Blogs Archives - Ockham Healthcare

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The Independence of General Practice Series – 3

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

This is the third in a five-part series of blogs discussing the independence of general practice. This week Ben looks to the Nigel Watson-led review of the partnership model and considers the possible threats this poses to that independence.

Why the review of the GP partnership model makes me nervous

In February Jeremy Hunt announced there would be a review of the partnership model of general practice, and that it would consider “how the partnership model needs to evolve in the modern NHS”. This review makes me nervous.

The number of GP partners is falling. As all practices are only too well aware, the number of applicants for a GP partner post has fallen dramatically, with many adverts not attracting a single serious application. General practice has to be attractive to the GPs of the future. The review will need to look into this, and discover nuggets such as “the prospect of unlimited personal liability in a hugely under-funded sector has limited appeal to new GPs”.

I am nervous about this review because it is very easy to conflate the issues facing general practice as a whole (the workload, workforce and financial pressures) with the partnership model. It is easy to imply it is the partnership model causing the challenges rather than the historic underfunding etc. etc. Correlation, regular readers of this blog will recall, is not the same as causation. If general practice was still receiving 11% of NHS expenditure would we still be having this review?

A review of the partnership model is also a review of independent contractor status. General practice is currently very difficult to control. The independent contractor status affords it an ability to act only according to what is negotiated within its contract. Changes to NHS rules don’t directly affect it. Persuasion rather than coercion is required, and for politicians seeking rapid change in general practice I can imagine this is hugely frustrating.

There is a widely-espoused view that the small business, or “corner shop” model of general practice is no longer fit for purpose. As the NHS seeks to move into a world of integrated care a new, bigger version of general practice is required that can partner with the rest of the system. Most sectors of the NHS can be instructed to actively participate in integrated care arrangements (or individuals moved on), but not so general practice. The sheer number of practices is making progress painfully slow, and there is no direct command lever that can be pulled to make integration happen any faster.

However, size and form are two different things. GP partnerships, operating as independent contractors, can operate at any scale. They are not limited in size. Our Health Partnership has done an admirable job of demonstrating how the partnership model can work at a population scale of over 300,000. Conflating the relatively small size of general practice organisations with the partnership model of general practice when they are two distinct issues is, at best, unhelpful.

The review makes me nervous because although the partnership model does not need to change for general practice to operate at greater scale, it does need to change if the system is to exercise greater control over general practice.

The only thing making me less nervous about the review is the appointment of Dr Nigel Watson, Chair of Wessex LMC to lead it. He appears to be a supporter of the partnership model. He recently said,

“My personal view is that the partnership model has not reached the end of the road, it can still have an important role to play in the future of the NHS but we need to make it a better place to work, which will encourage more GPs to remain working in general practice, address the concerns about the unlimited personal liability and with the move to a more population based approach to healthcare ensure that general practice is truly able to play a leadership role in the local NHS.”

The review does indeed need to consider these things, and build on the strengths and freedoms of the partnership model as it looks to the future. Let’s hope my nervousness (and, I admit, my cynicism) is unfounded.

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The Independence of General Practice Series – 2

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

This is the second in a series of five blogs where Ben is considering the issue of independence in general practice. This week he looks at the distinction between statutory bodies and independent contractors and asks whether the difference is of any consequence.

Can independent contractors be trusted?

During the 2017 Christmas holidays, when you would have thought attention may have been focussed elsewhere, there was something of a debate as to whether organisations that are not NHS statutory bodies, but rather ones that contract with the NHS, can be trusted.

The debate focussed on the pre-cursor of the new favourite (Integrated Care Systems) which was Accountable Care Organisations (remember them?). For example, Dr Phil Hammond, a doctor, radio presenter and NHS commentator, said,

“I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver.” (via Twitter, Jan 1^st)

Unfortunately, this debate brought the position of both GP practices and GP federations under the spotlight. If this is true for Accountable Care Organisations, is it not also true for GP organisations?

There is a fine line between being in the NHS and working with the NHS. Back in 1948, amidst the protracted negotiations required to start the NHS, a deal was brokered whereby GPs would not become salaried employees, but rather remain independent, providing services via a national contract with the NHS. This means GP practices provide NHS services, but are not NHS organisations, and “independent contractor” status was born.

Does the distinction between a statutory body and an independent contractor matter? At first it mattered little, but times have changed since 1948. In the 1980s the Conservative government privatised some of our national industries, including steel, railways, airports, gas, electricity, telecoms and water. Although the NHS survived the cut, the purchaser provider split was introduced in 1990. Ever since, fears have remained this was the first step in a plan to privatise the health service, and anything not a statutory NHS body is treated with suspicion.

Over 25 years later, we now approach the end game of the purchaser provider split, in a strange closing manoeuvre whereby the Health and Social Care Act of 2012 seemingly opened the NHS up to more competition, but in practice the NHS itself has closed competition down with a focus on integration through the Five Year Forward View. Fears that accountable care organisations were a Trojan horse to enable the privatisation of the NHS led to their re-badging as integrated care systems.

At some point these integrated care systems will take on a population budget. It seems that rather than allow them to do this as “independent contractors”, the government is prepared to legislate to enable new types of statutory bodies to be created.

Where does that leave general practice? Is the current review of the partnership model an attempt to shift general practice from independent contractor into some form of statutory body status? Are the new, semi-mandated GP networks the first step towards groups of GP practices as statutory bodies? Will the public tolerate at-scale GP organisations that are not statutory bodies, or will the anti-ACO sentiment shift its focus towards federations and the like?

The currency of the new world is trust. People trust their GP, more than they trust their local NHS organisation, and much more than they trust national (statutory) NHS organisations. Being a statutory part of the NHS won’t make the public trust GPs any more. Our experience of CCGs should at least teach us that. My sense is the benefits of being independent (to GPs and to the delivery of health care) outweigh the costs and challenges.

GP practices know it is not the technical difference between an NHS statutory body and an independent contractor that matters, but rather what they do, and the trust they build with the people they serve. The same will be true for at scale general practice organisations. And for integrated care systems. Ironically, it is the relationships integrated care systems develop with their local (independent contractor) GPs that may determine how much their local population eventually choose to trust them.

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The Independence of General Practice Series – 1

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Ben Gowland introduces an exciting new series from Ockham Healthcare:

“In the last couple of years I have written a few articles about the independence of general practice. The current review of the partnership model being carried out at the behest of government, which is considering what has been the bedrock of general practice for so many years, will inevitably have to consider the issue of independence. This prompted me to bring together and update what I have produced so far, along with some new thoughts, to create an autumn series of articles on this topic. Over the course of 5 articles throughout August I will consider the threats to the independence of general practice (from within general practice, from the wider system, and from the review itself), reflect on its importance, and identify what might be needed for it to be preserved.”

In this first blog Ben considers the impact that fewer and fewer GPs choosing to become partners will have on the independence of general practice:

Without GP Partners General Practice will lose its Independence

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

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

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

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

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

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

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

I do not believe GPs, even new GPs, by not choosing to be partners are choosing for general practice to relinquish its independent. But I believe that is exactly what is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

Nigel Watson is leading a review of the GP partnership model. My sense is we need to make becoming a GP partner more attractive. We must provide more training and preparation for GPs who do want to take up the challenge of becoming a partner. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. With or without the review, unless we take action now, general practice will lose its independence.

jul

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Funding GP Networks

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The general consensus appears to have fallen on integrated care systems and primary care networks as the way forward. CCGs have been instructed to encourage every practice to be part of a primary care network, which are to cover populations of (roughly) 30-50,000, and as a result a plethora of these new entities are now developing.

Here is a question: where should the funding for the management of these primary care networks come from?

We may not be convinced that another layer of management in the NHS is what is needed, but if the mantra of the day is primary care networks, and the point of them is to enable core general practice to partner effectively with other providers within an integrated care system, then some management function is going to be required.

What are the options?

1.Use the management margin gained from the delivery of additional services.

Traditionally this is how GP federations have made themselves sustainable. In some places this is the assumed mechanism for developing the management funds for these new organisations. The problem is that the networks are expected to represent the delivery of core general practice, not simply the delivery of the (small) range of new services they may provide. This method creates an incongruence between what the network does and the voice it is supposed to have. It also serves to inflate the management costs they have to charge for any service delivery, which is likely (at some point) to make them uncompetitive.

2.“Investment” by GP practices.

In this model GP practices chip in anything up to £2 per head of practice population. This ensures the network function has a clear sense of ownership from its member practices, and that it speaks on their behalf. The challenge comes here with the underfunding of general practice in recent years. Establishing the networks becomes another drain on GP practice resources, at a time when many practices simply do not have the spare financial capacity. As a result, many practices will choose to pass when the opportunity to directly fund the new networks comes along.

3.GP Transformation Funds.

The GPFV is investing a considerable amount of funding to enable “transformation” in/of general practice. Some STP areas are using the transformation funds to support the establishment of GP networks with appropriate management. This is a sensible starting point, but really is deferring the question of where recurrent funding will come from, rather than answering it (i.e. what happens when the non-recurrent transformation funding runs out?).

4.Additional Funds for the GP contract.

Essentially, a model could be introduced whereby additional funding is given to every practice through their contract, for them to use to fund the management resource required for primary care networks. A similar approach was used in practice based commissioning days when practices in many areas received an enhanced service for practice based commissioning, although then they could choose to use it themselves or pool it to create a shared function.

The benefit of this approach is it ensures GPs retain ownership of the management function because even if it is “pass-through” funding, it comes from the practice. This creates the accountability between the network and the practices that is required for them to be successful. The downside is that local disputes and disagreements make local arrangements hard to pin down and sustain over a period of time – just look at the blood, sweat and tears it took to tie down CCG configurations.

5.Transfer of some CCG management allowance

The final option (that I can think of) is the transfer of some of the management funding that sits within CCGs to these new networks. CCGs as member organisations at some stage in the move away from the commissioner/provider split are going to cease to exist, and the natural replacement for groups of practices looking to work together to improve population health (although this time as providers) is going to be primary care networks, so it seems a relatively logical move. It may also serve to stop the shedding of the huge amount of GP leadership talent that CCGs have uncovered.

This would be a recurrent resource, but the downside would not only be the lack of ownership from practices that this move may generate, but also a reinforcement of an unease held by some GPs that primary care networks are the next iteration of PCGs/PCTs/CCGs.

It will be interesting to see where this ends up. It is important that general practice fights hard against the result defaulting to option 1, which in the end will serve no-one, and put unrealistic pressures on network leaders. I suspect we will find ourselves in some form of amalgam of option 3 (to get things started) and option 4 or 5 – but with the proviso that additional recurrent funds build on and develop whatever was established in the start-up phase to prevent huge backwards steps.

jul

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The Tyranny of Governance

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

There is something difficult, elusive even, about the concept of governance. It should be straightforward. According to the universal fount of all knowledge (Google) the definition of governance is, “the action or manner of governing a state, organisation etc.” Yet somehow in the NHS, governance has drifted into becoming a stick managers wield over clinicians to drive compliance.

Am I overstating it? I am not sure. The first time I really saw evidence of this was when CCGs were first formed. Keen, eager and green, groups of GPs worked together determined to use NHS money to make a difference to local populations. But then these fledgling organisations were subjected to an “authorisation” process, where the focus was on governance and the ability of CCGs to operate as stewards of public money.

Whatever your views on the rights and wrongs of the authorisation process, the result of it was that it sucked the life and spirit out of nearly all of the CCGs. The model constitution, non-executives, multiple committees (etc. etc.) all contrived to create organisations too unwieldy to make any real change happen, to diminish trust between the organisation and its member practices, and to sap any sense of organisational pride or identity.

Last week we published our four step guide for practices working at scale. The real point of this was to encourage practices wanting to work at scale to think about why they wanted to work together and what they wanted to do before getting bogged down in questions of governance.

Don’t get me wrong, governance is important. But it is not more important than having a clear purpose for the at-scale general practice organisation, or more important than working out the guiding principles that will determine how the organisation will operate (its values). It is not more important than building trust between the new at-scale entity and the member practices, or more important than achieving the goals the organisation has set itself. Focussing on these things makes good governance an enabler, rather than governance existing for governance’s sake.

In the days when CCGs were being established, the key cry from practices was that it “did not become like the PCT”. Now the concern from practices about the development of new at-scale general practice entities is that they “don’t become like the CCG”. Yet the pressure “to have good governance” is often forcing some of these newly-emerging organisations down the same route. This is the tyranny of governance.

But things can be different this time. The cycle can be broken. At-scale general practice organisations are not statutory bodies in the same way that CCGs are. They do not have to hold population-based budgets (which will take them down the CCG route), and it is perfectly feasible for them to partner with other organisations (with the required governance) to enable that to happen. They can be whatever the member practices want them to be.

This means there is no ‘right’ model of governance for them. There is no checklist they have to adhere to. Appropriate governance will depend on exactly what it is they are trying to achieve and do.

New at-scale GP organisations have choices. First they must determine why they exist, then decide what they want to do and the way they want to do it, and finally choose what governance they need to enable them to do the things they want to do in the way they want to do them. Governance in its place is an amazing enabler, but out of place can create a fast track to failure.

jul

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Working at scale – the right way to proceed

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Many practices are considering the benefits of working at greater scale. But, from our experience at Ockham, we see so many approaching it from the wrong direction; by considering what form this expansion will take before even reaching agreement on why they are seeking to get bigger. So we have put together a simple and helpful guide on the steps practices should take to help them successfully navigate this journey.

jul

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Do GPs want to work at scale?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

When I was about 5 years old my brother and I became supporters of Liverpool Football Club. No-one told us we had to. Our parents were not football fans. We did not have to sit in a class to learn about Liverpool Football Club, or pass an exam before we could watch them play. No-one forced us to learn the names of all the players, or their shirt numbers, or the endless statistics from the previous decade. We learnt about the club because we were passionate about it which created our energy and enthusiasm to find out as much as we could, whenever we could, and to pester our father constantly to take us to matches.

