A GP posted this message on twitter last weekend:

“Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (you can find it here)

It is an interesting prediction.  I would say general practice is currently divided into two groups.  There are those sites that have a vaccination model that is working well, has a team that is functioning effectively and are not only delivering the vaccine but also deriving huge satisfaction from doing so.

Sadly this group do not seem to be in the majority.  The second (larger) group are those who are both struggling to make the vaccination model work financially, and personally finding the whole process physically and emotionally exhausting.

The financial challenge noted in the tweet comes for a number of reasons.  The Pfizer vaccine is much more expensive to deliver (because of the need to dilute the vaccine, to put a 15 minute observation period in place for those receiving the vaccine, and to staff clinics at incredibly short notice).  There is no additional payment that takes this into account.

The housebound patients simply cannot be vaccinated within the £12.58 available.  Even if the team delivering the vaccinations can be funded (not possible if a GP carries them out), there is no way of funding all of the additional work required such as carrying out the training, gaining consent, validating the Pinnacle records etc etc.

Then there are all of the unseen costs.  Finding staff to book patients at short notice, even on the day of clinic and while the clinic is still running.  Bringing staff in on a Sunday because of an insistence that all of this week’s vaccines are used this week.  Managing the complaints because of the national control-freakery that is being applied to any messaging.  Communicating with practices and GPs who are not crazy enough to engage with WhatsApp groups that spew hundreds of messages a day, but are the only way of finding out what is going on.

Et cetera, et cetera.

If it does come to pass that, once all of the housebound and elderly are vaccinated and the Oxford AZ vaccine is much more widely available, primary care sites are stepped down for other sites, it will genuinely be one of the most galling financial kicks in the teeth general practice has ever experienced.

However, the personal loss for many of those leading the vaccinations is far greater than any of the financial challenges.  It is hard to overstate how all-consuming leading the vaccination process has become for many.  It is 7 days a week with no respite.  There is the weekly wait to find out what vaccines will be arriving, with painful recent scars reminding these leaders not to book anything until national confirmation is received.  Then there is the mad scramble to staff rotas and find patients for the clinics.  Then there is dealing with the inevitable change or late delivery, and having to absorb all of the local patient and staff unhappiness this creates.

For many vaccination leaders their life is on hold.  On top of the clinic challenges, there come new challenges every week – changes to the second vaccine regime, delivering to care homes, to the housebound, changes to Pinnacle, the emergence of a local mass vaccination centre (etc) – all topped with constant pressure from above to do more, faster, better.

The staff they are leading struggle with the pace, but the leaders have to push forward.  The local practices who are not involved push them from the sides.  It is the leaders who bear the brunt of the blame for national rules that don’t make any sense but can’t be broken, like which cohort can be done when, and why vaccine can’t just be given to local practices to administer themselves.

These leaders are PCN CDs, GP partners, PCN managers, practice managers.  They are our local leaders of general practice.  And if not already then certainly at some point soon they will need a break.  Many will simply not want to return.  They won’t stop until the job is done, but I understand a message that says once we get there enough will be enough.  And what then?  Who will pick up the pieces?  What state will general practice be in?  Will it all have been too much?

We are at a difficult stage of the vaccination programme.  Some sites started in December, and have been able to largely complete the vaccination of cohorts 1 and 2 (care home residents, those aged over 80, and frontline health and social care workers).  Others have only just received approval for their local site to begin vaccinating, and are only now able to make a start on these priority cohorts.

The challenge is whether the sites that have completed the initial cohorts should carry on with the next cohort (the over 75s), or whether they should be stopped while other areas catch up?  By the time you read this the next cohorts are likely to have been announced, but at present strict national rules mean any area that has completed cohorts 1 and 2 is experiencing heavy pressure not to make a start on cohort 3.

The Joint Committee on Vaccination and Immunisation (JCVI) is clear that the priority for the vaccination programme is the reduction of Covid-19 mortality and morbidity, and the protection of health and social care staff and systems.  The age based strategy in place has been selected as the best option for preventing morbidity and mortality in the early phase of the programme, because “Current evidence strongly indicates that the single greatest risk of mortality from COVID-19 is increasing age and that the risk increases exponentially with age” (p4).

The strategy is clear.  So if the constraint in the system is the supply of vaccine it makes perfect sense that the supply should now be prioritised to those areas that are catching up and still have over-80s to vaccinate.  It is up to the national team who decide who is receiving supplies to ensure it goes to those sites.

The complexity comes when the constraint is not supply but delivery capacity/capability.  If a site has completed cohorts 1 and 2 and receives a supply what is it to do?  The national mandate is that this site must now help other sites to deliver cohorts 1 and 2.  This is sensible, but there are two problems with this.  One is geography – how practical is it for the over 80s to travel to an area that is further away to receive the vaccine; and the other is logistical – the Pfizer vaccines have to be used within a very short number of days, and so delays in booking patients leads to a much higher risk that the vaccines will be wasted.

Many sites have been scrambling around for patients to ensure that vaccine isn’t wasted at the end of a session.  There are reports that some sites have not been able to use all their vaccine because they have not been able to find people from the right cohort in time.

To an outsider this seems strange – surely no one would let any vaccine be wasted?  But there is heavy system pressure applied to sites about not vaccinating outside of the allowed cohort, even after Pfizer vaccine has arrived on site and the clock has started ticking.  Threats are made that sites supplies will be cut off if they go outside the cohort.  So some vaccine has been wasted.

There needs to be a balance between striving to achieve the strategy of delivering the vaccines in priority order and a pragmatism of applying this goal so that we make the most of the vaccines we have.  The JCVI itself advised that,

“Implementation should also involve flexibility in vaccine deployment at a local level with due attention to… vaccine product storage, transport and administration constraints… JCVI appreciates that operational considerations, such as minimising wastage, may require a flexible approach, where decisions are taken in consultation with national or local public health experts.” (p11)

It does not feel like we have got that flexibility in the system right yet.  As ever, the top down nature of the NHS is resulting in local inflexibility when flexibility is required.

If supply is not the constraint and some areas can go faster, and cannot for geographical and logistical reasons help other areas, surely it makes sense to let them vaccinate their local population as quickly as possible (in cohort order)?  Holding back supplies so that we all move at the pace of the slowest does not feel like an appropriate response to the crisis we are all currently in.

This is only the first time we are moving from one cohort to another; there are many more such movements ahead.  General practice has stepped up and is doing an amazing job of mobilising and responding to the call.  The numbers already vaccinated is  a testament to this response.  Let’s not let system bureaucracy impede the incredible effort that is underway.

Last week, on the 7^th January, the national primary care team wrote a letter to practices entitled, “Freeing up practices to support COVID vaccination”.  There is no question GP practices are struggling right now, so how helpful was this letter, and does it go far enough?

