Ockham Healthcare: Supporting innovation in General Practice

Guest Blog – GP Partnership: A Salaried GP’s view

Last week Ockham Healthcare hosted an event in central London looking at the rise and fall of the GP partnership model with the aim of encouraging GPs and trainee GPs to consider becoming partners (more information here and a video of the event is available here). One of the attendees was salaried GP Camille Gajria from London who, in a guest blog for us this week, summarises the event and outlines the messages she will be taking away.

On the eve of the NHS’ 70th year, Ockham Healthcare held a live panel event for GPs considering partnership.

GPs chose to be independent contractors when the NHS started. This has often enabled innovation and healthcare tailored to the local population. Although there have been trends towards and away from partnership over the years, currently unprecedented numbers of practices are becoming unviable and closing. So why would anyone want to be a partner now?

Dr Mayur Vibhuti, a GP partner and GP trainer opened by explaining that his role allows him to make tangible improvements to the health of his community. It was interesting to hear how a 7000-patient practice is thriving given the political thrust to work at scale.

Robert McCartney, who runs a primary care mergers consultancy, described practices as community hubs which will always be needed, particularly for people with long-term conditions.

Ockham Healthcare Director, Ben Gowland laid bare the responsibility, risks, and rewards of running a business, including the fact that if the profession became entirely salaried there would be even less control over various aspects of work. He gave a frank explanation on premises and equity- the market shows that GP property is a valuable commodity due to notional rent not being dependent on outcomes, and should ideally be owned by the business. An Ockham podcast published on 10 July has more detail on this.

When choosing a practice, the panel emphasised the importance of finding one with values appropriate to one’s own, identifying risks the practice may be due to face, their plans for the next 5-10 years, and how well they understand their income and expenditure (e.g. do they know at what list size an extra clinical session becomes viable). One point I had previously not considered when looking for a partnership is to assess the relationship with the locality- if one practice is struggling, there would be effects on the others, such as a sudden, unsustainable increase in list size.

There was discussion about how to gain requisite skills for partnership, and where to source help.

The session was expertly chaired by Nish Manek, the National Medical Director’s Clinical Fellow and Teshseen Khan, a Population Health Fellow at NHS Lambeth CCG. They asked and fielded probing questions, both from live and virtual viewers. It was refreshing to have an open discussion about these topics in relation to the current state of general practice, with a diverse and knowledgeable panel and audience.

GPs as independent contractors have been the foundation of the NHS and led innovation throughout its history.  Rather than necessarily having to change models to make partnership more attractive, I left feeling GPs need to be conversant with politics, finance, and management, so that we make informed decisions about our roles and the services we run for patients.

 

Becoming a GP partner – your questions answered

This week’s “blog” is, in fact, a video of last night’s (4th July) live event where an expert panel answered questions on GP partnership. The panel consisted of Ockham Healthcare founder and Director, Ben Gowland, Dr Mayur Vibhuti a GP partner and GP trainer and GP practice mergers expert Robert McCartney. Taking questions from a live audience plus those tweeted in from across the country, the panel discusses the idea of GP partnerships in today’s highly challenged environment for general practice. Should GPs become partners? What makes a good partnership? Should partners own their own premises? What are the risks? How does a partner achieve change with a group of difficult partners? These questions and many more are addressed in this highly topical and unique event…

General practice at the precipice

According to a recent article, in as many as 1500 practices (nearly 20% of all practices) the partners are earning less than the salaried doctors. If this is true (and I have no reason to suspect it is not), then it means the business model that has served general practice for so many years has finally run its course.

If salaried GPs earn can earn more than partners, without the responsibility, risk or workload of being a partner, then there is very little incentive for GPs to become partners. Instead there is a strong incentive for existing partners to become salaried.

But the existing business model requires partners in order to continue. If all GPs choose not to be partners, no one is left running the business. The obsessive focus on the total number of GPs is blinding us to the critical demise in the number of GP partners.

There are two schools of thought as to how this developing crisis should be handled. One is to take the line that GP practices are in fact private businesses, and that the NHS should leave it to the market to resolve the challenges of ownership. If GPs no longer want to run their own businesses, then let’s see who does. This will leave us with a smorgasbord of private providers (Virgin and the like), acute trusts (building on the example in Wolverhampton where the acute trust is now running a number of practices via APMS contracts), community trusts (like the Willow Group, in Gosport, Hampshire), general practice “chains” (such as Modality and Lakeside), alongside general practice operating within the new MCPs and PACS of the new models of care.

Is this the future we want? Attempts to introduce a market to the NHS have not impressed to date, and it is hard to believe this diaspora of provision will serve the population well, and provide a solid foundation for the delivery of transformed out of hospital care.