Whilst not a football fan, my mother was a catholic. So when we were the same age every Sunday she used to make me and my brothers go to church. We never asked to go, and we went because we had to. We didn’t pay attention, got out of going whenever we could, and spent our time when we were there daydreaming about Anfield and whether Liverpool would win when they next played, as well as generally causing trouble. Eventually, we made life so miserable for my mother that she stopped making us go.

Now I am older, things are not much different. I spend my time doing the things I am passionate about and enjoy doing. There are some things I have to do (chores, shopping etc.), but, as my wife will no doubt attest, I do them as quickly as I can (or try and get out of them!) so that I can focus my efforts on the things that matter to me.

My brother is the same. In fact, we all are. We all want to spend time doing the things we want to do and care about, and avoid doing things we are doing because we have to. GPs are no different. Most GPs want to spend their time in the practice, focussing on making a difference to patients and the things that matter, not doing the things they feel they have to do (but hate) like preparing for a CQC inspection, or attending yet another CCG meeting.

For GPs, where does operating at scale fit in to the spectrum, where “doing it because we have to” is at one end, and “doing it because we are passionate about it and the difference it can make” is at the other?

Looking around the country, it varies.

Some GPs are really passionate about operating at scale. They believe it is key to the sustained future of the profession, to ensuring GPs have a strong voice around the system table and to giving them the best chance of making a difference to the lives of their patients. They seemingly work 24 hours a day on making it happen, putting all their spare time into it, and do so with boundless energy.

But many GPs are doing it because they feel they have to. They feel the weight of system pressure pushing them in that direction, and go along with it because even if they recognise there is some logic to it, their heart is in small, independent general practice. Unsurprisingly, they rarely turn up to meetings, they contribute only what they have to, and are often negative and disruptive.

GPs working at scale because they want to, not because they have to, is what will create the energy to make something great happen. It is what already differentiates those really successful examples of working at scale from the rest. Getting the majority of your colleagues to agree to doing something they do not believe in is storing up problems for the future. Jumping into a federation or a network without even knowing why is a mistake, because you won’t invest of yourself in it.

Spend time on why. Spend as much time as it takes to generate energy for a movement, and only then move forward. That investment of time will repay itself multiple times in the future, because it won’t feel like (your equivalent of) going to church, but instead like going to Anfield!

jun

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Is working at scale just a trend?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.

jun

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It is not the model

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I had butterflies. It was my first day at only my second placement on the NHS management training scheme. I followed the directions I had been given off the motorway and into deepest Salford. The area had long rows of terraced houses interspersed with small corner shops. I passed a group of youths gathered on a corner, hoodies raised, and I hoped they would be out of sight before I had to park and get out of the car. I turned the corner and drove into the car park of an incongruously new and modern building, with immaculate red brick walls and gleaming windows.

It was the Willows Primary Care Resource Centre. It was run by Salford Community Trust; my placement was working with the manager of the new centre. I was excited by the new model of care being implemented here. The centre was based in a district of Salford called Weaste. It was (and I suspect still is) a deprived area, and the centre was part of a community regeneration scheme. The plan was for this centre, which was also home to a GP surgery, to host a range of community facilities, voluntary services and resources, and to act as a “one stop shop” to meet the needs of local people.

An interesting range of services were delivered from the centre. There was a community based leg ulcer clinic, who were using a maggot based treatment for wound care. The Citizens’ Advice Bureau held regular drop-in sessions. There were twice a week art therapy sessions. Physiotherapy and speech and language therapy were provided. Plus there were a whole host of other providers; the space was there, and was available to be used by the local voluntary groups who needed it.

Looking back, and this was over 20 years ago, the model was not hugely dissimilar to the primary care home model. It was serving a defined local population where health and social care needs were closely linked, and it was trying to bring a range of different skills and roles together in one place so that all of the needs of the individuals could be met in one place.

But something was missing. At the time it was hard to put my finger on it. I had a sense of it because sometimes we struggled to attract some of the voluntary groups in to use the centre, and I didn’t really understand why. The locals also seemed to steered clear of the place unless they had a specific reason to attend.

Looking back now, the problem was really one of ownership. The GPs were happy with their new building but by and large left the rest of the centre to others. The district nurses had their base there, but didn’t really interact with the other services running from the centre. Co-location wasn’t resulting in joint working, let alone joined-up care for patients.

The incongruity of the shiny newness of the building with its immediate surroundings meant that rather than local community being proud of it, they were wary and mistrustful. In all the time I was there it never felt like it became the vibrant hub I think was initially intended. Nobody really owned the vision for the place, there was no one driving with a passion to change the lives of the local community. So while the original plans were followed and put in place, it never took off or had the impact that once had been imagined.

What that whole experience taught me is that however good the “model” is, however well we design it, however shiny the building we put it in, it won’t work on its own. It is all about implementation. Not PRINCE-style implementation. But implementation that is about people, about partnerships and about passion. Implementation that is about leadership from individuals who care. And it needs GPs, community teams and voluntary groups to share a vision for the future, a picture of what can be achieved, and to find a way of partnering with the local population to make it happen.

There was nothing wrong with the primary care resource centre as a model. It was a good model. Equally, there is nothing wrong with the primary care home model. But the model will only ever be one part of the story. It takes people who care and who are prepared to step forward to turn a good model into something that will make a real difference.

jun

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Evolution is not mandatory

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I recently chaired a panel discussion that was considering the question, “what will the infrastructure of general practice look like in 5 years’ time?”. What was most interesting about the discussion was the debate the panel had as to whether general practice could evolve quickly enough to prevent itself becoming extinct.

I didn’t expect that either. Most of us would agree with the starting point which is that we expect general practice to become bigger in the next 5 years. However, it won’t get significantly bigger. We might make it to the 20-50,000 population primary care home size, but only because that is what one panel member described as the “mentally capable” next step, i.e. the one that isn’t too far away from where we are now to feel doable. Getting to a 300,000 or even 500,000 population size, one where real economies of scale can be achieved and system leadership exerted, feels like a distant dream in most places because it is too far away from where general practice is right now.

As one panel member explained, the reason anything like this can’t happen quickly is because getting practices to work together is hard work, and takes what he describes as “hand-to-hand combat” – tackling one practice at a time. That is why getting universal population coverage at a scale of 20-50,000 is challenging, and why getting to something bigger than that is simply out of reach.

This pace of change may simply not be fast enough. For two reasons: one, the system wants to drive integration at a greater scale faster than general practice can keep up with; and two, the technological disruption we have seen from GP at Hand is likely to only be the start and it remains to be seen whether general practice in its current form can survive it.

One panel threw in the example of dinosaurs, as a telling reminder that “evolution is not mandatory”. As another said, “all innovation is a generational war, and we know who wins that one…”

Which all then led to an existential discussion about the value that general practice adds. Do we really know what it is? One GP panel member stated he is not clear which patients he adds the most value to – the data simply is not there. The starting point for general practice to move into the future is to prove the difference it makes to people, and then to do more of that.

If the primary role of general practice is the place we take our symptoms to find out what is wrong with us, won’t that at some point in the (near) future get replaced by technology? If it is to act as a gatekeeper to the rest of the system will that role continue to be accepted by the coming generations who demand instant access to everything?

In a 2015 article in the NEJM, Martin Marshall argued that in the future general practice, “will have to get the support they need to continue to provide person-centred care and to deal with the complex and delicate balance among an individual’s health, illness (the perception that something is wrong), and disease (a confirmed diagnosis). General practices will have to facilitate the increasingly important interface between people’s management of their own health and the care that is delivered in partnership with, or by, health care professionals. And they will have to find ways to negotiate the complex trade-offs among the sometimes conflicting expectations and needs of individuals, populations, and taxpayers, whose continuing support for a publicly funded health system is essential for its survival.” N Engl J Med 2015; 372:893-897

I think the point the panel were making is that if general practice develops further as a place that is about compromise, about trade-offs, about individuals not getting the care they really want or need at the time they really want or need it, then extinction of general practice in its current form is a real possibility. Instead, key to the future is understanding, demonstrating and then developing the part of general practice that is genuinely value adding to individuals, their families and their local communities.

You can listen to part 1 of the panel’s discussion here. Part two will be published here on Monday 18^th June.

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Why the review of the GP partnership model makes me nervous

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The only thing making me less nervous about the review is the appointment of Dr Nigel Watson, Chair of Wessex LMC to lead it. He appears to be a supporter of the partnership model. He recently said,

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Practical advice for moving ahead in the new environment

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Even the most successful people and organisations can be caught out when the world around them changes. For Ben Gowland this was brought home by his personal transition from Chief Executive of a small successful federation employing 20 people to a large Clinical Commissioning Group employing over 200. He quickly discovered that the behaviours and approaches that had made him successful no longer worked in the new world. This week, in a “talking blog” he uses this revelation and his years of working with challenged general practices to advise how general practice can move forward in the new environment. Watch his presentation below (you’ll need your sound turned “on”):

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A new paradigm for general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The world has changed for general practice. A new, more challenging external environment means the behaviours that have been successful in the past no longer work. A new paradigm is required. New behaviours are needed for general practice to thrive in the new environment.

may

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Who is to blame for the current crisis in general practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Who is to blame for the current crisis in general practice? NHS England? The government? Jeremy Hunt? Workforce planners? The bankers because of what happened in 2008? Millennials, because of their demand for instant-everything? Somebody else?

Whose job is it to sort out the crisis that general practice is in? Is it the same people whose fault the crisis is in the first place? Or is it Simon Stevens, NHS England, Jeremy Hunt, the government, or maybe even the BMA and the national general practice organisations?

These will not be unfamiliar questions for GPs. The injustice of the current situation pushes them into almost constant consideration. But focussing on them does not help individual GPs and practices find a way through the challenges they have to contend with on a day to day basis.

I am sure many readers will have at some point come across Stephen Covey’s book, “The Seven Habits of Highly Effective People”, first published in 1989 with over 25 million copies sold. Within the very first habit that Covey identifies of very successful people (“be proactive”), he introduces the Circle of Concern and the Circle of Influence.

The Circle of Concern contains all those things we focus our energy and efforts on over which we have little or no control, such as the weather, Iran’s nuclear programme, or national debt. For GPs it includes working out who to blame for the crisis afflicting the profession, and considering how much of the soon to be announced additional NHS funding will make it to front line general practice.

The Circle of Influence contains all of those things that we can directly control or influence, such as our actions, our behaviours, our family and our colleagues. For GPs this includes their own individual practice.

The habit successful people have, according to Covey, is focussing their energy and effort in the Circle of Influence where they can make a difference, and not wasting it in the Circle of Concern over which they have little or no influence.

I see this difference regularly in GP practices. The factors causing the crisis are outside of the control of practices. The local response to them, however, is within their control. Some GPs and practices focus their energy on the former, and some on the latter.

The barrier that stops many GPs focussing on the Circle of Influence and the changes they can make is this question of who is to blame for the challenges the practice faces, and whose job it is to sort it out. If it is not my fault, and I am essentially a victim of a system failure, why should I be the one who has to sort it out? Letting go of the unfairness of the situation is far easier said than done.

But the practices who are thriving and doing best in the current environment are those focusing their energy within their Circle of Influence; the ones who are looking at how their own behaviours and actions and relationships can influence and change the current situation for the better. They have not waited to react to changes that others will make at a national or policy level, but have taken things into their own hands.

I recently visited Thistlemoor Medical Centre in Peterborough. The majority of their local population do not have English as a first language, and recruiting GPs has been a longstanding problem. But they have focussed on what they can control, and have created a really innovative model so that instead of relying on Language Line they have trained HCAs recruited from the local community to both interpret and take work off the GPs (you can find out more about their model in an upcoming episode of the General Practice Podcast). The practice is thriving and continues to grow at well over 1,000 patients a year.

In Plymouth three practices merged in 2014 to form Beacon Medical Group, and they created a new multidisciplinary team to manage the on-the-day demand. Since then, in the midst of a really challenging local environment, the practice has grown and continued to prosper.

These are just a couple of examples, and there are many across the country. What they have in common is that local GPs focussed on what they could control not what they could not, and took action. They did not waste their energy assigning blame or hoping for national solutions, but instead channelled their efforts within their own Circle of Influence to change the direction in which they were heading.

Thinking about who is to blame for the crisis in general practice is considering the wrong question. It is operating in the wrong circle. The real question to consider is what can I do, what can I influence, to create a vibrant and positive future for my practice, and to focus all my energy and efforts there.

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The impact of the new models of care on general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“Remind me what they are again” the GP responded. I was asking what his thoughts were on the new models of care. I jogged his memory with a few choice acronyms (MCP, PACS, PCH etc). “Oh those. Hard to say really…”. He trailed off, interest clearly waning, and then visibly winced as he saw the message on his screen indicating the number of patients waiting to be seen.

The concept of new models of care has not really taken off as a driving force for change in general practice since they were first proposed in the five year forward view (5YFV) in 2014. Certainly not within the specific frameworks outlined within that document. Frankly, general practice has been too busy. But some of the principles underpinning the models can be seen in some of the recent developments in general practice.