The letter follows a previous letter written at the start of the second lockdown in November, which headlined with an announcement of £150M of additional primary care funding.  The core message of this letter was that, unlike the first wave of Covid, GP practices are very much expected to stay “fully open” this time round.  The additional funding was to enable “expanded capacity”, and to be able to deliver (on top of day to day work), extra work including:

• Supporting the establishment of a Covid oximetry at home model
• Identifying and supporting patients with long Covid
• Supporting clinically extremely vulnerable patients and maintaining the shielding list
• Making inroads into the backlog of appointments including for chronic disease management and routine vaccinations and immunisations

As a result the £150M has been primarily deployed to support additional work in general practice, rather than to provide any extra support for the work currently being carried out.

Two months later we are at a point where the pressure of the pandemic has significantly increased.  Practices are having to juggle staff sickness and isolation alongside skyrocketing demand.  At the same time the pressure is on from all sides for practices to carry out an extremely challenging Covid vaccination programme, as well as well as completing the biggest ever flu vaccination programme.  This is before getting started on the list of extra work from the November letter.

And so it was into this context that last week’s letter landed.  There is no question that the financial protections it contains were very much needed.  The minor surgery DES, the QOF QI domains and the 8 prescribing indicators in QOF are all now income protected until the end of March.  I think just seeing something that recognised the need for additional support prompted an initially positive reaction from many.

Non-essential locally commissioned services are suspended, although there is no guarantee of income protection.  Instead “budgeted payment against these services should be protected to allow capacity to be redeployed”, which undoubtedly will mean some CCGs interpret this as local income protection while others make additional requirements of practices against it.

PCN CD funding is (rightly) increased from 0.25 WTE to 1 WTE in recognition of the complexities of the Covid vaccination response.  This can “be flexibly deployed by PCNs” – it will be interesting to see how this works where one PCN is leading on behalf of a number of PCNs.

The other main announcement was that extended access funding won’t be shifting to PCNs before April 2022.  You would think that “repurposing extended hours and access capacity to support the vaccination programme” would actually be easier once the funding moves across to PCNs, but given everything currently happening I can see that many PCNs would struggle to put effective new arrangements for extended access in place any time soon.

My sense is that when you dig into the detail of the letter it does not acknowledge the reality of the additional pressure currently on practices as a result of both managing Covid patients and the demands of the vaccination programme.  If the national aim is really to free up practices to support Covid vaccinations, I would suggest what is also needed is:

• The £150M announced in November is distributed to practices to enable them to manage the current demand rather than to create additional work for practices
• There is a national mandate that the income from locally commissioned services is protected for practices by CCGs
• PCNs are allowed to flexibly deploy the ARRS underspend to staff vaccination centres. The requirement for six month minimum contracts limited to the staff roles identified in the ARRS list feels like such a wasted opportunity.
• National financial commitments are made to practices that go beyond March. The vaccination programme will take at least six months (and longer), so surely arrangements need to be put in place now that reflect that.

The ask of primary care is really significant at present, and practices up and down the country are going above and beyond to meet these challenges.  But practices remain independent businesses faced with unprecedented operational and financial upheaval, and my sense is more active support for practices needs to be provided to go alongside the demands being made of them.  Without it the current situation may not be sustainable.

It has been a stressful few weeks for many practices.  Not only did practices find out via the BBC that flu vaccinations for the over 50s are to commence from December 1^st, they also had to agree with their neighbouring practices which sites are to be used for the delivery of the Covid-19 vaccine.

Working together is not easy.  Trust is hard to build between practices, and despite the progress made in recent months, agreeing a single site for Covid-19 vaccinations across PCNs within a week was always going to be challenge.

At the root of this challenge is the money at stake.  If the average practice has 8,000 patients, and we conservatively estimate that only half of these will receive the vaccine, then that is 4,000 patients x2 shots each x £12.58 a shot.  Which equals over a £100,000 per practice.  That kind of money will always create tension, but especially in a year like this when practices are under so much financial pressure.

Most practices would have preferred to deliver the Covid-19 vaccine in the same way that they deliver the flu vaccine to their patients – in their own practices with their own staff.  But the nature of this vaccine (it arrives in batches of 975, has a shelf life of only 5 days, is difficult to transport and wastage is not an option) means that it simply is not possible at this point in time.

The logistics are not the only reason it makes sense for practices to work together to deliver this vaccine.  Practices already have to deliver the flu vaccine to a huge new cohort at the same time as the Covid-19 vaccine becomes available.  The ask of practices already during this second peak of the pandemic is to manage the new virus on top of everything else that practices have to do.  At the same time as winter properly kicks in.  Individual practices simply do not have the spare capacity.

While the workload is growing, the workforce is much less resilient.  Everyday different practices are faced with the challenge of huge swathes of staff either sick or needing to isolate.  Individual practices cannot be sure they will be able to keep normal services running, let alone an additional vaccination service that requires 975 injections within a 5 day period.

Delivering this vaccine also requires a level of management capacity not present in the vast majority of individual practices.  We know the logistics are extremely challenging (think enabling national and local booking, cold chains, training staff, organising volunteers, working with other agencies on communication messages, managing the IT, without even getting into the reporting requirements that will inevitably be necessary).   It is not realistic to think a practice manager can do all this in their spare time.

The financial efficiencies are potentially greater working together.  A well run single site operating with a clear set of processes and flows can minimise the costs by maximising the numbers running receiving the vaccination each hour, and by working effectively with volunteers and partner agencies.

Many practices dislike working together, because it is difficult and requires a ceding of control.  But if there was ever a set of circumstances where it makes sense for practices to work together this is it.  That does not make it easy to achieve, or change the local politics or difficult relationships, but nonetheless it is an opportunity.

The vaccination programme has huge societal implications, and is a massive opportunity for general practice to be a key part of taking this country out of the situation it is currently in, but my one piece of advice to those trying to make this joint working happen is not to ignore the money.  Whether it is what is being talked about or not by practices, it is an issue that needs to be explicitly addressed.  Be clear how will the money flow, how it will be transparent, and how it will be fair.  It might not be the most important, but it is certainly an essential step to making the joint delivery of the Covid-19 vaccine by general practice a success.

It has been a difficult year.  Coping with Covid-19, and all the challenges that it has brought both personally and professionally has been difficult for everyone.  The first lockdown was hard, but the second lockdown in many ways feels harder, because we understand the scale of the challenge and what will be required to get through it.

This time round some of the fear from the first lockdown has gone, because we know what to expect.  But instead it has been replaced with a tiredness.  Without really having the time or opportunity to recover from the first time round we are having to do it all over again.

For general practice lockdown 1 and lockdown 2 feel significantly different.  When lockdown 1 happened the message was to stop everything to make sure that patients with coronavirus were looked after.  In lockdown 2 the message seems to be that general practice should be open for business as usual, and be absorbing the covid challenges on top of everything else.

Now the ask is for general practice to also take on the covid vaccination programme.

