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!

This week’s post is a clear and simple guide to an important new direction for 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.

Incredibly, the Ben Gowland podcast, a weekly podcast looking at innovation and new ways of working in general practice, is approaching a year old. We are taking this opportunity to count down our Top Five most popular podcasts and so highlight some of those you might have missed. So far, we have published 45 episodes…but which ones make it into the Top Five?

In reverse order, the Top Five are…

At Number 5 it’s Rebecca Rosen with Lessons from large scale general practice

In July the Nuffield Trust published a report, “Is Bigger Better? Lessons for large scale general practice”. I talked to Rebecca Rosen, one of the authors, to try and get underneath the implications of the report. One of the things the report found was the limited impact at scale general practice had on quality, and it begged the question as to whether the current mindset that bigger is necessarily better holds up to closer scrutiny. So I was really interested to find out from Rebecca, a practicing GP herself, whether she herself thinks “bigger” general practice is indeed better.

At Number 4 we find Tracey Vell with Trialling the MCP Contract in Manchester

Much has been made (and continues to be made) about the introduction of the new MCP (multispecialty community provider) contract, and in particular why GP partners would give up their existing contracts for one that is time limited and potentially relegates them to the role of salaried employee. Tracey Vell is a GP, LMC chair in Manchester, and the lead general practice negotiator on the introduction of the MCP contract in Manchester, one of the six pilot areas for the new contract. It was only after this conversation that I really understood why GPs are even considering it.

And at Number 3 sits Neil Langridge with physiotherapists in general practice

The introduction of new roles into general practice makes the first of two appearances in our top five at number three. Neil Langridge, a consultant physiotherapist, describes his experience of working in a GP practice, and explains the value physiotherapists can deliver is not in the direct provision of physiotherapy within practices, but in delivering the initial assessment of patient needs. He explains how not only has he diverted considerable work from the GPs, but also the impact he has made on the referral rate to orthopaedics, making the idea attractive to both practices and CCGs alike.

Straight in at Number 2 with a bullet is Jeannie Watkins with Physician Associates

Despite only being published in December this podcast was the fastest downloaded of all, and in less than 3 weeks still made number 2 on our overall list. Having already spoken to real-life physician associates (PAs) Ria Agarwal and Andy King in episode 40 about their experiences working in general practice, in this episode I spoke to Jeannie Watkins, the RCP lead for PAs, about the pipeline of PAs coming through the system and the opportunities this creates for general practice. It turns out while many GPs find the idea of PAs difficult, those that work with them in practice can’t speak highly enough of them and the contribution they make!

And, at Number 1 we have Stewart Smith with the transformation of general practice in St Austell

The runaway leader in terms of number of downloads in 2016 is Dr Stewart Smith, talking about the amazing transformation of general practice in the Cornish town of St Austell. Trouble beset one of the practices in the town and eventually it had to give back its list. What follows is an incredible story of how the other practices in the town responded, and turned what was a crisis into an opportunity to create real transformation. Stewart describes how all the practices in the town merged and took the failing practice over. They then closed it, refurbished it, and reopened it as an acute care hub using a multidisciplinary team to see all the on the day demand from across the town. All within the space of a year!

It has been a fantastic first year for the podcast, and I have had the chance to talk to some amazing people, and find out that, contrary to what we are regularly told, innovation and new ways of working are alive and well in general practice!

We have some great guests lined up for 2017, including the GP behind one single change that is saving GPs up to an hour a day of administration time! You can subscribe to the podcast on iTunes, or you can become an Ockham subscriber (here) and we will send you the link to the podcast and this blog every week. And if you know of, or even are involved, in any exciting developments in general practice do get in touch, and maybe you can be the next guest on the podcast and find yourself in next year’s Top Five…

This week Ben Gowland turns his attention to our quarterly review of all that is new in general practice. And what a three months it’s been…

The planning guidance is out there

First off, the release of the NHS planning guidance. You can read our take on what this means for general practice, but essentially its distillation of the GP Forward View (GPFV) was an extra £3 a head for practices from CCGs in either 2017/18 or 2018/19 (or split across the two), and extra money for access from 2018 onwards (£3.34 per head in 2018/19 rising to £6 per head in 2019/20). CCGs have to produce a plan by 23^rd December as to how they are going to implement (and fund!) the GPFV locally. We produced some thoughts for CCGs to ponder when crafting these plans, urging them to nurture and build on the seeds of local momentum rather than impose top down change.

Is operating at scale still an answer?

Many of these plans will inevitably include hopes of general practice operating at scale in future. We have seen some notable successes – City and Hackney GP Confederation put on a conference in November to share their achievements, and the country’s largest “super-practice”, Our Health Partnership in Birmingham, shared their progress over the last 6 months. However, all is not rosy in the at-scale garden. Horizon Health Choices Ltd in Bedfordshire, a 54 practice federation, went into liquidation proving yet again that scale itself is not the answer; but how you do it is. Our quick guide to introducing change in general practice will help anyone embarking on that particular journey.

Running with the GPFV

What of the GPFV? Well the latest allocations for the Estates and Technology Transformation Fund were released, and were generally less than expected and given a national prioritisation that differed from (and superseded) those made locally. We took time out to consider the trends in the world of primary care estates, where many GPs are looking for an exit route which the new models of care might just provide!

Interestingly, momentum in the GPFV implementation seems to have mainly come from internal productivity improvements within practices. CCGs received their share of funds for training medical assistants and GP receptionists, and (somewhat surprisingly?) it is having a huge impact. The 10 high impact changes, initially dismissed as a gimmick by most on first reading of the GPFV, are rapidly becoming one of the most useful parts of the document. Maybe even more surprisingly physician associates are starting to show the impact they can have on GP practices.