The relative isolation of GP practices has changed more in the last few years than at any point in its history. Practices are far more prepared to work with each other. We have seen mergers, super-practices, federations and networks proliferate. Practices are also more willing to work with other health and social care organisations, in particular those from community and voluntary sectors. A team based approach is both building resilience and creating a more attractive proposition for incoming staff.

Practices are also far more open to reviewing their governance model. The pressure the partnership model places on individual GP partners has led many to explore other options. There has not been a wholesale move away from the GP core contract in the way that maybe some envisaged when the 5YFV was published, but the desire to retain the “independent contractor” status is no longer as strong as it once was. We may well have only seen the beginnings of the rise of at-scale general practice entities like Modality, Our Health Partnership and Lakeside, as well as acute/primary care collaborations like those in Wolverhampton and Yeovil.

General practice has also shown signs of wanting to tackle the wider determinants of health, rather than simply meeting the ever-increasing presentations of health concerns. There is a dawning realisation that something has to be done to tackle the drivers of demand growth. This sits under much of the primary care home movement, and places like Fleetwood are leading the way in taking this on.

These changes have been framed far more by the challenges the profession is experiencing than by the 5YFV. If I had asked my GP colleague about the impact of the pressures on general practice in recent years, rather than about the new models of care, he would have been much more forthcoming.

But moving away from crisis can only be half a story. We know what we are moving away from, but where are we going? What will be the impact of the new models of care going forward? Do they offer a destination for the journey on which many have already embarked?

The emergence of STPs is the current manifestation of the 5YFV implementation. There is something of a battle around size within STPs, when it comes to integrated care systems. Is the local model to be built around primary care home sized units of 30-50,000 as the focal point of change efforts, driving improvements to health as well as health care in local communities? Or is it to be driven at STP level or acute hospital sized units, with primary care homes operating as sub-localities of sub-localities, languishing at the bottom of the health ecosystem? In many places both are still possibilities, but the window of influence isn’t going to stay open for long.

Much of this depends on voice. There is a challenge for general practice to create a coherent and cohesive voice for general practice as a provider within the STP arena. Some places (like Manchester) have worked hard to create this, but for others the primary care seat is still empty. Without a voice, let alone a unified one, it is hard to see the impact of the new models being a positive influence on the future of general practice, despite the opportunity they represent.

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Why is the GP Forward View not working?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

It is now two years since the publication of the GP Forward View (GPFV). Do things feel any better? Not for most GPs. In a recent Pulse survey 80% reported their workload had worsened over the last two years. So why has the promised £2.4bn recurrent investment, with all the trimmings alongside, failed to have any impact so far?

Looking back, I wonder what the GPFV was. Was it a strategy document? Not really, because there was no clear sense of direction. A recovery document for a service in crisis? Maybe, although it was written at arm’s length from GPs as providers. I think it was a commissioning plan, or commissioning intentions at a stretch. It was what NHS England, and the CCGs, would do to support a service in crisis. It was also a public, political document designed to demonstrate the concerns of GPs had been heard and were being addressed.

Understanding what the document was gives an insight into why it is not working. The headline investment figure of £2.4bn was an overstated figure. The real five-year investment plan was under £1bn. But the figures were extrapolated back to 2013 (the details are here) to inflate the figure to £2.4bn. Promising more than is going to be delivered is a sure-fire recipe for underwhelming results.

A cynical view of the document is that it was also a very clever way of packaging the extended access agenda to make it palatable to GPs, at a time when many were close to breaking point. While the share of funding for general practice within overall NHS expenditure has not really changed, the challenges of GP recruitment have not been addressed, and workload continues to rise, the one clear “success” of the document is that extended GP access is being introduced across the country. Ask any CCG which of the targets in the GPFV they are most closely monitored on and they will tell you it has been all about access. While the problems in general practice have not been alleviated, the government’s primary agenda for the service is being delivered.

There are some good things in the GPFV. The Releasing Time for Care programme and the work of Robert Varnum on the 10 high impact actions, which I admit I was initially sceptical about, I now think is possibly the most impactful part of the document. Practices changing themselves is the only realistic way out of the crisis, and this programme empowers and enables practices to do this. The support for indemnity looks like it is heading in the right direction, and the funding for new roles such as pharmacists has definitely helped.

But the reality is the workforce crisis persists (1,300 full time equivalent GPs left between September 2015 and September 2017), the workload continues to grow, the capital investment through the elusive ETTF simply has not materialised, and funding remains insufficient. Worse, the rhetoric around the GPFV has put general practice to the back of the queue when further funding is announced, e.g. the chancellor’s pledge of an additional £2.8bn to the NHS at the last budget had nothing earmarked for general practice.

Our collective failure to understand what the GPFV as a document was means we are now left without a clear plan or sense of direction for general practice. We initially thought (wrongly) the GPFV provided this, but what it needed (and what it still needs) is a provider led response to say this is how we will use the commissioner promises made in the GPFV to deliver a new future for general practice, and this is what it will look like. There are enough green shoots out there (the primary care home, the great work of NHS Collaborate, and the 108 episodes of the GP podcast are all testament to that) for this to be possible. But without it, either at a local or a national level, I fear the situation will be worse in 2021 than it was when the GPFV was published.

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The Millennial Opportunity for General Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

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Technology: Opportunity or Threat for General Practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The world is changing. We know it. We read books on a Kindle, download films, order just about everything online. Everyone has, and is permanently attached to, a smartphone. The NHS and healthcare has so far remained relatively unscathed, unlike many other industries. But that is starting to change. What will the impact of technology be on general practice?

A number of new reports have come out recently, heralding the changes. One of these, The Promise of Healthtech by Public, describes the rising impact of digital innovators and technology on healthcare.

The report identifies 9 trends where there is significant growth in technological innovation, the areas the report describes as “low hanging fruit”: procurement and productivity; recruitment and training; prevention; winter pressures and supported self-care; Artificial Intelligence (AI) in pathology and radiology; patient safety; mental health; social care; and research. It then maps the growing number of tech start-ups against each of these trends

You may think the report is overstating the pace of change, in its desire to encourage more tech start-ups to follow suit. But I don’t think so, because at the same time the big technology firms, like Apple, Amazon, Google and Facebook, are all moving into healthcare. According to this article published in March in Vox, “The most proven, forward-thinking, and, dare I say, disruptive companies in our country have decided health care should be their next big move.” So whether it is the healthcare equivalent of Uber or Fitbit, or one (or more) of the more established tech companies, the current (relative) status quo is not going to last long.

Early stirrings are starting to have tremors through primary care. The GP at Hand service led to (mainly young) patients deregistering from their practice to sign up in London. Echo enables online ordering and delivery of prescriptions.

The Public report identifies numerous barriers that have slowed the introduction of technology: lack of clarity about the evidence; fast evolving regulation of digital health products; slow procurement; partial interoperability; unclear data security standards; and limited change management and digital skills. A quick reflection on the reaction to the introduction of GP at Hand within general practice and the size of these barriers becomes apparent.

I don’t think, however, these barriers will stop the tide of digital health development (disruption?) from coming in. Instead, overcoming them may well be the catalyst for greater and quicker advances. The use of blockchain looks set to empower individuals to control their own clinical records, as it can guarantee single ownership without requiring a central trusted authority, which in turn will start to shift power from the NHS as an institution into the hands of patients. The benefits of bringing together health and social media data, of enabling professional and community resources to interact effectively, is at the heart of the argument that is persuading Facebook to enter the health space.

General practice, sitting at the cusp between individuals managing their own health and accessing healthcare when they need it, is ripe for technological disruption. A recent Harvard Business Review article entitled, Virtual Healthcare Could Save the US Billions Each Year outlined it was changes to primary care that could deliver these savings. It says, “Without expanding the primary care workforce, virtual health technologies can augment human activity, expand clinical capacity, and improve efficiency by ushering in a new health care model where machines and patients join doctors in the care delivery team.”

The independent contractor status of general practice means the barriers to entry are not as great as those that exist in the statutory NHS sector. Changes can happen rapidly in a small area and grow, without the need for national decision making. General practice has always prided itself on its ability to respond and act quickly.

The crisis engulfing general practice means the willingness to take risks is much higher than ever before. The incentive for a hospital within the NHS to take a risk on a new “carebnb” discharge option is simply not as great (given the potential for backlash) as for a practice facing financial hardship to try something new, however controversial.

Technology can help general practice become more efficient, but more importantly it can enable much stronger links between practices, their patients, and their local community. Shifting the demand curve is key to general practice emerging from its current predicament. The Public report, describing the trend for the development of technology in the area of prevention, states, “the need for digital solutions for wellness, supported self-care for patients with chronic conditions, AI driven behaviour change models and personalized patient education solutions is only going to increase.”

There is now an opportunity for general practice, given its current crisis, to reinvent itself as the supporter of communities and individuals to actively manage their own health, to act as a guide through the new environment as it evolves, and in doing so to make its own workload more manageable. The paternalistic “gatekeeper” role is unlikely to survive the changes that are coming, but the need for the expert generalist to empower, encourage and enable individuals and their decision making will be greater than ever.

The threat technological innovation presents is to the existing model of general practice. But given it is widely accepted that the current model of general practice is no longer sustainable, and in the absence of any meaningful investment in general practice, the opportunity technological innovation provides for general practice to reinvent itself seems to far outweigh the threat.

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Book Review – Perspectives by Judith Harvey

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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I am a Consumer of Health, and Why this Matters

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Are patients consumers? It is a question that has vexed those trying to introduce a market into healthcare for many years, and I think it is fair to say the consensus view is captured in Dr Jordan Shlain’s article, “There are no consumers in healthcare, get over it”.

He summarises that this is a consumer:

They have freedom to make choices based on their resources and their numerous options
They can decide not to make a choice
They add something to their lives (material or experience) after a purchase
They have a trust psychology based on being excited, not anxious
Consumers get immediate or near immediate benefit from their purchase

And this is a patient:

They often do not have freedom to make a choice and the options are limited
They must make a choice
They are trying to get rid of something (pain, nausea) and have no idea of the cost
They have a psychology based on anxiety
Patients often have no line of sight into whether they get a benefit or not

According to Wikipedia, a patient is “any recipient of health care services”. But how does prevention fit in to this? If a GP surgery undertakes preventative activity with its local population, is it doing that with them as patients or as consumers? When I as an individual decide to go for a run to improve my health, am I a patient or a consumer?

Let’s apply Dr Shlain’s criteria for consumers to my choice to go for a run:

I can choose whether or not I go for a run
I can decide to stay at home watching TV on the sofa instead
I feel more healthy (as well as slightly smug and self-satisfied) after I have been on a run
I am excited to lose weight, improve my fitness, and to (feel like I) look better
I feel great as soon as I have completed my run. My phone tells me how far I have run, at what speed, and how long it took. I can share it on social media and gain feedback from my own network.

So while there may not be consumers in healthcare, there are certainly consumers of health. Why does this distinction matter? It matters for two reason. First, if general practice is serious about changing the pattern of demand, of shifting the focus from healthcare for the sick to wellness for all (as described by Dr Amit Bhargava in our recent podcast), then the nature of the interactions need to be consumer-focussed rather than patient-focussed. We will need something very different from our current system of patient participation groups, something more along the lines of the “Beat the Street” initiative described by Dr William Bird.

Second, the big technology companies (e.g. Amazon, Apple etc) already understand that individuals are consumers of health. Their moves into healthcare are predicated on being able to reduce total expenditure by empowering individuals to manage their own health.

“Apple, Google, and Amazon are trying to lower the cost of health care for their employees by steering them toward outpatient clinics and wellness programs that they own or control…There is a potential convergence going on now. Electronic medical records, mobile phones, and wearables have achieved widespread adoption, creating new opportunities.”

Technology can make a real difference to us as consumers of health. But the opportunities for Apple, Amazon and Google are also opportunities for general practice. The risk is if general practice does not take them, it might be superseded by the technology companies who do.

Dr Shlain may be right that there are no consumers of healthcare, but there are consumers of health. The aging population and the rapid advancement of technology mean this distinction is more important than ever before, and its impact upon primary care is likely to be huge.

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What does GP at Hand mean for General Practice?

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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.

mar

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Where is general practice going?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We all know what general practice is trying to move away from (a crisis), but where is it going?

Anger, irritation, fear, or frustration with the current situation can be a great motivator to get change started, and provide an initial impetus to motivate a practice to take action. But if your only motivation is ‘away-from’ the current crisis, then your attention is consistently drawn to the negatives in your experience, filtering out the positives in the process.

It is also not sufficient motivation for sustainable change. For example, if a GP’s goal is ‘not to be in crisis’ (by their own definition of the term), then they have achieved this goal when they reach the level they decree to mean ‘not being in crisis’. They then lose a significant portion of their motivation so run the risk of dropping back down to a point at which they become motivated by their ‘moving away from being in crisis’ goal again. ‘Moving away-from’ goals produce inconsistent motivation levels which are rarely satisfying at any stage.

Sustainable change requires an element of ‘towards’ motivation as well; a vision of where you want to get to. Creating a vision based on aspirations and positivity and not on barriers or avoidance is both empowering and inspiring.

Where is the vision for the future of general practice? I don’t think it really exists. The GP Forward View seems to be more a public acknowledgement of the challenges general practice is facing while ploughing on with extending access, rather than the development of an inspiring picture of what is to come. So here at Ockham Healthcare (with help from whoever will give it!) we aim to put that right. We want to help build excitement and anticipation about the future of general practice, and to shift the focus from the crisis around and behind us, to an inspiring and attractive future ahead.