It easy to react from a position of tiredness.  How can we find the energy to take on all the logistical and operational challenges this brings, on top of everything else?  Especially when it feels like we are already running on empty?  I know I personally am guilty of reacting like this.

But the reason I (like many of you) chose healthcare as the industry that I wanted to work in, as opposed to investment banking or commercial law or anything else, was because I wanted to make a difference.  I wanted to not just earn a living, but to do so in way that a made a positive difference to others.

Playing a part in the covid vaccination programme is likely to be my opportunity to make the biggest difference maybe I will ever be able to make.  A vaccine is the only route by which we can re-gain our lives, our economy, our normality.  Without it, as we have seen, the pandemic takes over everything.

So yes it is hard, and it is difficult to summon up the energy and personal resources, but really it is a huge opportunity.  Undoubtedly general practice will rise to the challenge, and play a leading role in taking the country out of the crisis it finds itself in.  I want to be part of it.  I want to know that when it mattered most, I made a difference.

Nothing has gone well when it comes to care homes in this pandemic.  Care home staff trying to look after an extremely vulnerable group of patients have been left on their own, without access to the support, resources or equipment they need.  Figures from the Office for National Statistics show that between 10 and 24 April, there were 4,343 recorded deaths from Covid-19 in residential care homes.  The number of deaths in care homes is rising at a higher rate than hospitals.  Frustration with the lack of support has grown, not just among staff and relatives but more widely across the country.

It is probably in response to this frustration that Simon Stevens announced in his letter to the NHS on Wednesday 29 April, “To further support care homes, the NHS will bring forward a package of support to care homes drawing on key components of the Enhanced Care in Care Homes service and delivered as a collaboration between community and general practice teams. This should include a weekly virtual ‘care home round’ of residents needing clinical support.”

Now anyone paying attention to the events surrounding the 2020/21 PCN DES will have been able to predict the reaction from general practice.  One of the most contentious issues surrounding this year’s PCN DES was the specification that related to enhanced care in care homes with the workload implications it contained for GPs.  Eventually a care home ‘premium’ of £120 per bed was agreed, with a trimmed down version of the specification to be implemented from October 1^st, that allowed for “appropriate and consistent medical input from a GP or geriatrician, with the frequency and form of this input determined on the basis of clinical judgement” (as opposed to mandatory GP participation in weekly ward rounds at each home).

But this was a fragile compromise at best, and so it was no surprise that the new announcement attracted a vehement response from the GPC.  Chair Dr Richard Vautrey said the next day, “We were incredibly disappointed to see in the letter from NHS England yesterday that it intends to bring forward the introduction of key elements of the care home specification without engaging with the profession, and in the full knowledge of the serious concerns many in the profession have previously expressed about this earlier this year.  We have told NHS England and Improvement that this approach is unacceptable. The profession will be rightly dismayed that this element of the contract scheduled for October, which depended on an expanded workforce and additional resources, could be imposed without either being provided.”

Cue some backtracking from NHS England.  It turns out that anyone thinking that Simon Stevens letter was about bringing forward the DES specification was wildly mistaken.  In fact, as a letter from NHS England on the 1^st May clarified, it is rather a service that needs to be established “as part of the COVID-19 response”.  Of course it not the PCN DES specification, because, “We are looking for all practices to take part, not just Primary Care Networks (PCNs). However, it will be less burdensome for general practice, easier for community partners and better for care homes for this to be delivered at a PCN level as the default.”  What were we thinking?

But however we got here, we are where we are.  If we have learnt anything from coronavirus it is surely that care homes need to be tied much more closely into the health and social care system, and there is a  clear and pressing need right now to provide better support to care homes.  Such a need in fact that NHS England has outlined a two week deadline(!) for the new service to be put in place.

I know there are some places around the country that have tackled this in the past and have arrangements in place that effectively mean all the new requirements are already met.  There are, however, others where there are vast numbers of residential homes and no such arrangements in place.  The challenge in these areas cannot be underestimated.

Let’s hope the wider system puts the support and resources into general practice and PCNs that will be needed for an effective response to be mobilised.  And let’s hope that care homes start to get the support that has been so sadly lacking so far through this crisis.

Rapid changes are taking place across general practice as a result of the covid crisis.  Do these pose a long term threat to the profession, or are they an opportunity?

It is hard to over-exaggerate the level of change taking place in general practice right now.  The shift to telephone consultations, video consultations and remote working, borne out of necessity, is happening at a pace and a scale never previously seen.  Shared models of service delivery across practices within networks and boroughs are being developed and operationalised in a matter of days.  Models include covid face to face sites (“hot” clinics), covid and non-covid visiting services, and even non-covid face to face services, including essential services such as childhood immunisations and routine injections.

Such changes have raised concerns in some quarters of the profession.  Will general practice ever be the same again?  Once this is all over, will things be able to return to the way they were, or are we saying goodbye to general practice as we knew it forever?  The worry is that the scale and pace of the changes being introduced right now will have an impact on the profession way beyond being able to cope with the crisis that is front and centre right now.

It is, however, worth bearing in mind that all was not well in general practice before the current crisis.  The GP Forward View, and then the five year contract introduced last year, were put in place to help a profession that was facing significant workload, workforce and financial challenges.  Some areas had been making changes in an attempt to meet these challenges.  These changes largely focussed on new ways of working, working at scale, introducing new roles, and building stronger partnerships with the wider system.

What the current crisis is providing is a unique opportunity to test out these changes.  The rationale for making these changes is stronger than ever.  Rather than the changes relying on a critical mass of practices having reached the point of enough being enough, when in reality some practices were getting there while others were managing to find a way through, now the need for change is clear.  The safety of staff, and limiting exposure to the virus, requires virtual appointments and centralised models of face to face delivery.  This, alongside the limited supplies of PPE, means these models have had to be put in place very quickly indeed, when previously such changes would have taken months or even years to put in place.

At the same time, the system is providing resources to general practice to make these shifts in ways that it never has done before.  On the podcast Dr Ravi Tomar describes the advantage practices have in making the shift to remote working now compared to when his practice made it 18 months ago.  Laptops, dongles, tokens are all being made readily available to practices.  In many areas centralised models of service delivery for covid patients are being directly funded by the local CCG.

The need for rapid change right now, and the support and resources available to make this happen, represent much more of an opportunity than a threat to general practice.  Once all this is over general practice can choose the parts of the changes they want to keep and the parts they do not.  But right now there is a unique opportunity for general practice, a profession that has been in urgent need of resuscitation, to test out new ways of working.  These changes may not only help it get through the current crisis, but also enable it to thrive into the future.

A big part of this week has been about PPE (personal protective equipment).  GPs need it.  They need it to see covid/suspected covid patients, and, increasingly, they need it to see everyone because right now who isn’t suspected covid?

