradigm debate.

• GPs are trained in traditional thinking, like treating diseases, so they lack COIP-like understandings, including language empathy (deep listening to understand feelings and concerns); Planning services with all relevant stakeholders; Cycles of learning & change that allow services to evolve over time; Importance of story and context.

• The GP Contract forces GPs to address transactional concerns rather than complex issues - Registration requires documents that many hard-to-reach people do not have; Place of Care ignores mobile people, Value is Allocated to hospital concerns rather than Core Health Determinants (interconnected social, emotional, spiritual…).

Platforms to develop understanding of COIP

• CCCP Pilot sites, especially in NW England and London where they cluster.

• Networks of Carers, particularly those who are supporting people to die.

• City Health Conferences led by RCGP Faculties.

• Research institutions that use approaches, like 4th Generation Evaluation, that value multiple insights into complex case studies.

Other Considerations

• Climate Crisis and Long-Term Care are two issues that must be included in community-based healthcare developments.

• Human Nature - there is something fundamental about human beings that we need to re-invent ideas, imagining that we are the first to ever learn them. 

• Combine generic insights with local ownership in healthcare developments. Cycles of collaborative learning and coordinated change can do this.

Things that COIN could do to promote COIP-like thinking

• Develop with CCCP a generalist model of primary/community care that includes COIP. Pilot aspects in Liverpool/NW England and Brent/London. Describe it in journals and present it at City Health Conference, WONCA and similar conferences worldwide, targeting GPs, Nurses, Carers, Public Health, Politicians, Media & others who can advance this COIP-like thinking.

• Develop Courses, Coaching & Webinars that help Carers, HealthCare Leaders & Practitioners, Medical Students and School Children to learn the principles of COIP.