To kick this off we are holding a series of interactive sessions with some of the leading thinkers and practitioners in general practice. We are exploring with them some of the key changes they believe will impact the future of general practice. We will distil the key lessons, and capture the learning as a resource to enable GPs and practices to prepare for what lies ahead.

We are going to consider four questions:

How will technology shape the future of general practice?
What will the infrastructure of general practice look like in 5 years’ time?
How will the new models of care change general practice?
What do GPs (of the future) want?

We recently held the first of these panels, to discuss the technology question. You can listen to the first part of the discussion here. We will publish the second part in a few weeks’ time.

What is already clear from our first panel is there are huge changes on the horizon. There is an opportunity for general practice to embrace these changes and use them to create a future that will enable a greater focus on prevention, on building patient ownership and control of their health and their illness, on a new partnership between doctors and patients, and on new treatment opportunities (e.g. the use of virtual reality in pain management).

Finding a way out of crisis is not a plan for general practice. It is the start of the journey, but to ensure it doesn’t peter out there needs to be a vision, a future, a picture of what it will be like. Our aim, starting with these panels, is to help paint that picture.

mar

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The days of CCG Locality Groups are numbered

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“But we are a membership organisation!” the newly appointed GP Chair exclaimed. “Member practices have to have a voice. We need localities to ensure each GP practice is represented in the decision making of the CCG. Each locality needs its own GP leader, the support of a locality manager and we must pay for the time of a representative from each practice to attend locality meetings”.

The Finance Director looked sceptical. He could see the £25 per patient management costs rapidly disappearing into these localities. “But where is the return on investment?” he countered. “If we fund all of that, the costs of five localities could be nearly half a million pounds a year!”

“This is what will make CCGs different to PCTs” hissed the GP Chair. “PCTs had no route into the voice of GPs and GP practices. These localities will be the engine for clinically-led change and redesign, they will ensure we connect commissioning policies to change on the ground, and make sure we can put the decisions we make as a Board into practice. Without them, we won’t deliver anything.”

And so it was that locality groups started off in many CCGs as the great hope for the future, as the symbol of what could be different. But, as is the way of the NHS, the local freedom promised to CCGs did not materialise, and the voice of localities was overtaken by directives from NHS England, the pressures of the 4 hour target, and the need for centralised financial control. Locality GP Chair roles on CCG Governing Bodies were replaced by clinical lead roles for urgent care and planned care and the like. Localities have continued, GP Locality Chairs are still in place, some even have managers, and practices are still paid to attend meetings, but more often than not these meetings now consist of a one way flow of traffic where teams from the CCG present the latest clinical pathway, referral guidance or QIPP plan to the GPs.

What hasn’t changed are the questions from the CCG finance director as to the return on investment of the locality funding. Now the embattled GP Chair simply knows removing it would be just one step too far in trying to maintain any sense of support from member practices.

So what is next for CCG locality groups? As STPs develop, and the system moves to the introduction of integrated care, it is becoming increasingly unclear what is the responsibility of the local GP federation (as a provider, and the “provider partner” within the developing integrated care system) and what is the responsibility of the CCG locality.

There will come a time when all of the functions of the CCG locality – input into clinical pathways, liaison with practices, redesign of services, representing practices in system discussions – will fall to the GP federation, as power shifts from the old system to the new, from commissioners to partnerships of providers. For now, we are in a transition period between the two.

But a transition period is problematic. Already overstretched GPs cannot be in two places at once. Do we want practices to spend the limited time resource they have on existing commissioning localities or on establishing a strong GP provider voice for the future? Realistically we can’t expect them to do both, and doing so simply limits the capacity to do either. The funding we have invested in the localities is no longer in the right place, and would be better situated within the developing federations.

The extent to which CCGs and general practice accelerate this transition may determine the strength and influence of the GP voice in the new system. Because GPs do not have the capacity for double running in a transition period, it is now time to accept the end of the locality within a CCG and to create a new future for them, and maybe allow them to fulfil their initial promise, within (or even as) GP federations.

feb

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Who Represents Your Practice in Integrated Care?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

What is Integrated Care?

“Integrated care” is the term used to describe provider organisations in the NHS working together to improve care for patients. The ambition of the NHS, as described in the Five Year Forward View, is to move away from a system of care organised via contracts between providers and commissioners, towards one in which groups of providers are given the budget to work together to deliver outcomes for a local population.

Why is it important for GP practices?

Within an integrated care system GP practices will have stronger relationships with local community services teams, social care, the voluntary sector and even the local hospital. It will also change the way that GP practices receive (some of) their money. Whilst the core contract will remain nationally negotiated and paid directly to practices, other income streams such as enhanced services will ultimately come via the new provider partnership (or integrated care “system” or “partnership”).

When will this happen?

There is no national timetable for the changes, as there has been no new legislation to dictate it. Each area is implementing changes in line with their local STP (Sustainability and Transformation Plan). Eight areas nationally are acting as pilot systems to “fast track” the introduction of the new system.

The changes have, however, already started, primarily through a push for practices to work together in populations of 30-50,000. This is evident in the procurement of extended access for general practice, and CCGs have been explicitly asked to “encourage” practices to work together at this scale.

What will integrated care look like locally?

There is no blueprint for what integrated care will look like. The lack of legislation means there is freedom for each area to determine this for itself. We are currently in the critical period where each area is deciding and agreeing how integrated care will develop locally. Providers and commissioners are meeting together to work this out, in meetings with a range of titles but that generally include the terms STP or Accountable Care System/Partnership or Integrated Care System/Partnership.

How is my practice represented in these discussions about integrated care?

This is an important question. I carried out a quick poll on twitter to find out. The results are below:

Who represents your GP practice in discussions about integrated care? #generalpractice #primarycare

— Ben Gowland (@BenXGowland) February 26, 2018

It is not surprising that practices do not think they are represented by their CCG or LMC. CCGs cannot represent practices, as they are a commissioning body that exists to represent their local population not their practices. LMCs have traditionally been the representatives of general practice. The challenge for LMCs is convincing the other providers they are there as a genuine partner rather than trade union. Integrated care is about building partnerships between providers, not negotiating terms. Some LMCs have stepped up into the role (Tracey Vell in Manchester is the obvious example) but many are simply not able to.

This essentially leaves federations (where they exist) to represent their practices, unless practices are of a size (so called “super practices”) to represent themselves. Some federations have been reluctant to take this on, because their relationship with their members is not one where they feel they can speak on their behalf. Some areas have not included GP federations in the meetings about integrated care. Whatever the reason, the absence of a federation around the table means that many GP practices are not currently represented in these important discussions.

What happens if no one represents me?

There are (at least) two consequences of practices not being represented in discussions about integrated care. The first is that general practice, as the provider of by far the largest number of patient contacts, has no voice in determining what the local integrated care system will end up looking like. The second is that acute trusts, community trusts and other large provider organisations will have the greatest influence on how care is organised and how local funds are allocated between providers in the future.

Why is no one asking how I want to be represented?

The representation of general practice is difficult because of the large number of practices, and because it is not a contract negotiation but a building of relationships between providers. It falls to general practice to organise itself so that it can be represented effectively and build relationships with the rest of the system. There is no incentive for other providers to take on this responsibility for general practice. Tracey Vell talks about how she had to fight to secure a place for general practice around the top table making these decisions in Manchester.

How can I ensure I am represented?

Practices need to do two things:

Establish who (if anyone) is representing you in local integrated care discussions. If it is no one, agree with the other local practices who should be representing you, and then push for this to happen.

Create an explicit agreement with this organisation to establish what they can and cannot agree on your behalf, and what requires further discussion and debate with you directly. Don’t make their job representing you impossible, and ensure they have a strong mandate so they can have a powerful voice with the other providers around the integrated care table. Agree the feedback and communication mechanisms to be put in place between the discussions and the practices, and review them regularly.

Who represents your practice in integrated care?

In summary, it is of critical importance for the future that general practice is represented, and represented well, in the local discussions that are taking place now about integrated care and how the future system will be organised. It is up to each practice to ensure they are being represented, and for practices to work together to empower and enable those representing them to present a strong and unified voice. For federations it is vital they establish a mandate from their member practices to undertake this role on their behalf.

feb

0 1

What is a Primary Care Network?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

feb

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Guest Blog – My GP by Sarah Smizz

Posted by IanBlogs, The General Practice BlogNo Comments

The following Blog was previously published by Sarah in a series of tweets (@smizz) and is published here with her kind permission. Thanks Sarah!

Ah, my GP is flipping amazing. I can’t explain how good it really is to have someone who knows you & your medical conditions & what matters – someone who just, like, knows this without ever looking back at the records. Someone who sees a longer & bigger picture.

Sometimes we have disagreements on what the longer picture looks like. In the beginning we’d argue. But he was the only GP at the time who decided to take responsibility for me. Most let me jump from GP to GP. But after every test he’d say, “you do this & you come back to me”

I didn’t know at the time the benefits of having continuous care. I was young & impatient. But now I really get it. Today he instantly knew I had an infection (cuz he knows what my normal is), he prescribed me more stuff cuz of a previous diagnosis to help with current sickness

I whined about my leg being numb esp when I run around 5K & how I wanna run half a marathon & I can’t get past 10K (which is still a HUGE mile marker for me). I said all of my friends can run a (half) marathon & I can’t! & he was like:

“Not all of your friends Sarah. I can’t run a half marathon & I’m your friend.” It sounds proper Cheesy to write but also it felt really genuine.

He asked me about PhD work, what Prague & Japan was like. He told me about a beautiful Japanese animation he watched the other night on Amazon Prime. Even Googled it. I gave him Japanese weird tasting Kit-Kats & he seemed pretty made-up by my gesture.

Then I went on my way, not before he gave me his wise-words full of living life & selfcare wisdom as I went to leave. Dude has his moments as a proper philosophical guru. Then of course, he made sure – as per – that I come back to him to check-in in a few weeks.

GP’s will NEVER be replaced esp by apps. And we need to make sure we take care of them, as they take care of us because they’re the backbone of the NHS and the community. And my GP turns out to also hold me up when I feel like I’m falling down. I know they do this for everyone.

feb

2 1

What the 2018/19 NHS Planning Guidance Means for General Practice

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

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!

jan

0 1

Funding Federations – The Accountable Care Conundrum

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

You will need to bear with me this week as I try and explain why the funding of GP federations is a critical issue for emerging accountable care systems, because moving to a new non-legislated system is (unsurprisingly) complicated.

Let’s start at the beginning. The principle behind accountable care is one of providers working in partnership with each other to redesign services to improve outcomes. By the way, if “accountable care” does become “integrated care” (or some such) in the next few months, it won’t change anything other than introduce a new set of terms for exactly the same thing – it is simply the price (in my view acceptable) we have to pay for non-legislated reform.

For accountable care to work, one of these providers has to be general practice. In an accountable care system/partnership/organisation (delete as locally appropriate) general practice needs to work in partnership with other local providers. The whole concept builds on the registered list of general practice, and of providing services that are joined together and tailored to meet local needs.

But there are lots of GP practices. Too many for local providers to all build a relationship with each of them individually. As a result, someone has to act on behalf of practices. Partnership between general practice and the rest of the system can’t work without this.

Who, then, should take on this role for practices? Well it can’t be the CCG because they have been established to represent the needs of their local population, not of GP practices as providers. LMCs? The main problem here is that practices need someone to partner on their behalf with the rest of the system. While LMCs are good at representing and articulating the needs of practices, partnership has not historically been a strength. They are also often perceived more as a trade union by other NHS providers. So while in theory LMCs are an option, the reality is without exceptional leadership they are not. Which leaves GP federations (in the absence of a local super-practice) as the best vehicle to enable general practice and the rest of the system to partner with each other.

GP federations are experiencing something of a resurgence at present, as practices seek to gain the benefits of working at scale without formally merging. But one of their challenges, as anyone working within a developing federation will know, is that they don’t have any money. The delivery of some services will create a small margin, but this is rarely enough to fund enough more than a skeleton management team.

Here we (at last) come to the crux of the problem. The system needs GP federations to ensure general practice are part of the provider partnership that underpins accountable care. But partnership working and the building of effective relationships takes time, which someone has to pay for. For GP federations the task is doubly difficult, because at the same time as creating new relationships they have to ensure they have a mandate from their practices and keep them on board with any agreements they make. How can the leaders of GP federations find time for this? Should they do it out of goodwill, and effectively pay for it out of their own pocket by giving their time for free? Should the host practices of the emergent GP leaders bear the cost? Or do we expect the member practices of the federation to contribute the ongoing cost of federation leaders both attending system wide meetings and reporting back to them as the accountable care model develops?

None of these are realistic. So the conundrum is how can federations and those representing general practice be funded to ensure that accountable care systems develop to include general practice?

Answers on a postcard. If this conundrum has been solved in your area I would love to hear how. Email me at ben@ockham.healthcare. Next week I will share the responses (if there are any!) and attempt to consider what mechanisms might be available to find a way through this thorny issue.

jan

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What does “being resilient” mean?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The letter I had been waiting for dropped through the letterbox. I had been an “A” student right through school, and my sights were now firmly set on Oxford University. The interviews had been hard to read, but seemed to go ok. I opened the letter. “Thank you for applying to Oxford. After careful consideration it has not been possible to offer you a place”.

I didn’t take it very well. Maybe we are less resilient when we are younger. My (somewhat sulky) response was to decide university wasn’t for me, and I headed off to do voluntary work (“something that mattered!”) instead.

A key part of resilience is described by Bruce Cryer and his colleagues at HeartMath as “releasing the emotional grip” that stress has on us. In their 2003 Harvard Business Review article they describe how to do this, essentially by using techniques to accept the current situation and to develop a new perspective centred on what actions you can take to change the situation.