The problem is that the supplies have not been there.  Initial supplies were sent to GP practices in early March.  But these supplies are widely regarded to be inadequate for what is required, and are rapidly running out (if they have not already done so).  Last week GPs were informed that a hotline had been established (0800 9159964 in case you don’t have the number), and for GP practices ringing the hotline that kit would be arranged within 72 hours.  So far (as of the weekend) reports are that problems remain.

As a result, GP federations and organisations have been working to see if they can secure supplies on behalf of their member practices.  Supplies do exist, but they are primarily in China.  But as we have been discovering this week, there are a number of problems dealing directly with suppliers in China.

First, the products need validating.  Just because the supplier says the masks are FFP3 masks does not mean they are.  Someone needs to go and check the products.  But finding someone you can rely on to carry out the validation is difficult.

Second, the PPE products need to be transported from China to the UK.  The cost of air freight is eye-watering.  On top of that the exporters need to have all the correct licenses to be able to ship products to the UK.   There are reports that hand sanitisers and overalls are being stopped at the UK border, and being returned to China as the importers did not have an alcohol or medical supplies licence.  This urgently needs to be addressed, but it falls within the remit of government and is out of the control of GP federations.

Third, the products are expensive.  They are not just expensive – prices are escalating on a daily basis, as the worldwide demand for the products soars.  Not only are they expensive, the Chinese suppliers demand payment upfront.  They hold products that everyone wants, so they can set their own terms.  Their terms are that they will only sell to those who are pay upfront.  Some will only sell to those who provide cash upfront.

However, the NHS does not work that way.  The NHS will not make payment up front ahead of supply.  It, understandably, does this on the basis that any supplier not prepared to extend credit to a state backed entity is a much higher risk of fraud.

So here comes the dilemma. How much financial risk is it reasonable to take to secure PPE supplies for GP surgeries?  Because ultimately we are weighing that risk against the health and lives of our GPs and their staff.  Should the NHS be prepared to say that in these exceptional circumstances we will take risks that normally we would not take, because these are not normal times?  Should government be encouraging and enabling NHS organisations to take these risks?  Or is the financial risk not worth it?

Whatever the view of the wider NHS, a number of GP federations think it is a risk worth taking.  If at the end of the day the PPE isn’t what they said it was, or it doesn’t arrive, they view it as a risk worth taking, because ultimately what we are actually risking is the health and lives of those we are asking to deliver care.

I spend most of my time at present working with a GP Federation in North East London.  What has become clear in recent days is that the crisis we are in is a key moment for the federation.  The role of the federation is, and always has been, explicitly to support member practices and delivery of care to their practice populations.  If the federation cannot support practices right now at the time when they need it most, I don’t think it ever will be able to.

This situation is not unique to the federation I am working with.  I think the challenge equally applies to other federations, to super-partnerships, and even to Primary Care Networks.  If there was ever a time when working together could add value, then it is now.

Individual practices are working extremely hard.  They are trying to get to get to grips with whole new ways of working – some practices have had to move to full telephone triage in a week, when many practices have taken years to make such a shift.  Every day there is a new challenge, with different staff off sick or isolating.  The priority is simply to make it through to the end of each day.

What is the role of at scale general practice?  Things are changing at such a pace that what is needed today might be completely different to what is needed in only a couple of weeks’ time.  But for right now, the role appears to be threefold.  First, identifying what immediate support can be provided to practices.  That could be help with ordering equipment, setting up IT equipment or establishing remote working, help obtaining locums, and directly helping when a practice goes into crisis (as some practices inevitably will).

Second, preparing for what is coming next.  We know the scale of the challenge will increase week on week, certainly for some time to come.  What worked last week may not work next week.  Local at scale general practice has to think about what is coming next, and what needs to be put in place to enable practices to cope.  This might be ensuring robust escalation processes are in place between and across practices, the introduction of “hot” sites, establishing an at-scale visiting service, plus things we have not even thought of yet.  Practices are (rightly) focussing on today, so at-scale general practice has to make sure it is doing the thinking about tomorrow.

Third, ensuring there is two-way communication with practices.  Practices need to have the up to date information on what is happening locally, and at the same time need somewhere to raise questions and concerns.  At-scale practice needs to provide that visible local leadership for practices which is so critical at a time when individual practices could easily feel isolated and alone.

But the challenge this presents for the at-scale organisations themselves should not be underestimated.  They often operate with a very limited number of staff, and clinical leaders in more or less full time roles in practices themselves.  They will also have their own internal challenges with sickness and isolation.  Meeting this challenge will not be easy.

In the coming weeks on the podcast I am going to be talking to Tara Humphrey who is working with a PCN, and we will both share our experiences of working with a PCN and a federation to see whether at scale general practice is able to rise to the huge challenge ahead.

We have had quite a week in general practice.  The LMC conference voted to “reject the PCN DES as it is currently written” and yet, frankly, it feels like an irrelevance given the unfolding situation with regards COVID-19.

The irony of course is that, just when the profession has chosen to reject PCNs, the need to work in groups of practices has become more important than ever before.  The reality is that many practices will have to close for periods of time over the coming weeks, and so right now need to be working and planning with their neighbouring practices to be prepared for when the time comes.

In turn, this reinforces the point that those who voted against the PCN DES were making.  If Primary Care Networks were genuinely about strengthening core general practice (and there is no better example of the need for this than right now) they would have voted for them.  It is the sense that, as the LMC motion put it, they are “a trojan horse to transfer work from secondary care to primary care” that has caused the disillusionment, not the idea of PCNs or working together per se.

Let’s see where we end up, but it may be that when all this is done and dusted we have much stronger, supportive networks of practices, regardless of whether or not they have signed up to the PCN DES.

At the same time practices have been asked to move to a total triage system (whether phone or online), and to undertake all care that can be done remotely through remote means.  The threat caused by coronavirus means that practices are very keen to move to such a system, to reduce the risk to their own staff as much as they can.

Now this is in sharp contrast to the situation we have had previously, where there has been a relatively slow rollout of first telephone triage and then e-consultations.  What situation will we be in a few months down the line when practices have grown used to operating primarily via remote consultations?  Even at this early stage it is hard to envisage a full regression to the point we were in maybe only as recently as last week.

So right before our very eyes general practice is changing at a pace that it has never changed at before.  It is change borne out of the necessity and challenge the current crisis is placing upon us.  What the service will look like once the dust has settled none of us know, but my guess is general practice will never look the same again.

Coronavirus: Disabling or Enabling?

As someone who has worked in Emergency Health and Disaster management situations throughout the world, it would not be unreasonable for me to suggest that crises beget opportunity. Whether it be changes in political power and influence, the displacement of refugees or the rapid development of technology to counter impending threats: There will always be individuals and organisations that can benefit from disaster situations.

Coronavirus presents just such a situation. And whilst not every individual or organisation will stick to the moral high ground when exercising that right, there are plenty of opportunities for well-meaning groups to provide assistance during this current outbreak.