The second school of thought is that there should be some form of intervention. This would require a clear definition of what current/future sustainable general practice looks like, including the business delivery model, and support provided for this to be delivered. We change the model of general practice in order to make partnership attractive again.

The impact of the GPFV has been limited because it has lacked a clear vision for the future of general practice. It has shied away from defining what the future needs to look like – presumably in an attempt to preserve the autonomy of practices (or even the market) – and has not been brave enough in its delivery of support (practices can choose the bits of support they want from whom they want etc).

This is in stark contrast to the Midlands Health Network in New Zealand. Their response to the challenges facing general practice was a to create a very clear model of care, that included patient call centres, a different skill mix, use of technologies, and improvements to the business model. They recognised the management skills in practice were primarily in operations rather than in transformation, and so they provided support to their member practices to introduce the changes over a six month period.

Helen Parker, one of the local leaders, describes this process in more detail here. They called the programme the Health Care Home and practices have to graduate to become a Health Care Home (they can’t simply decide to be one). The programme is systematically creating a sustainable future for the member practices.

The current model of general practice is at the precipice and hanging on by its fingernails, and it won’t be long before it lets go altogether. Carrying on the way we are now is a default decision to allow the market to decide the future form and structure of general practice. Instead, action is urgently required to create our own version of the Health Care Home, to support practices to implement it, and to preserve and strengthen the general practice service that forms the cornerstone of our NHS.

Guest Blog – My Introduction to Collaborative Working

Liz Carter is a Locality Manager for NHS Horsham and Mid Sussex CCG. In a guest blog this week she writes about her experiences in trying to develop collaborative working between practices in Haywards Hearth and Burgess Hill – and how she was supported by Ben Gowland and the Ockham Healthcare approach…

I joined both the NHS and Horsham and Mid Sussex CCG in September 2016, having spent most of my working life as a Partnership Manager in a Local Authority. I was to be the new Locality Manager for Haywards Heath and Burgess Hill. At first, I was keen to get started on introducing the Primary Care Home / primary care at scale approach to Haywards Heath and Burgess Hill.

The plan seemed simple enough: bring groups of practices together (with a combined population of between 30,000 – 50,000) and enable them to work collaboratively to address the health needs of the local area.   The practices would benefit from the potential to address common workforce and capacity issues, share best practice, and look at how the new extended access requirements could be met.   The plan also seemed to make perfect sense. This collaborative approach would enable the newly established Communities of Practice (extended primary care teams) to wrap around the practices, providing a joined up approach to health and wellbeing which would ensure that the patient receives the right care from the right person in their town, and GPs could find some breathing space.

And then reality hit. What looks like a sensible plan on paper isn’t necessarily perceived in quite the same way by all!

Ben Gowland was employed by the CCG to support the process of collaborative working and was asked to support the practices in Burgess Hill. When I met Ben I was under some pressure to describe how the towns I work with were planning on meeting the extended access requirements, so I thought that would be the hook we would use to engage the practices. After all, they needed to do it, we needed them to do it, and Ben could help us scope how they’d do it. Again, simple and sensible.

But no, it appears that’s not what works. Ben is against rushing in with ready-made solutions. He avoids the straight forward, ‘here’s the pressing problem and this is the solution’ approach. I learnt that we needed to start with what matters to the practices, not what matters to me. We needed to listen. We needed to understand. We needed to know what they wanted to achieve. We needed to know how they thought they could achieve it.

So how do you do that? We met with all of the practices on an individual basis and talked and listened and reflected back to them what they had said.   We then identified the common issues the practices were facing and provided an opportunity for them to share these issues with their neighbouring practices. This process of building trust and relationships takes time but can’t be bypassed, whatever the CCG deadlines.   The practices met and shared information, and in so doing built new relationships. They considered the common issues they were all facing which gave them a reason to work together. They looked at who was best placed amongst them to drive this work forward and together they chose one Partner from one of the practices and his Practice Manager (paid from the CCG locality budget) to draft a business plan for the town.    Whenever there was dissent or concern, they were brought back to the common issues they had all agreed were troubling them.

During this time I regularly reminded Ben of the CCG deadlines and felt quite anxious about the passing weeks and months. But the end result is that the town identified its own issues, found a common reason to change (not one necessarily based on CCG priorities), identified people within the town to drive it forward, and a way to keep plans on track when there was disagreement. And you’ll never guess what? One of the issues that was highlighted and resolved by the town was how it would address the extended access requirements!

And if you’d like support with introducing collaborative working, don’t forget our Podcast this week which you can find here and information about a new training programme we are running with Kaleidoscope Health which can be found here.

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