It took me a long time to do this. After my rejection, I actually did well in my A-Levels, but the following year refused to apply to Oxford again on principle (the principle of, “if they don’t want me, I don’t want them”). I was hanging on to the pain of rejection instead of thinking positively about the future.

Changing our own mindset that things need to and can be different is at the heart of resilience. I think this is the hardest part. In the end, I was sat down by an individual who had become something of a mentor to me. He laid out some different options of what my future might look like. One involved going to Oxford. It did look like the most attractive path… Something seemed to click inside me. It might have taken 18 months(!), but finally I could accept it was me who hadn’t been ready for Oxford (and not vice versa) and I decided to swallow my pride and reapply.

While tenacity and perseverance are key parts of resilience, it is adaptability, and the ability to change mindset, that are more important. Blockbuster Video, Borders Books, Kodak (and many others) kept going for as long as they could when things were tough, but they did not adapt to the new world and the changed environment around them, and ultimately were not able to survive.

I recently had a conversation with Dr Mike Holmes, the newly elected vice chair of the RCGP, about resilience and the importance of it for GPs right now. In echoes of the HBR article, he identified three elements to GP resilience: pragmatic optimism; making do with what you have while making things better; and allowing yourself to think differently.

There are opportunities and new ways of working that can help general practice. Mike Holmes outlined some of these in our conversation. The hard bit for many GPs, as for anyone in a difficult situation, is letting go of the unfairness of what is happening and shifting into the “pragmatic optimism” that Mike describes.

Some GPs and practices have not yet been able to make this shift in mindset. Some will never make it. My life was probably changed forever (with a lot of help!) by shifting my focus from unhappiness with my rejection, to taking action to remedy it. I was accepted into Oxford at the second time of asking. Changing the direction of our lives starts with ourselves, with us releasing the emotional grip our current circumstances have on us, and changing our focus from causes and blame to our response and what we can do about it. This is being resilient.

jan

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Is General Practice Responsible for the pressures in A&E?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Well what do you think? Is it? It may well depend who you are. If you are a GP you are unlikely to think so, but as a hospital Chief Executive, who has heard all about the workload and workforce pressures general practice is under, it is easy to draw the alternative conclusion.

But correlation, as my PhD wife constantly reminds me, is not the same as causation. The fact that general practice is struggling with workload pressure at the same time as there is rising demand in A&E only means the two are correlated. It doesn’t necessarily mean one causes the other. And so it is that research was published this week in the British Journal of General Practice looking at the factors affecting emergency department attendance. They found (drum roll),

“…the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.”

In other words, people are living longer with more long term conditions. This in turn is causing the growth in demand, both for GP practices and A&E departments. The more GP consultations a person has, the more likely (for many groups) it is that they will also have more A&E attendances. Growing demand is the causative factor. Pressure on A&E departments and GP practices are simply correlated.

I am on Twitter (@BenXGowland – the X is actually my middle initial, as opposed to denoting membership of some secret society). You should be too. The GP I most enjoy following on Twitter is Dr Steve Kell (@SteveKellGP). He recently ran a survey (now I recognise I need to be careful here as having preached about the difference between correlation and causation, I know I am going to get stung on the validity of a small sample size, but nevertheless) which found that, of the 48(!) GP practices that responded, 81% had not been asked if they were busy or managing in the first week of the New Year, with only 19% saying that they had. Steve’s concern is that “sadly we value what we measure”.

But simply knowing that a problem exists (there is too much demand, and it is getting worse) does not actually help. Nor does finding someone to blame (whether it is GPs blaming hospitals, or vice versa, or the government, or Jeremy Hunt etc etc). The only real option is to work out what we can do about it (because even if there was more money, which there isn’t, there will never be enough).

Which brings me to another interesting exchange on Twitter involving my friend Dr Kell. His practice is a leading light in the Primary Care Home movement, and he announced on Twitter that his practice had achieved a (highly impressive) 5.5% year on year reduction in emergency admissions. Now that prompted a question in response from Professor Harris of Lakeside Health asking,

“where lies the incentive (other than patient benefit) of GPs working harder/differently/more productively if the £ benefits remain with trusts or CCGs?”

The essence of this question is what is the point of the primary care home, of groups of practices working with other agencies, and managing demand in a different way in the way that Dr Kell’s practice has, if there is no financial return for the practice? His response was that while there is no direct financial return, it makes things better for patients, for staff, and is more efficient.

If we think about this in the context of constantly rising demand, the challenge practices face is how to adapt to meet this demand in different ways. Not because there is a direct and immediate financial benefit, but because the current system is not working, and without change the system is likely to collapse. Everyone working in the system has a responsibility to understand and accept the current realities, and to think and act differently as a result, so that things can improve.

General practice is not responsible for the pressures A&E is experiencing, but it is responsible for adapting and finding new ways of dealing with the demand (like the work being undertaken within the primary care home sites) so that general practice, and the NHS, can continue to manage the rising burden of disease. And if you take nothing else away from this, at the very least you should follow @SteveKellGP on twitter…

jan

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General Practice Podcast – Highlights of the Year 2017

Posted by IanBlogs, The General Practice BlogNo Comments

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

dec

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What is new in General Practice – Late 2017

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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!

dec

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What got general practice here won’t get general practice there

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

There’s a tricky issue at the heart of the general practice crisis. Ostensibly, those working in general practice need to do things differently. It’s tricky because if I accept I need to do something differently, it means I am taking responsibility for the difficulties I am facing, even though the situation is not my fault.

To try and pick a way through this, I am going to lean heavily on a book by Marshall Goldsmith, “What got you here won’t get you there: How successful people become even more successful” (2008). I found this a really helpful book when I was a newly appointed CCG accountable officer. Previously, as a middle manager and running a small organisation, I had always been successful by being very task focussed, by making things happen, and by delivering results. What soon became clear was that this style of managing was not effective when I was the leader of a larger organisation.

It turns out what I needed to do was spend less time trying to force things to happen, and more time communicating what the organisation was about and where it was going, and listening and talking with those who worked in and with the organisation. I needed to be visible, and trust the managers working in the organisation to make things happen, whilst I focussed on making sure the direction and priorities were clear and understood by all.

It might sound obvious, but it was a very difficult personal transition. As Marshall Goldsmith explains, it was difficult because of my personal beliefs. He describes it like this, “One of the greatest mistakes of successful people is the assumption, “I behave this way, and I achieve results. Therefore, I must be achieving results because I behave this way.”

It was hard to change the way I behaved because it had always worked for me in the past. But the world around me had changed, and to be successful I needed to do things differently. The difficult bit was really believing that it was me that needed to change, rather than falling into victim mode and blaming the people and organisations around me. Marshall Goldsmith puts it like this,

“Many people enjoy living in the past, especially if going back there lets them blame someone else for anything that’s gone wrong in their lives. That’s when clinging to the past becomes an interpersonal problem… When we make excuses, we are blaming someone or something beyond our control as the reason for our failure. Anyone but ourselves.”

I remember the point at which I realised it was me that needed to change. We had been a really successful practice based commissioning group, but had struggled in the transition to becoming a CCG. It was easy to dwell on the successes of the past, and blame the challenges we were facing on others. But ultimately that wasn’t going to help. For me it was facing the feedback from our CCG authorisation process (remember that?) – it was as if that was the event I needed, to get me to understand I had to do things differently to change the situation. Back to Marshall Goldsmith,

“There’s nothing wrong with understanding. Understanding the past is perfectly admissible if your issue is accepting the past. But if your issue is changing the future, understanding will not take you there. My experience tells me that the only effective approach is looking people in the eye and saying, “If you want to change, do this.”

Focussing on my own past successes, and how events had conspired against us, was not helping me. In fact, it was holding me back. Which brings me to general practice. Practices are in a difficult position. It is not their fault. But they are the ones in the difficult position. Getting out of this position requires different behaviours to those that were successful in the past.

This is the kind of thing that is easy to say (or blog about!), but hard to act upon. It only becomes possible when an individual really believes things need to change, because without that conviction people take half-hearted steps (or none), or do the same as they have always done, which won’t lead anywhere productive. I don’t know what the equivalent of my ‘authorisation-moment’ will be for individual GP partners, or practice managers, or federation leaders, but the truth of it is that for their situation to change, they are the ones who will need to change. Not to satisfy others, but for themselves.

The environment general practice now finds itself in requires collaboration (with other practices, NHS organisations, the voluntary sector, social care), a willingness to explore new ways of working, and an openness to letting others do what for many years has been the sole domain of GPs. The changes themselves are not that difficult, but personally getting to the point where you are prepared to make them, and adopting the new behaviours that are needed, is.

If we could apply Marshall Goldsmith’s work to general practice directly, perhaps it would read: “What got general practice here won’t get general practice there: How successful practices become even more successful”. Or “What got GP federations here won’t get GP federations there: How successful federations become even more successful”.

The world has changed for general practice, and, like it or not, it is GPs and those working in general practice that will need to change if general practice is to thrive into the future.

dec

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Accountable Care Clinical Commissioning Part 2

Becoming a butterfly…Part Two

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

General Practice and the Transition from Clinical Commissioning to Accountable Care –2

Last time (here) I explored the negative impact that dual running the existing commissioning system and the future accountable care system was having both on general practice, and on the success of the new accountable care models themselves. We want GPs to focus on engaging with accountable care, to ensure general practice and the registered list is central to it. But the commissioning system hasn’t stopped, and we still want GPs leading and actively participating in the commissioning system.

By creating an artificial split between general practice as providers through federations and general practice as commissioners through CCG localities we are making it difficult for core general practice to be involved in the new models (How are practices represented? Do federations have a mandate to speak for practices? etc.), wasting valuable general practice time, and unnecessarily limiting the GP leadership capacity available to the new system.

If the heart of the transition is moving where the energy for redesign sits, how might we shift it from the GPs sitting in their commissioning role, to the GPs sitting in their provider role (rather than simply asking two different groups of GPs to do both)?

Could we transfer the responsibility for redesigning services from CCGs to groups of providers now? In practical terms, could we cope now without GPs carrying out their commissioning role, and ask them to take on the redesign role as providers, working with local partners? Could we transfer the resource we spend on our CCG locality structures to the GP federations (and what is the real return on the investment of that money anyway?), against a set of outcomes and outputs that we want in return? Wouldn’t that, in fact, be modelling the future?

Immediately I can feel the unease growing around the dreaded conflicts of interest. How can we give GPs the responsibility to design something they will potentially benefit from as providers? It has been the bane of CCGs in recent years, and this could feel like a step backwards.

But isn’t is true that within an accountable care model of providers working together within a fixed envelope of money, some of those providers sat round the table will end up providing more, and some will end providing less? The prevailing wisdom suggests the likely shift is from secondary care into primary care (a shift the purchaser/provider system singularly failed to enact). The logic of the new system is that, for the new system to be successful, exactly what we fear from a conflict of interest perspective (general practice designing services that shift resources into primary care) is what is needed for the new system to succeed.

If we place the redesign resource for a system into a provider partnership that the GP practices are part (maybe a major part) of, then all we are doing is modelling the future. We have to unlock the creativity of front line clinicians working together to improve the lives of the populations they serve. We can’t do that if we bind them in bureaucracy.

Attempts to develop a contractual approach to overcome the potential conflicts issue (the dreaded ACO contract) has already proven unwieldy and time consuming, focussing energy on form and governance structures and away from the key challenge of making change. In our transition plans from the old system to the new we need to find a way of shifting the energy for redesign as early as possible to make it central to the new way of working.

We are wasting valuable GP resource in dual running a system we are winding down alongside the new system we are trying to put in place. We need to accelerate the shift from the old to the new. The longer we wait, the harder it will be to engage general practice in the new model, and the more disenchanted they will be with the old model as it is dismantled around them. If we don’t do this now, then when?

nov

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Accountable Care Clinical Commissioning Part 1

Becoming a butterfly…Part One

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

General Practice and the Transition from Clinical Commissioning to Accountable Care – 1

The NHS is faced with something of a conundrum at present. We have the system of commissioners and providers as laid out in the legislation and statutory architecture, and the system of providers working together as laid out in the Five Year Forward View and STPs. The two are fundamentally different. The conundrum is how to manage the transition from one to another, without any legislation or mandated transition plan.

General practice sits at the very heart of this transition. The new models of care are based on the registered lists of GP practices, yet all the while it remains mandatory for these practices to be part of a CCG. We want GPs to (eventually, at a time yet undetermined) stop doing “commissioning”, and (immediately) to start doing “accountable care”. Unsurprisingly, the early lessons are that general practice needs to be involved in accountable care from the outset.

The transition has of course already started. STP leaders and teams are growing in number and power, and we are starting to see reductions in the number of CCGs and also in the number of CCG Accountable Officers, as CCGs increasingly share management teams. The overall system leaders are no longer exclusively commissioners, and they are grappling with how to make the transition from the existing system to the new one a reality.

At the heart of this transition is the shift of where what I would call the “energy for redesign” comes from. In a commissioner/provider split, the commissioner designs the pathways and ways of working and contracts each provider to deliver their part. Within an accountable care model, the providers work together to redesign the pathways and the interfaces between organisations and clinicians. For me, it is this shift of the energy for redesign from commissioners to providers that is critical to the success of the new system.

If we go back to why we wanted GPs involved in commissioning in the first place, it was because of their unique perspective on the wider healthcare system and how it impacted on their patients, and their ability to use this to drive change for their registered list. Is it any different with accountable care? I don’t think so. We are simply trying to harness the same insights, knowledge and experience within a different system. In truth, we are doing it because the commissioning system has not worked as the driver for the change that the NHS needs.