One such group are the emerging Primary Care Networks (PCNs), who are in prime position to grasp this opportunity and respond to this rapidly developing crisis.

Now there is no escaping the fact that PCNs are still new and in varying states of cohesion; there is still wrangling about what is expected of them and the funding that will support them – but none of that matters in a crisis.  None of that matters if you start to dig deeper into the potential community impact of the Coronavirus and Covid-19.

The government is moving to phase 2 of its containment plan ‘Delay’, prompting strategies to defer the impact of Coronavirus beyond the winter pressures by limiting social and occupational interactions and the movement of people. There is no criticism of the strategy per se, but this implies a resignation to the fact that, with the predicted numbers of cases rising steadily, it will no longer be possible to contain the virus simply through contact tracing and isolation within specialist units.

This in turn means that the burden of responsibility for the management of acute cases will fall on other secondary care facilities, which makes it even more vital that there is a robust response to manage cases that present in the community.  There is also an increasing likelihood that patients who might ordinarily require admission may have to remain and be cared for at home or in the community.

All practices are being asked to consider their continuity arrangements and the NHS England Emergency Preparedness, Resilience and Response Framework (2015) highlights the importance of Mutual Aid in successfully managing such incidents.

PCNs are mutual aid units and have a unique capacity to provide such continuity not just within practices but to the community at large.

Staffing

The first consideration when responding to any emergency situation is ensuring the safety of your own workforce.  NHS England guidance for Primary Care (5^th March 2020) has provided assurances that sufficient PPE will be delivered to protect staff.  Consider also the existing health needs of your staff and whether their own existing co-morbidities may place them at risk and rotate staff as required.  With an assumption that at its peak 1/5^th of workers may be self-isolating, it is vital that a wide range of staff have the capability to manage basic system functions.  If schools are to shut, then some staff will have unplanned caring responsibilities.

Estate

PCNs should consider how they can best use their facilities across a wide area, e.g. some facilities may be easier to clean than others or there may be centres where it easier to isolate patients and keep them away from patients in waiting areas.  At its peak, one practice could be designated for testing.

Service Delivery

Increased demand may mean that existing services need to be rationalised.  Encouraging patients to phone for triage rather than attend the surgery will reduce the risk of cross-contamination. Residential and Nursing Homes may require a PCN to set up a support service using telephone support and risk stratification to identify those most in need of a visit.

Working at scale requires resources to be used in the most expedient way whether it be the deployment of specialist practitioners, the allocation of support staff, the rational use of facilities or the prioritisation of care.

Our nation and the world have been confronted by a new and at times deadly virus. It is vital that we use our precious resources wisely and work together to mitigate its impact.

Stephen Kemp works as Senior Consultant for McCartney Healthcare Associates and provides advice on governance, quality and performance issues for Urgent and Primary Care service providers. Stephen is a nurse with 40 years’ experience, mainly spent within Accident & Emergency and Urgent Care. Between 1994 and 2001, Stephen developed health responses to humanitarian crises around the world, including in Rwanda, Afghanistan, Liberia, Mozambique, Honduras and Albania.

The national LMC conference caused a stir in the national press last week when they passed a motion instructing the GPC to negotiate the removal of home visits from the core contract.

Hardly surprising given the timing and the forthcoming election, with each of the main parties falling over themselves to say how many extra GPs they are going to train and recruit should they be elected (Conservatives an extra 6,000 GPs, Labour and Lib Dems an extra 5,000 GP training places).  And of course it was easy for the press to sensationalise the story as an “end to home visits”, and for Matt Hancock to reject that notion out of hand, when that was not what the conference voted for.

So what did they vote for?  The specific motion was:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

1. Remove the anachronism of home visits from core contract work (passed 54%-46%)
2. Negotiate a separate acute service for urgent visits (passed 74% to 26%)

• Demand any change in service is widely advertised to patients (passed 90% to 10%)

Let’s be clear, the motion was not really about the merits or otherwise of home visits.  It was about GP resourcing and workload.  Despite the existing promise of 5,000 more GPs, the number of GPs has gone down while the workload has continued to rise, at a rate exceeding any increase in funding.  And so, inevitably, we end up with motions like this, which are statements that the current situation is unsustainable.

Something needs to be done.  I don’t think many of those at the conference believed the GPC would be able to negotiate such change to the contract, but rather they wanted a line drawn in the sand.

If the contract itself isn’t going to change, what can be done, and can the visiting system be changed to reduce pressure on GPs?

It is interesting that the level of support at the conference was so high (74%) for the introduction of a separate service for urgent visits.  Whilst some portray the debate as one of access versus continuity, this is snot necessarily the case.  Most current visits by a practice will not necessarily be by the patient’s own GP.  There are systems that have developed in different places around the country where a paramedic or nurse practitioner report back into the surgery before, during and/or after carrying out a home visit.  It does seem there is mileage in such a system that could potentially (according to the LMC conference debate) release 2 hours a day of time for practices.

Of course, not all visits are equal.  Many GPs in the debate have drawn the distinction between urgent on the day visits particularly requiring a “convey to hospital or not” decision, and the scheduled complex visits for very frail elderly people, those with severe disabilities, and those at end of life.  An acute visiting service would be for the former of these types of visits only.

What interests me is why practices are not planning to use the new roles coming via the PCN contract to set up such a service.  The LMC conference gave its own verdict on PCNs, passing a motion that PCNs would not reduce GP workload and would not address the workforce crisis.  But if practices chose to use the new PCN roles in the way they are asking for in relation to visits, it does seem as if PCNs could have an impact.

If the conference had slightly amended its motion as follows, NHS England may have potentially been more receptive:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

1. Shift the requirement of home visits from core contract work to the PCN contract
2. Negotiate sufficient resources for PCNs to establish an acute service for urgent visits

• Demand any change in service is widely advertised to patients

Would this, though, have garnered the same media reaction?  Would it have drawn the line in the sand that the LMCs were seeking?  Unlikely.

But do practices within a PCN require such a motion to be passed?  What is stopping them from deciding for themselves that this is how they are going to use the new roles that are being funded within their PCN?  I doubt local commissioners would get in their way.  Indeed, I suspect such an initiative would be welcomed, and could even attract additional local resource.  The bigger barriers are internal: the change capacity within PCNs; and of actually making change happen across multiple practices.

Relying on the promises of the major political parties to resolve the challenges in general practices is unlikely to be any more successful in the future than it has been in the past.  Whatever the right changes to make are, the best ones are going to come from within the service itself.  If 74% of an LMC conference believe an acute visiting service will help, maybe now is the time to push ahead with its implementation.

I am not a millennial. I am not a baby boomer either. To be honest with you, I don’t really know what I am (although apparently I am part of the “lost generation”). How could this possibly matter? Aren’t they just analytical constructs marketing people have developed to try and categorise different age groups?