Collaborating with patients

Social prescribing, meanwhile, is gaining increasing credibility as a way of blurring the boundaries between primary health care and social care. Its most practical (and, in our view, finest) application is the development of leg clubs – using the need for medical treatment to create a sense of community and to tackle the social isolation leg ulcers can bring. New life has even been breathed into the often-dreaded patient participation group (PPG), with the development of virtual PPGs enabling much wider local participation in the practice than the traditional meeting format.

Sustaining and transforming…

The STP plans were also (finally!) published. The main complaint pre-publication was the lack of GP provider involvement on the STP boards. We looked at how general practice should be represented, and argue it is a choice GP practices should make for themselves as opposed to one imposed by the system. Given most of the STPs are reliant on a “transformation” of out of hospital care, lack of early involvement of general practice may be something areas come to rue later on.

New models of care

GP enthusiasm for MCPs has (at best) remained neutral over the last few months. Dudley CCG have published the first specification, but the promised draft MCP contract due in September has been put back until January, with growing murmurings of unrest from some of the practices involved. The second wave of primary care home sites was announced. Despite having no money attached, it was heavily subscribed. Even Simon Stevens acknowledged this is where the enthusiasm in general practice lies.

In fact one of the original primary care home rapid test sites, Beacon Medical Group, houses the newly acclaimed GP of the Year, Dr Jonathan Cope. Richly deserved. If you don’t know what he has been up to you can listen to him explain both how they transformed the way the practice works by introducing new roles , and how the practice has become a system integrator by building an impressive range of partnerships.

The legacy of CCGs

Simon Stevens hasn’t just spoken of the value of primary care homes. At the NAPC conference, as well as saying that QOF “was now nearing the end of its useful life”, he exhorted GPs to make general practice the CCG’s priority. If the legacy of an underfunded general practice remains after the period when GPs have been in charge of the money, and after an extra £2.4bn has been promised nationally, the implication was that it will be on GPs’ own hands.

What do you buy the GP who has everything?

But the highlight of the last few months has undoubtedly been the publication of our first book, “The Future of General Practice”. Described by one reviewer as, “probably the best summary of the options open to general practice that I have seen. It is… packed with examples, tips, lessons and practical guidance… I heartily recommend it to everyone interested in the options for GP development”. Christmas present – sorted.

Have a great Christmas!

There has been something of a frenzy of activity over the summer, following the publication of the General Practice Forward View (GPFV) earlier in the year, and if you have been away it is easy to have missed what has been going on!

Arguably the biggest development was the publication of the new MCP (multispecialty community provider) contract framework.  This, potentially, represents the end of the independent contractor model for General Practice.  Our 15-minute guide tells you all you need to know, but essentially it is about creating new organisations that general practice are part of, as opposed to new general practice organisations.

They are entirely voluntary, which begs the question why would GP practices choose to join.  I spoke to Tracey Vell, the LMC GP lead for the implementation of the new contract in Manchester, and she told me practices are falling over themselves to join for three main reasons: a way out of the current pressures; because they will be bought out of their building; and because the new organisation will pick up indemnity.

The publication of the MCP contract guidance, which outlines the new contract length will be 10-15 years, coincided with a resurgence in APMS contracts.  North Derbyshire, Blackpool and elsewhere are now introducing these not as a tool for competition to “market test” general practice, but as an enabler of integration between GP practices and other providers.

For some, the MCP is seen as the lesser of two evils because the alternative new model of care, the Primary and Acute Care System (PACS), is regarded as the takeover of general practice by the local hospital.  However, Dr Berge Balian, the GP lead at Yeovil Hospital for the local PACS, contends instead it provides an opportunity for general practice to be paid for work transferred from the hospital.  As a result, practices in Yeovil are choosing to give up their contracts to join Symphony Healthcare Services, an organisation wholly owned by the hospital.

The big question following the publication of the GPFV is where is the money?  This was brought into even sharper focus following the revelation much of the GPFV money would be allocated via the STP areas (cue the introduction of RCGP ambassadors to each STP area).   I spoke to Maureen Baker about the GPFV money to get her take on where it is and what it will really amount to, and for those still in the dark we have produced our own guide on how to find it.

“Primary care access centres” were trailed in the GPFV as a mechanism for extending GP access.  The BMA has since produced its own document, “Safe Working in General Practice”, renaming them “locality hubs” and describing them as overflow facilities for “full” general practice.  Either way, they amount to the same thing and require practices to work together to create them.  Handily, the Nuffield Trust published “Is Bigger Better? Lessons for Large Scale General Practice”.  They found evidence of improvements in quality lacking, but author Rebecca Rosen did conclude bigger is indeed better as a mechanism for enabling general practices to cope with the current challenges.  For those wanting to up their scale, Jenny Stone gave us a guide to practice mergers, and Nigel Grinstead shared the lessons he has learnt supporting federations and super practices to develop.

Meanwhile, the challenges of recruitment in general practice have not gone away.  We looked at the transformational impact paramedic practitioners have had on one practice, and asked the question more broadly as to whether social workers could form part of the practice team.  However, the action that can make the biggest impact locally in our view is the introduction of a local locum GP chambers.  Chair of NASGP Richard Fieldhouse explains what they are, and we heard from an ex-GP partner, a newly qualified GP, and a GP seeking a portfolio career about the impact chambers had on them.  We explained why you need one, how a CCG can support their development locally  , how a CCG can make the most of one they have, and we tackled the difficult questions and dispelled some of the myths about locums.

Finally, the Kings Fund produced a new report, “Clinical Commissioning: GPs in Charge”.  Author Ruth Robertson revealed they had discovered a frequently fragile relationship between CCGs and local practices, and predicted fewer, larger CCGs in future.  Less clear was whether GP leaders would remain in these bigger CCGs or take up residence in the new models of care.

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