How, then, do we make this transfer of the energy for redesign from commissioners to providers a reality? How do we empower GPs to start to make the changes we wanted them to make in commissioning, but not through contracts but by building relationships with other providers?

Most places are encouraging the development of federations, or other at-scale general practice vehicles. These are then seen as the GP “providers”, and the sub-structures of commissioning groups, often called localities, are seen as the GP “commissioners”. We then try and talk accountable care and the future with the federations, and commissioning and business-as-usual with the localities. But this has three fundamental problems. First, we are halving the already limited GP capacity available by splitting it between the two. Second, engaging GP federations rather than practices and practice representatives in emerging models of accountable care (unintentionally) limits the general practice input to those activities the federation undertakes and often excludes core general practice. And third, the GPs who have built experience of working in partnership through their CCG work are left in the commissioning camp when they are desperately needed in the accountable care camp.

Dual running general practice as both commissioners and providers suits the system because of the complexity of the current situation, but we are not serving an already overstretched general practice well, and we are diluting the potential impact of the new system right from its very inception. Next time I will explore whether within the transition we can empower general practice to make a fuller shift to the new system earlier, without resorting to the bureaucracy and upheaval of the proposed ACO contract.

nov

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Seven good (and seven bad) reasons to join a federation

Posted by IanBlogs, The General Practice BlogNo Comments

Joining federations is currently de rigueur in general practice. But is it right for everybody? For federation leaders, is it important that practices join for the right reason, or is it more important that as many practices as possible join? And for a system trying to push for general practice at-scale, does the underlying motivation of practices to work together matter, or should we be pursuing the goal of scale regardless?

As someone who has led a federation in the past, and now works with practices and federations up and down the country, my view is there are good and bad reasons for practices to join a federation. When federations form with practices joining for “good” reasons, federations can fly quickly. Initiatives can get off the ground rapidly, a powerful voice for general practice can be formed, and partners can find the group easy to do business with.

Conversely, when practices have joined a federation for the “bad” reasons, progress can be painfully slow. The group can be beset by internal arguments and in-fighting from the start. Gaining practice agreement for any, even minor, initiative can be extremely challenging and the leaders are often disconnected from their members; unable to speak with any real authority for them.

Here are my seven “good” and “bad” reasons to join a federation:

nov

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How to get GPs involved in accountable care?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

It is one of the perennial challenges of NHS management – how do we engage the GPs? I remember when I was an NHS management trainee, in the days when GP fundholding was imminent but had not yet arrived. There was a look of fear in the hospital contract manager’s eyes, as he grappled with the prospect of engaging GPs, with no real clue of how to do it. Some STP meetings feel similar. We want GPs to be central to the whole process, but (ahem) as we look around the table, there are none to be seen.

It works the other way. GPs have previously been duped into participating in a whole raft of system initiatives, largely against their better judgement. Generally, if it works for them (e.g. fundholding) it gets taken away, or if it gives them any real power (e.g. CCGs) the power gets taken away, or if it has the promise of power (e.g. practice based commissioning) it turns out to be an illusion and built on sand.

Which leaves GPs facing the prospect of accountable care systems with an understandable lack of relish. Promises and reality have been so different over the years that scepticism seems like a reasonable starting point.

So how do you get GPs engaged? Professor Kotter, Harvard professor and one of the leading current thinkers on change, is clear the first (and most important) step is to create a sense of urgency. What he talks about is creating a clear reason, a rationale, for getting involved in the change, and why action is needed now. If you haven’t read his “penguin” book, Our Iceberg is Melting, I would highly recommend it.

There are potentially three ways to create a sense of urgency for GPs related to accountable care. The first is the current crisis engulfing GPs. Accountable care, and partnerships with other organisations, represent a potential way out for GP partners who no longer want to continue with the daily struggle of trying to keep up with ever increasing demand without the staff or resources to realistically cope. Certainly this has been one of the drivers in some of the vanguard areas.

In my closeted management world, a distinction is drawn between “towards goals” and “away-from goals”. Towards goals are ones like winning a medal at the Olympics, where individuals have a very clear picture of what they are trying to achieve and they use this picture to motivate everything they do in pursuit of that goal. Away-from goals are ones like wanting to change job because you hate your boss, where individuals don’t necessarily want the job they are going to, they just don’t want to remain in the situation they are currently in. You know where I am going with this. Towards goals work well, away-from goals do not (you end up in a different job that you hate equally), and using the crisis in general practice to motivate GPs to engage in accountable care is an away-from goal.

The second way is to draw out how the NHS world is changing, and how involvement in accountable care is the only real way for GPs to shape the environment they will operate in in the future. The voice of GPs through CCGs is getting lost as commissioners merge and align with STP areas. Despite assurances about where the core GP contract sits, the reality is accountable care includes all of what general practice does (not just the extra services the local federation provides), and the changes will include to a greater or lesser extent some aspects of how GPs are reimbursed.

This is a tough sell, largely because the default GP strategy of head down and wait for the wind to blow over has by-and-large worked for the last 70 years. Why will it be any different this time? Worse, there is no legislation to fall back on. At least with CCGs you could point to the Health and Social Care Act and the 1^st April 2013 for CCGs taking on real responsibility. No such luck this time. But on the plus side, the threat of acute hospitals controlling primary care expenditure will corral many GPs into action.

The third way is to attempt what I describe as the Martin Luther King approach (“I have a dream…” etc.). In the true spirit of “towards goals”, we could start with an inspiring vision of what accountable care can do for our communities. What if we asked our local community what they really wanted from their health system, and what if we could work with our local partners to make their vision a reality. What if consultants, GPs, social workers and the voluntary sector could really work together to change the experience of diabetes or asthma or frailty (or all of them) in our area. Starting with the difference individuals wanted to make when they chose to become a GP and tapping into that may ultimately be both the hardest and most productive route to follow.

In the end, the contracts manager did what these days we often fail to do: he went out to all the practices, listened to what they had to say, built a relationship with them, and the hospital survived fundholding. There are no shortcuts for this. If we want to engage GPs in accountable care, whatever arguments or approach we want to take, we have to get out to the practices and talk to GPs about it.

nov

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Guest Blog – Six Secrets to Active Signposting Success

Posted by IanBlogs, The General Practice BlogNo Comments

In Episode 62 of the General Practice podcast (here) Nick Sharples explained Active Signposting; a system of non-medical telephone triage. In this guest blog Nick describes the six keys to successful implementation.

With the GP Forward View strategy now well established, many CCGs, GP Federations and individual Practices are seeking to commission training in the two High Impact Actions (HIA), for which NHS England has provided ring-fenced funding.

Active Signposting is one of these and has the potential to save up to 26% of GP consultation time if fully and effectively implemented. But how do you introduce Active Signposting in such a way that the potential savings are optimised? And what do you need to consider when commissioning such activity?

Here at DNA Insight we have identified six key elements of success:

Preparation is Vital

Introducing Active Signposting brings a change to the way in which the Practice currently operates, and it will affect the entire Practice Community, albeit for the better. It is not just the training of the reception team that is important – but how the system is introduced to the whole team.

You or your training provider should consider:

The need, scope and creation of a Service Directory (start small and build over time)
The building of an EMIS or SystmOne template to allow signposts to be recorded and exported for analysis
The need for Red Flag Protocols to be articulated, written down and available to Receptionists
The need for the GPs or the Federation/CCG to decide which of the available alternative services (in-Practice or outside in the community) offer the most potential for early Signposting wins. These services should be amongst the first to be introduced but will almost certainly need some additional consultation to ensure they are ready for the increased flow of patients. (Where available, Pharmacy and MSK/Physio related services top the charts for delivering the greatest numbers of signposting opportunities.)

All of these activities can be developed concurrently while you are going through the procurement process for a training provider, but ideally, they should all be in place before the training of your Reception team starts. In that way, your Receptionists can train on scenarios that will be immediately relevant when the Signposting starts.

Engage the Whole Practice Community

Active Signposting will not happen just because you’ve been on a course. GPs, Practice Managers, Clinical staff and external service providers such as Pharmacists and Physiotherapists all need to be engaged in the programme for the benefits to be realised.

The training programme offered by your provider should be bespoke to your specific needs. They should take time to understand the local dynamics of the Practice and the wider Federation or CCG within which it operates – customising the training accordingly, so that it is both relevant and valuable.

Face to Face or Online?

Whilst some training works well when delivered remotely, in Active Signposting it is the face-to-face practice and the interaction with colleagues that goes a long way to making sure the techniques will be adopted on return to the Practice.

Trying out new techniques in a safe training environment, with a colleague on the end of the phone playing the role of the patient, provides the necessary self-confidence for Receptionists to introduce the techniques when they finish the training.

Bring Everyone to the Training

Encourage your commissioners, Practice Managers and GPs to attend the training, alongside the Reception team. Such high level attendance not only empowers the Receptionists with the authority to apply the techniques they are taught, it also exposes managers and GPs to the realities of life behind the Reception desk.

If training budget is an issue, consider running a pilot with a complete practice team or several. This is far preferable to trying to spread the knowledge across the organisation by training a couple of Receptionists from each Practice, and then hoping that they will magically be able to train their colleagues when they get back. Whilst nice in principle, it almost never works in practice.

Promote the Service to your Patient Community

Active Signposting is a Win-Win for all members of the Practice community, and the patients are no exception. Making them aware of the introduction of Active Signposting/Care Navigation will encourage them to share their symptoms with the Receptionists, which will allow a signpost to be offered.

One of the most effective ways to do this is for the senior GP to record a message on the front end of the Practice phone system encouraging patients to share their symptoms with the reception staff.

Have a Formal Go Live Date

It’s not unusual in our experience for the training of the Reception team, and the separate but necessary preparation of the Service Directory, Data Collection template and consultations with chosen service providers, to get out of sync.

It is important however that all are in place prior to your ‘Go Live’ day. As the saying goes, “You never get a second chance to make a first impression”. With so many stakeholders involved and affected by the change, getting it right first time is essential.

DNA Insight provides support and training to GP Practices in Active Signposting, the Management of Medical Correspondence, Reducing Missed Appointments, and Quality Improvement & Leadership. These High Impact Actions are designed to transform General Practice as part of the NHS England’s GP Forward View strategy. Please contact us on 0800 978 8323, email info@dnainsight.co.uk or visit our website at www.dnainsight.co.uk.

oct

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Collaboration in general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The Nuffield Trust have published a new report [1] on how collaboration between GP practices has developed over the last 2 years. It is based on a survey of 565 GPs and practice based staff, and 51 CCG chairs and accountable officers. It makes for fascinating reading. But what can we learn from it?

The first point is the findings have been skewed slightly by the availability of funding for extended access to general practice, including recurrent funding from this year onwards. As a result, over half of collaborations made improving access one of their priorities, and it was also the highest ranked potential benefit. The access funding has not been available to individual practices, and even if it was few were keen to take it up. Consequently, it has ended up almost as a system lever to provoke more joint working between practices. The concern is that its success in that regard may lead to similar types of “incentives” in the future.

But that aside there is much to consider. I have two hypotheses about federations. The first is that the current crisis in general practice is driving collaboration between practices to support delivery at practice level. In the past, federations were primarily about transferring services to the community, but I would suggest this has changed to a focus on practice-sustainability over recent years.

Does this hypothesis stack up in light of these survey results? It would seem so. 67% of respondents identified improving the financial and organisational stability of practices as a potential benefit of collaboration, higher than the 53% who identified the transfer of services into the community.

But interestingly only 46% of respondents reported their collaboration had identified improving the financial and organisational stability of practices as a priority in 2016/17 (the exact same percentage who identified transferring services into the community).

Why might this be? If GPs and practices are joining federations to improve the stability of their own practice, why is there this discrepancy in the number of federations who then prioritise it? Other survey responses provide clues. Smaller collaborations, covering less than 100,000 population, were much more likely (47%) to have it as a priority than larger collaborations of 100,000 population plus (37%). And collaborations formed more than two years ago were more able to fully or partially achieve the aim of improving practice sustainability.

It is because the ability to improve practice sustainability requires trust. It requires practices to trust the federation enough to allow them to take control of parts of the business that have historically always been within their control, right through from ordering supplies to employing staff and managing their visits. Smaller groups of practices, and practices that have been working together for a longer period, are more likely to trust each other (because they know each other), and as a result encourage and enable the federation to take steps that might benefit them, even if it means ceding bits of control.

If federations really are going to make a difference to member practices then this journey of building trust is one they and their practices will need to go on together.

My second hypothesis is that federations are needed to ensure GP practices as providers have a voice in the emerging new models of care. Well at present, it would seem, GPs don’t agree, with less than 9% of respondents identifying it as a potential benefit of a collaboration, and an even lower percentage reporting it as one of their collaboration’s 2016/2017 priorities.

At the same time over half of GPs responded that general practice had been not at all influential in shaping their local Sustainability and Transformation Plan (STP).

Maybe GPs don’t see it as the federation’s role to represent them in discussions about new models of care. But if it is not the role of the federation, whose role is it? The GPs in the CCG have to go to great lengths not to be seen to be favouring practices over other providers in their role as local commissioners, so it can’t be them. LMCs are the only other option, and other providers do not see LMCs as a fellow-provider they can collaborate with in an accountable care set up. Like it or not, it has to be the federation.