Broadly speaking millennials are those currently aged 18-35. The first concrete example of the importance of this generation to general practice has been the startling growth of the GP at Hand service, where the practice of offering video consultations grew by 20,000 in 4 months. 85% of the patients joining were millennials.

So maybe there is something in the “millennials are different” mantra after all. This South African analysis resonates:

“The nature of the digital age is to prioritise speed, convenience, and value. The millennial, being digitally native, is exactly the same. This extends from their interactions online to their experiences in healthcare. Doctors do need to look at ways to adapt their practice to meet these expectations in order to meaningfully connect with their patients. From online bookings to …SMS alerts and online calendars, practices already have a multitude of digital solutions to choose from. It is OK that you make changes incrementally, but it is vital that practices start thinking about ways to increase the convenience and speed of the new doctor-patient process.”

Millennials: Getting to know the Patients of Tomorrow, Healthbridge, South Africa

The consensus is that the number of millennials is about to surpass the number of baby boomers, and the differential between the two will grow in the coming years. It is not only our patients but also our doctors who will increasingly be millennials.

Millennial doctors may well be less a product of a technological age, and more a group affected by the junior doctor dispute, the Bawa-Garba case, and training in a system where both they and their senior role models are struggling to cope. It is hardly surprising they feel unsupported, under-valued, and uninspired.

Add to that the growing rejection of the “deferred life plan”, of putting off what you really want to do for what is expected of you, of the idea of working hard until you are 65 to enjoy the benefits later. This is evident in the conflict between a generation of doctors who accepted intolerable conditions when they were training with a new generation who simply will not.

Lucy Cohen, in her article Why Practices Must Engage Millennials, writes,

“As a business owner, millennial, and employer of millennials, I see how different our lives are to that of previous generations. Expect to see them sitting at their desk for set hours of nine to five? Those days are long gone. And if you want millennials to engage with you, then you need to get on board with that idea. We’ve grown up accustomed to communicating and receiving answers almost instantly. So if your (practice) wants to engage with us, we need you to have systems in place to keep us posted on things.”

What I see in all of this is a tremendous opportunity for general practice. The NHS, and its constituent statutory bodies, is not going to be able to respond quickly to the demands of the new generation. The entrenched culture runs too deep. But general practice is far more agile. Individual practices can find ways of letting go of the past and of creating a new, different future that caters for the changing needs of the patients and the staff coming through the doors.

By strengthening the connection with their local community, by valuing individuals over traditional structures and ways of working, and by embracing the opportunity of technology, general practice can become the destination of choice for millennial doctors. It can also harness the growing engagement of millennial patients in their own health to improve health outcomes.

Understanding the changing needs of millennials is important because understanding the needs of our staff and our patients is important. It is an important place to start as we try and shift our thinking from “how do I get out of this crisis?” to “how do I build a sustainable future for this business?”

I will be exploring this issue in much more detail with a panel of experts this month. Watch out for the podcast episodes of these discussions which we will publish over the summer.

In his latest blog Ben reviews GP Judith Harvey’s latest book “Perspectives: A GP reflects on medical practice and, well, just about everything…”

There are not many non-autobiographical books where you feel like you get to know the author, but Perspectives by Judith Harvey is definitely one.   There is something compelling about getting inside the mind of a doctor, not just as a doctor but as a person, and getting a sense of how they see the world.

Judith Harvey is a GP, a patient, a charity founder, and a unique individual. She is also a very talented writer. “Perspectives” is a collection of articles she has written over a 10 year period. Her articles have been published each week in the National Association of Sessional GPs newsletter, as well as other GP publications. While they were written primarily for GPs, I am not a GP and I still found them highly accessible, as well as insightful, stimulating and challenging at the same time.

Her writing is characterised by her honesty. In “It’s a knockout!” she describes her own experience of having concussion, of how it impacted her ability to think clearly, to work effectively and to sleep properly. In “Sleeping with the patient” we find out why she spent the night sharing a bed with one of her patients. In “Giving up… or stopping?” she shares what the prospect of retiring from clinical practice is like in real time.

As the book progresses you start to sense her underlying frustration with the system, borne out of a deep concern about health inequalities. In many ways, Judith was always ahead of her time: a proud portfolio GP when the voice was not as loud as it is today; writing about the impact of employment on health as a medical student and being summoned to the Dean to be reminded she wasn’t training to become a social worker; to advocating walking (for staff and patients) as a route into cutting the NHS budget back in 2009, well before the social prescribers had moved into town. Her passion for learning from others systems is clear (Judith founded Cuba Medical Link, a registered charity which enabled medical students to travel to Cuba for their electives), as is her frustration that we are not learning more from the system that exports doctors and achieves some of the best outcomes at a fraction of the cost of systems we frequently refer to.

When it comes to dealing with difficult issues, no stone is left unturned. She tackles self-prescribing by doctors (an issue rarely considered by non-clinicians), whether placebos can (and should) be morally prescribed, and the impact discussing an elderly patient’s driving ability can have on the doctor-patient relationship. She talks about the problems of evidence based medicine, about the social pressure put on potential organ donors, and questions whether it is ethical to provide a new face to a healthy person whose face is damaged when the price is premature death.

Ultimately, what I enjoyed most was the sense I was starting to get to know Judith as a person, as someone who loves travel and film festivals and the paintings of Goya, as someone who embraces all of life, rather than choosing to be defined by her profession or one particular aspect of it, and as someone prepared to share some of her innermost thoughts so that we, the readers, can better understand the points she is making, simply because she cares.

Maybe the book would have been even better if it had included more of a biography at the beginning or end. The only thing missing for me was a more direct insight into Judith’s life, into where she has been and what she has done, as a canvas to enrich the colour of the articles.

That said, this book is much more than “a GP reflecting on medical practice and, well, just about everything” as it says on the front cover, which hopelessly undersells it. It is a rare insight into what the world looks like through the lens of someone who is both a GP and a fascinating individual, and as someone who had never previously read any of her articles, I found it captivating.

Judith’s book can be purchased via Amazon here. We will be talking to Judith about her life and career in a future episode of the General Practice Podcast

The world is changing. The days of popping down to Toys ‘R’ Us for a present for the kids are over. Last week Toys ‘R’ Us announced it was closing all of its stores. According to toy industry analyst Jim Silver, “They lost online and they didn’t adapt.”

It is not just the toy industry that is changing. It is everywhere. Earlier this month Countrywide estate agents reported significant ongoing financial difficulties. In a statement they acknowledged they had not yet learned how to deal with the challenge from digital property services (such as Purple Bricks).

General practice is not immune to these changes. Lillie Road Medical Centre practice in Fulham, which last year started to offer the GP at Hand video consultation service to anyone outside its area living or working in London, has seen startling growth. Taking up the service requires patients to leave their existing practice and register as an out of area patient. The list size of the practice has grown from 5,000 to almost 25,000 in 4 months, and 85% of registrations have been patients aged 20-39.

