Ockham Healthcare: Supporting innovation in General Practice

Without GP partners, general practice will lose its Independence

For me, one of the biggest strengths of general practice is its independence. It contracts with the NHS, but is not part of the monolithic NHS structure. For some this may feel like a technical difference (after all GP practices can still access the NHS pension, and they are funded with taxpayer money) but for someone who has spent 20 years working in the NHS like myself the difference feels much more fundamental.

GP practices are bound by the terms of their contract with the NHS. But within the boundaries of those terms they are free to innovate, make changes, and take whatever decisions they want to improve care for their patients and the working lives of their staff. This is in stark contrast to NHS organisations that are bound by NHS-wide restrictions, ways of operating and approval mechanisms that often stifle innovation and directly impact on culture.

It is now widely accepted that GP practices require more money – whether they are funded directly or through a contract. Moving away from the independent contractor model is not the answer; it will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Their independence is not a cause of those problems, but rather is the only reason GP practices have been able to continue the way they have despite the current pressures.

Yet, sadly, the independent contractor model is teetering on a knife’s edge. I visited a practice recently that a year ago was a relatively stable, well-run, 4 partner and 7500 population practice. Within the space of two weeks two of the partners resigned. One was retiring, and one was emigrating to Australia. A few weeks later a third declared they were also resigning as they wanted to become salaried. This left a single GP, who had neither the skills nor the desire to be the sole partner of the practice. She wrote to the CCG informing them of the situation and declared that if a solution was not found she would be forced to hand back the list.

This scenario and others like it are being played out throughout the country. The inability to recruit GP partners is rising to the top of the challenges facing GP practices today. Every resignation of a GP partner creates panic within practices, a sense of being trapped, and a fear of being the one left carrying the costs of closure.

The recent push to secure 5000 new GPs, whilst unlikely to be achieved, has brought new GPs into the profession. But many of these GPs are choosing part time or portfolio careers. The competition for new GPs is pushing up the pay for salaried GPs. The new extended access and A&E based services provide well-paid, flexible alternatives for new GPs, further increasing the challenges of recruitment for practices.

The risk is that, unconsciously, we are creating a system that rewards salaried GPs and punishes GP partners. By not intervening, general practice as a profession is risking its independence. Without GP partners, there are no businesses that can deliver against the contracts, no practices as we know them today. The NHS will have to directly deliver the service. Once independence is gone, it will never be regained.

I do not believe GPs, even new GPs, would actively choose to give up their independence. I believe it is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

We need to make becoming a GP partner more attractive. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. In a tougher financial environment, we need to make sure GPs are given training and support to be confident to take on the challenge of becoming a partner. The one afternoon designated in the current GP training programme is insufficient.

Here at Ockham we are taking a step (albeit small) to fill this training gap. On Tuesday July 4th at 7pm we are holding a free event in Central London on being a GP partner. Join us in person or on twitter (#gppartners) – find out more details of this unique event here. Unless we take action now, general practice will lose its independence.

Six months is a long time in general practice

Christmas may seem like some far-flung memory, but over the last 6 months much has happened in general practice. While much of it might feel familiarly depressing, there are at least flickers of light for some at the end of the tunnel.

In December 2016 NHS England published the draft multispecialty provider contract. We examined what it means for general practice (essentially the fully integrated model means the end of independent general practice as we know it, but only if GPs choose it, which seems unlikely), and what it means for CCGs (another nail in their coffin).

One thing that didn’t change in the last six months was the money (or rather the lack of it). The contract for 2017/18 was finally agreed, but promised additional GPFV money was nowhere to be found. Indeed, despite our campaign to try and find it, no one was really sure where it was, until eventually the NHS England “Next Steps on the Five Year Forward View” document revealed there never really was an additional £2.4bn.

Despite the “highest ever number of GPs in training” (a ministerial phrase we are already growing heartily sick of), the total number of GPs continued to fall. GPs left faster than they were coming off the end of the burgeoning production line. Nick Mattick gave us an expert insight into GP recruitment, as well as a six stage guide for practices to follow, and Dr Mayur Vibhuti told us how he is developing a new generation of GPs.

For many practices, the challenge of recruiting a GP partner has been the biggest recruitment challenge of all. We tentatively suggested what a training programme for GPs considering partnership might look like, and are now working with Dr Mayur Vibhuti to see what we can put in place. Get in touch if you want to know more.

Not only is there a crisis in GP recruitment, there is also a crisis in GP nursing. Mia Skelly outlined the crisis and what needs to be done, and we found out detail from nurses in Lambeth about the tremendous work they are doing to support recruitment and retention of practice nurses.

It is not just nurses who can help GPs. Physician associates are just starting to be accepted as a possible support for practices – Dr Joanna Munden explained the impact they had had in her practice. Paramedic led visiting services may also be the future.