In summary we have learned that clear financial drivers like the access funding can successfully drive collaborative working across practices. Practices want collaborative working to help them with the challenges they are facing, but the reality of making that happen is proving difficult. It relies on trust, which is a hard won and easily lost currency. And finally the need for practice leadership within the accountable care arena by federations is one that has not yet been fully recognised.

[1] Kumpunen, S. Curry, N. Farnworth, M. Rosen, R. (2017) “Collaboration in general practice: Surveys of GP practice and clinical commissioning groups” Nuffield Trust, Royal College of General Practitioners survey www.nuffieldtrust.org.uk/research/collaboration-in-general-practice-surveys-of-gp-practice-and-clinical-commissioning-groups

oct

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Your Easy Guide to the Next Steps

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

oct

0 2

What does accountable care mean for general practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The NHS world is changing. I wrote last week about the impact of commissioning on general practice, and this week I consider what the move towards accountable care organisations and systems means for GPs and practices.

What is accountable care? The Kings Fund has helpfully described it as comprising of three core elements,

“First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.”

Rune reading, particularly in the NHS, is a difficult game. But all the signs point to accountable care organisations and systems (often used interchangeably to describe very similar arrangements) as the direction of travel. STP plans, NHS leaders and politicians are all making noises to suggest it is exactly where we are heading, despite the reticence to create new legislation with the disaster of the last NHS legislation so fresh in people’s minds.

If accountable care is where we are going, what does it mean for general practice? To help answer that, there are three further questions for us to consider.

1. What role will general practice play in an accountable care system?

Here the options appear to be threefold. General practice could choose simply not to engage. Indeed, some of the early accountable care pilots report engaging GPs to be one of their key challenges. The problem here is some of the budget for general practice will transfer from local commissioners to the accountable care system. If this is dominated by the acute hospital and other large provider organisations there is an obvious risk some funding streams will dry up.

Conversely, for accountable care systems seeking to deliver outcome rather than activity goals within a fixed funding envelope, international examples such as the Canterbury Health Board in New Zealand have shown the rate of growth of hospital activity can be moderated by investing in services in the community. There is opportunity for general practice within accountable care systems, meaning active engagement could well benefit the profession as well as the local population.

General practice could choose to play the role of “strong voice around the table”. It could ensure it is involved in accountable care system decision making, and almost take on an LMC type role to ensure risk to practices is minimised and funding streams are maintained and, where possible, developed.

Or it could attempt to play a leading role. Accountable care systems are very much at the developmental stage. There is no fixed blueprint for how they will look or how they will operate. Active leadership now could drive the evolution of these systems to ensure they are built around core general practice and the delivery of joined up and effective prevention and out of hospital care.

2. What scale will the accountable care system operate at?

Equally, the answer to this question is not clear yet. On the one hand we have the devolution project in Manchester creating an accountable care system spanning the whole of Greater Manchester. On the other, the primary care home (PCH) initiative is promoting accountable care for populations of 30-50,000.

In most places, size has not been determined. It may be that “layers” emerge, with smaller local areas where they exist (maybe PCH size) feeding in to larger areas (maybe acute hospital catchment area size), in turn feeding into even larger areas (whole STP size, a la Manchester). What “feeding into” in this context means is anybody’s guess.

For general practice, the scale chosen is likely to be important. If an accountable care system operates at acute hospital catchment area size, general practice would need to be well led and organised to be able to match the voice of its acute counterpart. At STP level, how does it prevent its voice being drowned out by the multitude of other big voices around the table?

Even operating at a locality or neighbourhood level of 30-50,000, practices will need to find a way of working well together and creating a strong single voice. To influence the scale at which accountable care operates locally practices will need to be involved at an early stage of the discussions. Once final decisions are taken, they will be hard to undo.

3.How will general practice build the relationships it needs to participate in accountable care?

It is clear a system reliant on collaboration between providers is going to be a challenge for general practice which is currently organised into nearly 8,000 individual business units. Practices will first and foremost need to build relationships with each other. Some practices are merging themselves into a size that means they will individually be ready. Some are forming federations. For others the currently existing CCG localities may provide a platform practices can build on. Key here is if practices want accountable care systems to work for them, as opposed to simply becoming their new masters, the ability to work effectively together is undoubtedly task one.

Equally, GP groups (whether it be large practices, federations, or localities) have to find a way of working together. Ultimately there is going to be one GP voice in an accountable care system. For that voice to be effective it will need to be unified. The acute trust, for example, will have a single, clear voice. If general practice cannot create the same level of cohesion, its voice will be diluted, and influence correspondingly diminished.

Finally, GP groups will need to be able work collaboratively with other providers. The aim is not that these systems become the fora within which providers fight each other for their share of the fixed amount of funding available. Rather, it is for barriers between organisations to be removed and for more effective ways of delivering care to be developed for patients. This requires productive relationships based on trust. For general practice it will require strong local leadership that practices believe in and are prepared to back when decisions are made – there will not be the time or opportunity for every decision to go back to each practice for a vote.

The overriding message for general practice is accountable care is coming. As such, practices may want to consider how they want accountable care to work locally, to identify what role they want to play in both shaping and delivering this future, and to reflect on how ready they are for this new system which has significant implications for the future of general practice.

sep

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The impact of commissioning on general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future. The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.

sep

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General Practice in 10 Years’ Time – Part 3

Posted by IanBlogs, The General Practice BlogNo Comments

This is the third in the series of blogs where Ben asks the questions that he believes will shape the future of general practice. This week he asks

What Role Will Federations Play?

As with any look into the future, dipping into the past is a good place to start. Federations have changed significantly over the last ten or even twenty years. Post fundholding, and during the practice based commissioning years, federations were set up primarily to deliver services historically provided in hospital, in the community in order to generate an additional income stream for GPs and practices.

Since then, two things have materially impacted on the role of federations. First is the crisis that has engulfed general practice. Where federations historically operated at arm’s length from practices, they now have an important role in supporting member practices through the current challenges. This is a critical difference. It means the activities federations undertake are much closer to the delivery of core general practice e.g. visiting services, delivery of extended access, employing pharmacists and other new roles for practices. They have to work hard to ensure the cost of the additional layer of administration is offset by the value they bring to their members.

Second is the rise and fall of CCGs. At their inception they gave a powerful voice to general practice, as arbiters of how the NHS pound would be spent. No need, then, for federations to take on this role. Indeed, where they tried to assume this role, GPs were herded in and out of rooms to satisfy increasingly confusing conflict of interest requirements. But now power is shifting away from CCGs and away from commissioning. As CCGs get bigger, the local GP voice is getting smaller. As STPs and accountable care systems develop, the influence of general practice via commissioning continues to diminish.

Suddenly, we have a really clear role for federations: to support local practices to meet their current (and growing) challenges and to provide a strong voice for general practice as local systems move towards integrated models of working. Whereas in the past federations were something of an optional extra, it no longer feels like that. The challenges facing general practice and the wider integration agenda require an ability for practices to function coherently as a collective.

Federations provide that acceptable middle ground, where individual units can retain the independence and individuality they prize so highly, while at the same time gaining the benefits of joint working. They provide a vehicle for collective voice and collegiate working without necessarily requiring wide-scale restructuring into larger, formal organisations. Where trust levels grow between practices, and the ambitions for working together become greater, some are starting to move beyond loose federations into more formalised joint working arrangements, such as super practices.

Federations will play a key role in the development of general practice into the future. Where they are successful, owned by and adding value to practices while at the same time leading them through the integration agenda, they may well evolve into more formal partnership structures. Where leadership is weak and trust levels remain low, they may fall by the wayside, most likely to be taken over by more successful groups seeking to expand their footprint. Either way, we are already seeing well-developed federations able to play a leading role in local system integration plans. Moving forward, federations will have a critical role in both supporting the transformation of general practice into new sustainable ways of working, and shaping the role general practice plays within accountable care models and systems.

sep

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General Practice in 10 Years’ Time – Part 2

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

In the second of his blogs looking at the questions that will determine the future of general practice Ben asks

At What Scale Will General Practice Operate?

I find the answer “general practice needs to operate at greater scale” often precedes the question. Indeed, in many cases there is no sign of a question, it is simply presented as a statement of fact, as though 70 years of effective working at the current scale counts for nothing and there is no need to even make a case to support the statement.

As I have previously been at pains to point out, scale does not, of itself, automatically generate benefits for general practice. We only need to look at the graveyard of federation failures to know this to be true. Equally, the Nuffield Trust report “Is Bigger Better?” found instances where the quality of general practice reduced with increased size.

The authors of that report ultimately felt scale was better for general practice, but only where it is led by high quality leaders who understand the value general practice provides and work hard to preserve it. I have been fortunate enough through the podcast to be able to discuss with some of those leaders the rationale that sat behind their move to scale. What is striking is how different those rationales are. This is important, as it means there is not a single basis for general practice operating at scale. Further, it is the rationale for operating at scale that ultimately determines the answer to the question of at what scale general practice should operate.

There are seemingly two ends of the spectrum. At one end, the question is, “how do we create the efficiencies, voice and shared infrastructure to preserve and strengthen independent general practice”? This, for example, is broadly the question the super-practice Our Health Partnership (OHP) is seeking to answer.

They believe the optimum population coverage for their model is c500,000. This is based on each member practice contributing £2 per head, which creates a £1m budget to fund a management team. This is the size they believe is necessary to deliver real value. What is impressive about the model is it is maintaining a focus on working for the member practices (efficiencies), while at the same time creating a strong position within the local STP (voice).

At the other end of the spectrum, proponents of NAPC’s primary care home model advocate strongly for a population size of 30-50,000. Here the question is, “How can general practice really understand and best meet the specific needs of local communities, and retain and build on the sense of belonging that local communities have”? They believe if general practice operates beyond that size it cannot maintain the personal relationships fundamental to its success. Local needs vary so much that a service providing an average of the needs of two communities is in fact not meeting the needs of either.

Of course these two perspectives are not mutually exclusive. OHP want to build their organisation around specific geographical localities. Nav Chana, GP Chair of the NAPC, is clear a bigger population size might be required to create the infrastructure needed for these individual primary care home sites to deliver.

Futures are journeys not destinations. Beacon Medical Group is a great example of a practice on a journey. Already at 30,000, they have plans to scale significantly beyond that. But they understand what is important about general practice is continuity of care, and the ability for local areas to tailor services to the needs of their local population. So as they grow they are building on units of around 30,000, each with some degree of local freedom. Imposing a one size fits all operating model is not, in their view, going to work, even within a single practice.

General practice may be heading to a place where it operates at a large scale (over 100,000 population, maybe higher than 500,000) to create the new infrastructure it requires, while at the same time finding a way to retain some level of autonomy at individual locality level (30-50,000 population). But this concept of the journey, like the one that OHP and the Primary Care Home sites and Beacon Medical Group are all on, is the one that Rebecca Rosen and the authors of the “Is Bigger Better?” report believe to be critical. The most important question is not what size general practice is going to be, but rather how it is going to get there.

If you’d like to find out more about the future of general practice and meet some of the key voices in contemporary general practice (including Mark Newbold from OHP, Nav Chana Chair of the NAPC and Jonathan Cope from Beacon Medical Group) then why not buy a ticket to our first General Podcast LIVE event? For more information including a full programme and how to buy tickets visit our website here.

sep

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General Practice in 10 Years’ Time – Part 1

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

This is the first in three linked blogs where Ben poses three questions that, taken together, will paint a picture of the future of general practice. In this blog the question is:

Will General Practice Remain Independent?

When thinking about what general practice will look like in ten years’ time, one of the questions that immediately springs to mind is whether it will remain independent. Will general practice (finally) become a full-blown part of the NHS, or will it continue in its current peculiar position of half in and half out.

First off, what does independence mean? While the average person on the street considers general practice to be an integral part of the NHS, the description of general practice as independent comes because practices (in the vast majority of cases) are not run by NHS organisations, but by independent organisations (usually GP partnerships) that contract with the NHS.

Is this just a technical difference? Well not really. It means GP partners can choose what they do, which contracts they will enter into, and which they won’t. They can invest in property, form partnerships, decide on their staffing model, and choose how they will operate. They are bound by the constraints of the contracts they enter into, and more recently by CQC regulations, but they retain a level of autonomy and freedom of decision making not available to those working more directly within the NHS.

The opportunity for practices to give up this independence has become much more real recently, since the publication of the GP Five Year Forward View and the emergence of the new models of care. These new models provide what is described as a “fully integrated” option whereby practices can transfer their contract into the new multispecialty community providers (MCPs) or primary and acute care systems (PACS), and the GPs can become salaried employees within the new larger organisations.

Will practices take this opportunity to give up their independence, and if so why? On the podcast, I have asked this question to some of those involved in the new models of care. They explain some will, and the primary reason is the pressure general practice is currently under. For some the workload, financial and leadership pressures have become too great, and focussed on too few individuals. When presented with a way out, they are eager to take it.

For other GPs there is more of a strategic sense that general practice cannot continue on its own. They feel that to thrive into the future and to best serve local communities, general practice needs to work as part of a wider team. They see the future of general practice as no longer being small, independent businesses, but instead operating within a new style of NHS organisation that harnesses the benefits of full membership of the NHS (indemnity, VAT exemption etc), of scale and of fully integrated clinical teams.

But large organisations in the NHS do not have a strong track record of maximising the benefits of scale, of enabling effective multi-disciplinary working or of innovating around the needs of patients. If GPs have learnt anything from the rise and fall of CCGs, it is that the statutory world of NHS stifles rather than enables, creates bureaucracy rather than removes barriers, and controls rather than empowers.