The GP at Hand experience means the digital threat to general practice has just become real. The capitated payment system of reimbursement for general practice means losing the younger, healthier patients on the list, and being left with patients who are older with more complex health needs; and could result in income not matching costs. It could well be the final straw for many practices already experiencing financial pressure.

Should these changes be resisted? Are video consultations a “good thing”? In a paper published in the Journal of the Royal Society of Medicine, the team from the Department of Primary Care and Public Health at Imperial College London said that while there is evidence that video consulting is acceptable to patients and offers many potential benefits, at least to those of younger age, its safety and efficacy in primary care currently remains largely untested. It raises concerns that while online consultations may help practices manage demand more easily, it may conversely increase pressure through supply-induced demand, or defensive practices.

In our new society, video consultations are more about allowing patients to access services in the way they want to, and less about reducing workload for GPs. Increasingly, it is patients who are going to set the pace for changes like this. The early results from GP at Hand demonstrate for some there is an impatience to see these changes now. Our recent technology panel ultimately felt the profession would not be able to keep control of the use of technology, and it would be driven by patients, if not now then certainly at some point in the future.

We are only at the start of the “digital journey” in general practice. Technology is evolving all the time. Jim Forrer on the technology panel talked about an app currently in development that can monitor blood pressure, pulse rate, oxygen saturations and respiratory rate through the camera function on a smartphone. Technology will change the doctor patient interaction and the way patients manage their own health. Google and Amazon are entering the health space, using global cloud-based health platforms and data, and this is going to have an impact on general practice.

We may think in a tax funded system based on needs not wants that market forces won’t apply. But the reality (as demonstrated by GP at Hand) is they will, because people will not accept what they perceive to be a second class service when it comes to their health, and will demand that health services evolve in the same way as every other aspect of the world. Resisting the implementation of technology will, at best, be a short term strategy. The risk of that approach is that others will move in to fill the void and the opportunity to respond positively may be lost.

If we can’t stop the march of technology, and given the significant potential financial impact, can general practice survive the changes that are coming? Well, established players in other industries (unlike Toys ‘R’ Us and Countrywide) have. Take the experience of the supermarkets. Online grocery shopping is the fastest growing area in the sector, but it is the major supermarkets who understood the change was coming and set up their own services. While new entrants have come into the market, Sainsbury’s, Asda, Morrison’s and Tesco are the major players. Morrison’s are now building partnerships with those with better distribution networks such as Amazon and Ocado to further cement their place.

The world is changing. GP at Hand is simply the indicator that general practice is not immune to these changes. Right now the onus is on general practice to respond, to respond quickly and to respond positively. Part of the opportunity of the move to scale in general practice is precisely for this, as it enables practices to invest in technology or partner with technology firms, to test and develop its usage and to evolve the model of care. By working together, practices can meet this challenge. The other option, to resist the changes, to pass motions that “more needs to be done” by commissioners and policy makers to preserve the status quo has the whiff of King Canute on the beach, and may leave current GP practice businesses in a position like Countrywide or Toys ‘R’ Us, rather than evolving with the changes like the supermarkets.

The concept of “primary care networks” is one of the most confusing I have come across in recent times. This is saying something given the plethora of new acronyms and ideas that have sprung to prominence in the last few years (think STP, PACS, MCP, PCH etc). Here I try and unpick what they actually are.

Primary care networks have something of a mysterious past. They first appeared in NHS England’s update last year on the Five Year Forward View, where they claimed they would,

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care networks or hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access. They also involve working more closely with community pharmacists, to make fuller use of the contribution they make. This can be as relevant for practices in rural areas as in towns or cities, since the model does not require practice mergers or closures and does not necessarily depend on physical co-location of services. There are various routes to achieving this that are now in hand covering a majority of practices across England, including federations, ‘super-surgeries’, primary care homes, and ‘multispecialty community providers’. Most local Sustainability and Transformation Plans are intending to accelerate this move, so as to enable more proactive or ‘extensivist’ primary care. Nationally we will also use funding incentives – including for extra staff and premises investments – to support this process.”

I remember reading this last year and thinking that it looked anomalous, out of kilter with the prevailing rhetoric of supporting GPs to manage their way out of the current crisis with the promise of extra resources and extra staff. They had not featured in the GP Forward View, where you would expect such a dramatic change for general practice to take centre stage, or even before that in the Five Year Forward View.

Maybe there had been a mistake, some sort of internal breakdown in communications within the towers of NHS England. But no, in an article in GP Online from March last year, NHS England’s Director of Primary Care Dr Arvind Madan said of these networks,

“This now becomes the new delivery scaffolding across the system. And it may be how they organise themselves in terms of access, and population and place-based care, and how they will be meaningful neighbourhoods for services to patients in terms of the offer they get too.”

But then all went quiet again on the primary care networks front. Despite the boldness of the earlier claims, nothing was seemingly happening to make these stated ambitions a reality. Efforts focussed on supporting practices through clinical pharmacists, resilience support and the like.   Until, that is, the recent planning guidance was published, which mentioned “incipient primary care networks” (like they are even a thing) and CCGs were told to “actively encourage every practice to be part of a local primary care network”.

What should we make of this? What is a primary care network? I can imagine CCG leads reading the words in the planning guidance and scratching their heads at what exactly it is they are being asked to do.

The use of “primary care network” seems to have appeared because learning from the vanguards demonstrated that for accountable/integrated care systems to work, they require general practice to be joined together into populations of 30-50,000, as the building blocks of the new system. This joining together of practices, how it happened and what it looks like is very different within each of the vanguards, although was consistently borne out of a huge investment of time, relationships and effort into building and developing trust. The term on its own, however, merely describes the end-state.

It also appears to be a term used to retrospectively fit the move in general practice towards operating at a greater scale into a policy direction. According to NHS England the “routes” to primary care networks include “federations, super-surgeries, primary care homes, and multispecialty community providers”. All very different things. Yes, they all involve previously separate GP practices working together, but they cover a very broad spectrum of what that means in practice. The term primary care network is seemingly used as a generic descriptor of where different areas who have embarked upon a journey of practices working together have arrived.

Herein lies the complexity. A primary care network is not an actual thing that can be defined or described in any detail. This is because the journey for each group of practices that chooses to work together is different and will lead to a wide range of different destinations. For some it will end up in super-practices, for others a federation, for others a primary care home, and for others something totally different. Most confusingly, very few (if any) will end up at a place that is called a “primary care network”.

So let’s not add “primary care network” to the already full lexicon of NHS terminology. Joint work across GP practices is a journey not a destination, and use of the term primary care network pulls focus unhelpfully away from the journey and onto the destination. Let’s hope CCGs do not take their new commands to heart, and that a new industry doesn’t arise in trying to create something that we can’t define.