We also discovered the largely hidden work of Community Education Provider Networks (CEPNs) up and down the country, eloquently explained by Tara Humphrey. For those interested in developing the community workforce these are well worth looking into.

Glimmers of hope for the profession have started to emerge. The 10 high impact changes outlined in the GP Forward View are beginning to provide genuine benefit to some practices. In particular workflow optimisation (or GP post being managed by administration staff) is saving some GPs up to an hour a day, and active signposting is shifting up to 25% of patient appointments away from GPs in some practices.

Passionate advocates for general practice have become bolder and more vocal. Dr Jon Griffiths told us about his TedX talk promoting general practice, and Nish Manek inspired us with her passion for the profession.

Unlike MCPs, the “primary care home” movement has grown in popularity. GP of the year Dr Jonathan Cope explained how his practice now functions in what felt like a glimpse into the future of general practice. Adopted by Dr Cope’s practice, Beacon Medical Group, the shift to “hot” and “cold” sites is becoming increasingly common, and was explained to us by Dr Rachel Tyler from Ocean Health. We also had a live commentary from Dr Rebecca Pryse on what it feels like to be in a practice making such a change.

Getting bigger remains a key strategy for practices in trouble. A whole new lexicon of general practice organisations is emerging (do you know your super practice from your practice chain?).  Mergers expert Robert McCartney outlined the key to a successful union between two practices. The rise of the primary care home has led many to believe that reaching a population size of 30,000 is now a magic number for practices to aspire to, and Robert gave us his thoughts on how to get there.

The rays of hope are still, however, few and far between. The profession remains engulfed in crisis, while the government seems more concerned with extending access to GPs and putting GPs into A&E departments. If your practice has reached crisis point and you don’t know where to turn, have a look at our video, in which we examine the options open to GP practices and help you work through which one might be right for you. One thing continues to remain clear – the best hope for general practice remains the changes it can make for itself, not those it waits for others to make for it.

At-scale general practice must stay independent

The BMA has found GP practices with a higher CQC rating earn more income. My PhD wife regularly pulls me up for mistaking correlation with causation, so I wonder whether outstanding practices earn more income (i.e. the cause is that they are outstanding), or whether they are outstanding because they receive more income (i.e. the cause is that they receive more income).

More research is required to test these hypotheses, but my money would be on the former. I know many areas where the opportunity for income is equal across practices, yet the better practices earn more (through better recovery of QOF income, through delivery of a wider range of enhanced services, and through private income streams).

So in the independent world of general practice, the practices that provide a better service to patients earn more money, while the less well run practices earn less. Independence, of course, means there is no bail out. The risk sits squarely with the GP partners as business owners. Compare this with those leading statutory bodies, such as CCGs. They will earn the same amount of money regardless of how well the CCG does. Salary is not linked to performance. There is no meeting with the accountant where the slow realisation descends on all of the partners that they are going to have to take a pay cut. Instead the CCG goes into deficit and money is spent on management consultants to “help” the CCG get back into balance.

I was fortunate enough recently to spend some time learning about how the system of general practice works in New Zealand. There, a key component is that each practice is part of a network. These networks are not statutory bodies. They were formed by practices nearly 30 years ago, essentially as a protectionist manoeuvre by practices, and their purpose is to strengthen and improve general practice.

The great thing about non-statutory bodies is that they cannot be abolished or reorganised. While in this country we have seen PCGs, PCTs and now (probably) CCGs come and go, in New Zealand over the same period the networks have been constant. They have been able to adapt and thrive over that time, and provide better and better support to their member practices. Indeed, the government has even channelled the contracts for practices through the networks, enabling the networks to take on the role of improving quality across their member practices.

I was the Chief Executive of Nene Commissioning, one of the leading practice based commissioning groups. We were a non-statutory body, but we worked with the PCT, with our member practices, and with many others to drive some impressive innovations across the system. With the advent of CCGs we transitioned into a statutory body. There is no doubt in my mind that becoming part of the NHS system, hounded by layers of hierarchy and regulation, strangled the innovation out of the organisation. It is because CCGs are statutory bodies that ultimately they have not been able to fulfil their promise.

Meanwhile the networks in New Zealand have thrived and continued to innovate. Pinnacle, one of the leading New Zealand networks, has developed an improvement programme for its member practices. It funds it itself, it tests it on practices that it directly manages (the equivalent of our APMS contracts), and is working with its members to make them fit for the future. Not because it has to, not in response to a government initiative, but because its role is to strengthen and improve general practice. It only answers to its member practices, and because it is independent it cannot be abolished or reorganised.

This is an important lesson for us. Moving to at-scale general practice in many areas is the right thing to do. But finding ways to do it that maintain the independence of general practice, and the independence of any at-scale organisations it creates, is absolutely critical. Independence rewards success, and penalises failure. It fosters and encourages innovation. Most important of all, it creates stability and strength for the long term.

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