Ockham Healthcare: Supporting innovation in General Practice

Why £2.4bn is not really £2.4bn

Hidden away in the latest NHS England publication[1], on page 19, is this graph (above). It is not good news for general practice.

At first glance it would seem to present a positive picture. Spending on general practice has gone up, and is planned to continue to go up until 2021. So what is the problem?

In the General Practice Forward View, published in April 2016, an additional recurrent investment of £2.4bn was promised to general practice. The parlous state of general practice was at last recognised, and (or so it seemed) that recognition was backed with real cash.

But what this graph shows is the additional investment of £2.4bn did not begin on the date of the publication of the paper. It begins around 2013, some three years earlier. A specific highlight is given to the formation of NHS England, to correlate this date with the turnaround in the funding fortunes of general practice.

The implication of this graph is that those awaiting £2.4bn of investment should really only expect less than £1bn between now and 2020/21. The graph also indicates the rate of funding increase will slow compared to the last two years. Worse, £500m of the extra money still to come has been promised for extended access, and at present most of that funding is being awarded via private tender, and not to local practices.

This should not be about headlines or political statements. It should be about properly funding a critical part of our NHS. It is no wonder that GP partners are at breaking point. According to one recent survey more than 90% of GPs have either left, have considered leaving, or have reduced their hours to be able to cope[2]. The additional funding is not a reward for general practice. It is what is necessary to keep it functioning and operating effectively at the front line of the NHS. This graph shows that not only is the funding required not going to materialise, but that the system is also going to pretend that it is.

[1] Next Steps on the NHS Five Year Forward View, March 2017

[2] http://www.weloveourgps.co.uk/

General practice organisations explained

If you don’t know a PACS from an MCP or if you are unsure of the difference between a Super Practice and a Federation then look no further! Click here to see Ockham Healthcare’s interactive guide to the confusing world of general practice organisations. The guide will take you through the eight main general practice organisations with links to the relevant guidance. The guide will open in another window. If you find this guide useful, or if you feel there are any other areas of general practice that would benefit from a similar approach – why not let us know in the comments section above.







What the “Next Steps on the NHS 5 Year Forward View” means for General Practice

Ben Gowland was excited by the promises made in the General Practice Forward View (GPFV) last year but, in this blog at the time, he expressed concern about the lack of any kind of accompanying financial plan. Now the government has published a “next steps” document which outlines the key priorities for the NHS over the next two years; and those concerns appear to be well founded.

There are 6 things general practice need to know about this document:

1. There will be £1bn less investment into General Practice than expected

In a cunning sleight of hand, the document reveals in a graph on p18 the promised £2.4bn additional expenditure into general practice uses a start point of April 2013, not the publication date of the GPFV (April 2016).   As well as leaving a bad taste in the mouth, it means the “extra” from 2016 is closer to £1.4bn, with the rate of growth of increase slowing from 2017 (now) onwards.

2. “5000 additional GPs” will become “the highest number of GPs in training ever”

Instead of saying there will not be an additional 5000 GPs and fronting that out, the document trails what will undoubtedly be the line the government and others will take in future that there are more GPs in training than ever before.

3. Extended Access is all

The one part of the GPFV the government really does care about is extending GP access. “By March 2018, the Mandate requires that 40% of the country will benefit from extended access to GP appointments at evenings and weekends, but we are aiming for 50%. By March 2019 this will extend to 100% of the country” p19. The additional funding for access, meanwhile, does not kick in until April 2019 and April 2020, a fact the document makes no attempt to address.

4. QOF will go, and be “reinvested”

Any practice bruised by the recent PMS reviews or removal of MPIG may be nervous to read the following, “We will seek to develop and agree with relevant stakeholders a successor to QOF, which would allow the reinvestment of £700M a year into improved patient access, professionally-led quality improvement, greater population health management, and patients’ supported self-management, to reduce avoidable demand in secondary care”. GPs are rightly nervous of the term “reinvestment”, as it generally means expecting them to continue doing what they are doing now, as well as undertaking additional activities to earn exactly the same amount of money, or even less if some of that “reinvested” money is siphoned off into networks, hubs, or CCG financial positions.

5. 30-50,000 is definitely the magic number

Most practices are seeing the writing on the wall that getting to this population size is going to be necessary one way or the other, but this document clearly reaffirms it. Badged as encouraging practices to work in networks or hubs, it clarifies (underlined) “the model does not require practice mergers or closures” (p21), while at the same time promising funding incentives to accelerate the move to reach this magic population number.

6. GP-led CCGs will be usurped by more powerful STPs

The whole section on STPs is crafted as a work around legislation to take responsibility away from CCGs and give it to STPs, and in some cases turn them into something called Accountable Care Systems (ACSs). These “will be an evolved version of an STP that is working as a locally integrated health system. They are systems in which NHS organisations (both commissioners and providers), often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health” (p35).

Nearly exactly one year on from the publication of the GPFV it feels like we have just moved two steps backwards from the forward steps of last year. Then it felt like the current plight of general practice was recognised, whereas now that recognition feels absent once again, replaced instead with a simplistic view that operating at scale is a straightforward solution and an almost blinkered focus on extending GP access.

Putting the pride back into general practice

In his second guest blog for us, mergers expert Robert McCartney argues that general practice will best thrive where there is a good balance of strong leadership and co-operation coupled with independence and the freedom to innovate.

The old expression of ‘herding cats’ was used when I first told people that I would be moving into primary care and working with GPs. Moving from the structures of an NHS trust the initial impression of primary care did feel like this.

Processes would be agreed and targets set but whether they were actioned felt like it depended upon the whim of the individual. As they hold significant power regardless of the position within the practice it was difficult to influence and change this mind set.

It dawned on me that traditional management structures and processes, particularly those largely learnt within the NHS were not appropriate for working with GPs. They are partially based on the belief that teams do need to be controlled and directed as a ‘herd’. Although this does have its place, particularly in larger teams needing to pull in the same direction it is less efficient with smaller groups were individuality is held at a greater value.

When considering the nature and reasons many doctors decide to specialise as GPs it was evident that the analogy of the cat remained relevant. Both are independent, don’t like to be interfered with, enjoy opportunities to explore new avenues whilst always being loyal to their home.

These are strong characteristics and have both positive and negative affects if they are not identified and managed appropriately.

If there are these similarities, then instead of thinking about the ‘herd’ we should be thinking about the ‘pride’. Within the ‘pride’ there is strong leadership, a close-knit family feel to the group and clearly defined roles emphasising the importance of co-operation. They allow independence and encourage exploration, especially of the younger members, whilst ensuring that they work together for the common purpose.

By recognising these qualities and purposes we can improve the structures and relationships needed to continue the success of primary care. Within most practices the traditional partnership model allows this structure to exist. It allows the retention of freedom and independence, whilst clearly defining the boundaries to ensure it ultimately helps the common purpose.

Other professionals who often work in this ‘pride’ mentality include lawyers, IFAs and accountants and they frequently work in variations of the partnership model. Working at scale can and does work with this model.

Partnerships are under-pressure and there are many different alternatives being explored but as long as the principles of strong leadership offering independence with controls are applied these models can succeed.

I would recommend that when GPs, practice managers, commissioners and anyone else look at how primary care can be provided at scale that they do not forget the frequently shared personal traits and ensure new structures maximise the benefits these bring.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the second in a short series of blogs he will be writing for Ockham Healthcare. If your practice needs a helping hand with its fledgling relationships, you can contact Robert via e-mail at rm@mccartneyhealth.co.uk or call 0203 287 9336.

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