I have always wondered who actually reads NHS planning guidance. It contains really important information, but it is always so dry and impenetrable (deliberately?) that most will rely on “bluffers” briefings from others. So here is my “bluffers” briefing for you (although it is here in full for the brave hearted). There are three key messages for general practice:

1.The Obsession with GP Access Continues

Buoyed by the apparent success of introducing extended access across groups of practices at evenings and weekends, the timetable for 100% coverage across the country has been moved up by 6 months to 1^st October this year. How much of the heralded 52% of the country that is already covered have permanent (as opposed to pilot) arrangements in place is not known, so expect a plethora of hastily put together procurements to emerge in the coming weeks. These are likely to represent something of a risk to local systems, because if the tenders are not awarded to local practices it will mean a fifth of the GPFV investment going elsewhere (£500m of the promised GPFV £2.4bn is for extended access), and GP engagement in integrated working may suffer as a result.

2.The Rise and Rise of STPs and Integrated Care Systems

And integrated working, as I am sure you already know, is now king. The furore over accountable care systems/organisations has led to a renaming as “Integrated Care Systems”. That should do it. More interesting is some of the insight the narrative provides as to how these will operate in future.

In the short term, the power and influence of STPs will rise. They will have “an increasingly prominent role in planning and managing system wide efforts to improve services”. They are expected to develop their management infrastructure. They will be the conduit for capital allocations.

It doesn’t stop there. Over time “we envisage Integrated Care Systems (ICSs) will replace STPs”. These ICSs will have one plan across all their constituent organisations, rather than there being a collection of individual organisational plans. It will be the role of the ICS to assure and track the progress of its member organisations. If an individual trust or CCG has financial or quality issues “the leadership of the ICS will play a key role in agreeing what remedial action needs to be taken”. This is code for ICSs being able to fire the CEOs of the member organisations, the key determinant of where the power lies.

What role this leaves for CCGs (the guidance also all but outlaws the use of contract penalties) is very difficult to identify. Most likely is an acceleration of the merging of CCG teams and the development of a (heavily reduced) “strategic commissioning” functions coterminous with the STP/ICS area.

The development of ICSs will also impact general practice directly. For an area to become an ICS they need “compelling plans to integrate primary care, mental health, social care and hospital services using population health approaches to redesign care around people at risk of becoming acutely unwell. These models will necessarily require the widespread involvement of primary care, through incipient networks”.

Incipient networks? Anyone? All becomes clearer later on in the guidance as CCGs are directed to “actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000”.

“Geographically contiguous” is new. I know plenty of areas that have encouraged practices to form networks with like-minded practices, regardless of geographical location. They won’t be happy. It is all very reminiscent of CCG-formation days. And what “actively encourage” means is anyone’s guess. Carrot or stick? Time will tell.

3.There is No New Money

Were you expecting any? The message for general practice is essentially investment will continue as outlined in the GP Forward View (and if you missed it, here’s a quick reminder of why the promised £2.4bn is not £2.4bn) – i.e. there is no additional, previously unannounced money. You should still expect the balance of the £3 a head one-off commitment from CCGs between 2017 and 2019, as well as the remaining sustainability and resilience funding to be spent next year (75% by December 2018, and 100% by March 2019).

Financial pressure in the system means “non-elective demand management” is to make up the majority of the CCG Quality Premium scheme. Urgent care will be a focus, but the elective position essentially just must not get any worse. GP referrals are assumed to remain flat (“increase by 0.8% i.e. no change per working day” – whatever that means). And, the guidance confidently states, “there will be no additional winter funding in 2018/19” (there will).

There is a push on CCGs to reduce the routine prescribing of 18 ineffective and low clinical value medicines, and savings against this are “assumed” for CCGs, so expect more pressure here. There is also a national consultation on reducing prescribing “of over-the-counter medicines for 33 minor, short-term health concerns, as well as vitamins and probiotics”.

Finally, there is one other bizarre addition I wanted to point out – a requirement for CCGs to ensure every practice implements at least two of the high impact “time to care” actions. Make of that what you will, but it does seem to highlight the persistent inability of the system to distinguish between top down and bottom up.

There you go – the essentials of the planning guidance in one five-minute chunk – now you can bluff with confidence!

2017 was a brilliant year for the General Practice Podcast with 50 episodes and well over 2,000 downloads per month. In this graphic (below) we pick out a few of our favourite highlights including some of the most downloaded. We hope you enjoy. The Podcast returns on 8th January 2018 with a brand new episode and then continues with a new, free episode every week. You need never miss out on an episode – why not subscribe to our weekly newsletter here.

Open the graphic here: Podcast Highlights Graphic

The end of 2017 marked something of a watershed for general practice. For the first time, the focus seemed to shift away from the crisis general practice is in, to what the future that awaits general practice will be.

And threaded throughout the free content from Ockham Healthcare, we saw glimpses of this future. There was outrage (in some quarters) at the growth of e-consultations – and I spoke to Mark Harmon from e-consult about where we really are currently. We saw the continued growth of the super-partnership and I spoke to Mark Newbold for the latest update from Our Health Partnership as they continue to develop. There was the continued development of new roles in general practice and I spoke to Jenny Drury about paramedics undertaking the majority of GP visits. Jonathan Serjeant and Mark Spencer from NHS Collaborate shared pictures of the future with general practice bringing whole communities together, and we learned of a new style of management leader in general practice from Claire Oatway at Beacon Medical Group.

3 important questions for the future of general practice were identified: Will general practice remain independent? What scale will general practice operate at? What will the role of federations be? In the end it became clear that it is ultimately all going to be about collaboration. The Nuffield Trust produced a report on collaboration in general practice, and federations have come back into vogue. We identified good reasons for practices to join (and not to join) a federation. No longer just needed to subsidise meagre general practice earnings with additional revenue streams, now (and in the future) they will also need to support the delivery of core general practice and to give general practice a voice around the accountable care table.

All the more important because “accountable care” has developed into the potential new game-changer for general practice. Nick Hicks explained what accountable care means, and how an outcomes based contract might actually work. The new ACO contract was published back in August, but the involvement of general practice is more likely to come from leaders getting out and talking to practices. Anna Starling shared lessons the Health Foundation has distilled from the work of the vanguard sites, and Nick Hughes explained first-hand what it is like to lead a federation within a PACS vanguard. We thought about the impact commissioning has had on general practice (overall, not good), and highlighted the importance of a proactive transition from CCGs to accountable care for general practice (here and here).

In the end, we concluded the general practice forward view is not going to change general practice, STPs are not going to change general practice, the revitalised federations are not going to change general practice – it is GPs themselves accepting the situation they are in and making the necessary changes that ultimately provides the only way general practice can move into its new future.

Merry Christmas and a Happy New Year to you all from everyone here at Ockham Healthcare, and I look forward to sharing the continuing journey with you in 2018!