As a result, some prize the independence of general practice much more highly, and are much less willing to give it away. Our Health Partnership (OHP) is a “super practice” with a population of over 200,000 that aims to demonstrate it is possible for independent general practice to thrive into the future, by operating at greater scale. What they, and others like them, are already showing is the choice to remain independent or not is real for general practice, and while changes might be necessary to preserve it, there is certainly no inevitability it will be taken from them.

To thrive into the future, general practice has to change. While some cling to the status quo as a “tried and tested strategy”, the reality of the changed political, social and economic environment is change is necessary. General practice has to operate at greater scale, to manage risk, deliver greater efficiencies, build partnerships and have a strong system voice. But independence is something general practice can choose to keep. Whether or not it will do so I suspect will largely depend on how actively it works at redesigning itself, or the extent to which it allows the system to determine its future form.

If you’d like to find out more about the future of general practice and discuss these issues and many others with Ben and a range of expert GPs then why not buy a ticket to our first ever General Podcast LIVE event next March. You can find all the relevant information and book your ticket here.

aug

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The Future of General Practice – Have Your Say

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Here at Ockham Healthcare, the question we have been giving most thought to is what the future of general practice will be.

We asked Mark Newbold what he thought the biggest change to general practice would in the next 10 years. Find out what he said here. We will be asking the same question to a whole range of people over the next 6 months, in an attempt to build a picture from a variety of perspectives as to what the future will hold.

We also want to ask you the question. We want you to be part of the debate. We want to know what you think the future of general practice will look like in 10 years’ time. Do you think independent general practice will still exist? If not, what do you think will be in its place? Will the role of the GP have changed, and if so what will they be doing? Will technology have transformed the way patients and GPs interact? Will the registered list even still exist on a local basis? Will we have moved all the way to 10 or 20 large providers of general practice? Or will the profession have been subsumed within acute hospitals, community trusts and the nascent accountable care organisations? Or will it be exactly the same as it is now?

These are important questions. Each practice is regularly faced with decisions about its future. GPs have to determine how much autonomy to give up to federations and networks, and how much to retain for themselves. Commissioners have to choose how to invest the GP Forward View money in general practice for best effect. Everyone has to work out how to cope with the falling numbers of GPs.

A clear vision of the future will help. At present, there isn’t one. If general practice knows where it is going, it is more likely to be able to control its own destiny, to make the right decisions today that will impact tomorrow, and to build for the future instead of protecting the past.

Be part of the conversation. Tell us what you think. We literally want to hear your voice. You can do this in a number of different ways. Either record your views on your phone or ipad or computer, and send the MP3 file to me, Ben Gowland, at ben@ockham.healthcare, or we can set up a 5 min Skype call where we can record what you think, or just email me and we will work out a way to do it!

We will be bringing all of the different thoughts and thinking together at our conference in March next year. Get involved now, so that we can shape the future together!

aug

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What is the Future of General Practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We all have questions about the future of general practice. In his latest blog Ben discusses some of these key conundrums and introduces an exciting opportunity where you could be involved in developing some of the answers…

What is the future of general practice? What will it look like? Will we still have local GP practices? Will GPs continue to do what they are doing now? These are big questions, and probably ones we don’t spend enough time thinking through.

For most of us, general practice has always been there. It is one of only two fixed points of our health service (along with hospitals). I have met many GPs who describe themselves as being on a ship that is sinking, and they can’t see any way that disaster can be averted (other than a serious investment of funding, which seems unlikely in this economic environment and with this government). They urge each other to get off the ship (Australia, retirement, locum), and as a result the number of GPs is falling, despite best efforts to increase it by 5000.

The fixed nature of the GP practice means it can be hard to envisage a new future for the service. I have previously argued that general practice requires more than incremental change at the individual practice level, and that a more radical transformation is needed. But what will the nature of this transformation be? We know what we need to change from, but what we need to change into is less clear.

There are different views about the future. I have met some who are 100% certain that scale is the answer to general practice. They talk about it as being self-evident (which isn’t an argument), and say it with such conviction that many go along with them without careful questioning. I have talked about the potential benefits of operating at scale (essentially: lower costs; higher income; ability to manage demand; and readiness for the future), but have always been clear that these benefits are not automatic, and that they only come by making the changes not possible at a smaller scale.

If big really is the answer, then how big? Here we do have a divergence of answers. The primary care home model is clear that populations of 30-50,000 are what is needed. But on the other hand, Mark Newbold, Managing Partner of super practice Our Health Partnership, recently told me that the full benefits of scale required a population of over 400,000. Now, those two models are looking at two different things – the former is about redesigning local care, and the latter about reducing costs (broadly) – but just the diversity of answers to the “how big” question makes the future feel more complicated than simply “bigger”.

Some are adamant that new models of care are the answer. One GP was clear with me on Twitter recently, “ACO/MCP are the future of NHS and community care. Call them what you want but GP HAS to be core and influential within them”. In episode 66 of the General Practice Podcast Tracey Vell, LMC lead in Manchester and intimately involved with the development of the ACO there, started to describe how general practice would look differently within the new models of care. In this scenario, scale is needed primarily for practices to be able to partner with the rest of the system.

And what about the impact of technology? How long will it be before we no longer go to the doctor, but the doctor (virtually) comes to us? We are now tiptoeing over the boundaries between health and social care, through the introduction of social prescribing and the like – is that just the beginning? Will surgeries develop from health centres into something more akin to community centres? Has the general practice practitioner already been replaced by the general practice team? How will the shortage of GPs shape the future of the primary care model?

These are all questions we are going to be discussing in our first ever live event. We are bringing together some of the most interesting guests (see the Programme here) we have had on the podcast to learn from their different experiences of re-shaping general practice, often in very different ways, and to debate what the future of general practice will look like and how it will develop.

If you are interested in understanding what the future of general practice will look like, how we will get there, and in contributing directly to the debate then register for this conference today. The future of general practice remains uncertain, but this is a chance to develop a compelling and coherent view of what that future will be.

aug

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What the new ACO contract means for general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

It appears NHS England have gone cold on Accountable Care Organisations with the publication of the latest guidance. But what might the new draft contract mean for general practice and what should interested GPs consider doing next? Ben Gowland works his way through the tangle of documents and suggests some of the answers.

NHS England have recently published an updated version of the MCP contract, now termed an Accountable Care Organisation or ACO contract. As ever with NHS England, there are an inordinate number of documents, all of which are inexplicably difficult to find on their website (here). I discussed the original publication of the draft MCP contract in detail previously, and would strongly recommend you take a look at this to understand the key components of the different versions of the model (the “virtual”, the “partially integrated” and the “fully integrated” MCP) and their implications for general practice. In this article I will focus on what is different or has changed in the new publication.

The most noticeable shift is the overall drop in enthusiasm the documents display for the new models. Where previously you had the sense that those producing the documents believed ACOs to represent the next step for the NHS that is now no longer the case. Instead, it has become clear that Accountable Care Systems (ACS’s) are the new black, and ACOs may instead be something of a distraction. Take this paragraph for example, ‘ACO procurements are lengthy and complex, and the development of ACOs relies on a strong underlying approach to care design, engagement and collaboration. For these reasons, most parts of the country are looking to become ACSs before they consider whether to introduce ACOs for some or all of their local population.’

An ACS, for those not familiar with the concept, ‘is an evolved version of an STP, potentially covering a sub–set of an STP’s geography, in which commissioners and providers, in partnership with Local Authorities, take explicit collective responsibility for resources and population health. In return, they will gain greater freedom and control over the operation of their local health system and how funding is deployed’. ACS’s can cover large areas relatively quickly, do not require contractual or legal changes, and represent the quickest route for the NHS out of the current purchaser provider split. ACOs must demonstrate ‘consistency with STP/ACS plans for the future’, and, just so that we are clear, ‘In most places, we expect that ACS development will precede the development of ACOs in order to lay the right foundations.’

The shift from “MCP” to “ACO” has come about whilst previously the draft contract applied only to MCPs, with a separate contract promised for the PACS models, now the contract ‘is usable for accountable care models generally, including MCP and PACS models’. A sceptic might think that given the shift of focus towards ACS’s, and the lack of traction generally for the PACS model, that centrally it was not deemed worth the effort to fulfil the initial promise of a separate PACS contract.

Nevertheless, there have been some interesting developments in the iteration from the original draft. There is confirmation that activity sub-contracted from the ACO to practices will be pensionable. The fully integrated model no longer relies on APMS directions, replaced by less prescriptive directions that offer more local freedom. GPs can sell their premises to the MCP, ‘where the MCP has the capital to buy the property and there is clear value for money’. GPs may be able to buy in as partners or owners of MCPs, but given the cost that is needed to cover (amongst other things) the downside risk of the contract I would suspect it will be beyond the reach of most individuals.

Much has been made in the GP press of the changes to GP practices’ “right to return” (from the fully integrated model back to the original GMS/PMS contract), whereby the patients will not necessarily follow the contract (you can have your contract back but not your list). What it actually says is, ‘If the GP reactivated in the first two years of the ACO Contract the default would be that patients previously on their registered list follow the GP to be re-registered with the practice. If they reactivate after these first two years the patients will remain with the MCP unless they request to follow the GP.’ In reality this means the practice has to decide whether or not it is going to stay or leave within the first two years.

Not all GP practices in the same area have to go down the same route, ‘It’s important that individual GPs have a choice and do not feel pushed into a particular contractual model because it is preferred by the majority. In many of the emerging MCP localities GPs are expressing interest in a range of contractual models in the same locality.’ I assume this is an attempt to move at the pace of the enthusiasts rather than be hampered by those resisting change, but I am not sure how well it will serve general practice going forward to end up in this type of mixed economy.

This version of the ‘GP participation in an MCP’ document is littered with examples and case studies of benefits existing areas have achieved or foresee. I suspect this is in an attempt to make what is essentially a very dry document into something more accessible to GPs. However, the lingering sense left by these is that the majority of the benefits highlighted can be delivered through practices working together, and so do not directly encourage GPs to take the radical step of joining an ACO. It would make sense if they were benefits that could only be achieved as part of an ACO, but by and large this is not the case.

At the same time there a strong reference in the documents to the emerging primary care home model, ‘All accountable models build on strong primary care foundations. In many Vanguards the model is based on local units of integrated primary care provision serving natural communities of 30–50,000 population.’ I think this is an important statement for GP practices trying to find a way through all of this. If ACO development is uncertain whilst Accountable Care Systems come to the fore, and the many of the purported benefits can be delivered by working with others, then developing a clear focus on a local population and building effective working relationships with the other local practices (in whatever form that might take) might be the most pragmatic step for practices to take right now.

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Navigating the podcast: Introducing new roles

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Every week here at Ockham Healthcare we publish a new episode of the General Practice podcast, in which I interview people introducing new ways of working into general practice. Now with over 18 months of episodes in the podcast library there are a whole range of different case studies and individuals to choose from. As a result, the most relevant episode may be increasingly difficult to find. We have introduced a podcast index, but we wanted to create some more useful “maps” to help you find the most relevant episode for you. This week I take a look at where to find the best information about introducing new roles into general practice.

Where do you start? A helpful place is in our recent podcast with Dr Stewart Smith (Episode 75) from St Austell Healthcare. He describes how when thinking about introducing new roles their practice started by undertaking an audit of everything the GPs were doing that could potentially be done by someone else. New roles are not a luxury item in general practice. They are necessary because GP recruitment is becoming increasingly difficult (in some places impossible!), and as the workload becomes increasingly unmanageable new roles are necessary just for practices to remain sustainable. Stewart and his team used the results of the audit to identify locally what work could be taken off the GPs, and who could undertake it.

The headline new roles in general practice are paramedics (Charmi Rogers, Episode 23) who can support GPs with managing the urgent demand as well as undertaking home visits, pharmacists (Karen Acott, Episode 15, and Ravi Sharma, Episode 5) who can undertake medication reviews and run their own clinics, and physiotherapists (Neil Langridge, Episode 17) who can help with the high volume of patients presenting with joint pain. All of these can make a real difference to GP workload, while at the same time improve the quality of care for specific groups of patients.

Also on the rise are physician associates or “PAs”. Initially met with some resistance by the profession (seen as under-qualified for the challenges of general practice) they are now increasingly being welcomed by practices, because of the more general support they can provide to GPs. We ran a podcast mini-series in which I spoke to GP Dr Joanna Munden (Episode 52) about her experience of employing PAs, to Ria Agarwal and Andy King who are PAs working in GP practices about what it is like from their perspective (Episode 40), and to the RCP’s PA lead Jeannie Watkins (Episode 43) who explained that while there may not be many PAs around at present, the pipeline means they will be much more plentiful in a few years’ time.

What Stewart Smith’s audit also found was that it is not just on the clinical side that GP time can be saved. We spoke to Jonathan Serjeant (Episode 46) about how training administrative staff to manage GPs’ post can save each GP half an hour or more a day, and to Nick Sharples (Episode 62) about how work can be triaged away from GPs by trained receptionists in what is known as “active signposting”.

One of the reasons Stewart, and Jonathan Cope at Beacon Medical Group (Episode 57), are worth listening to is because they describe how these different roles can be brought together into one practice, and harnessed to redesign the way on the day appointments are managed, visits are carried out, in fact the way the whole practice operates. I also provide an overview of some of the wider lessons I have gleaned from talking to the experts about the introduction of new roles (Episode 32).

I hope this serves as a useful map to the podcast for those of you seeking more information about the introduction of new roles. If there is any individual role, or aspect of the introduction of new roles that we have missed, or that you think we could cover in more detail, do let me know (ben@ockham.healthcare) and we will try and include it as a future episode!

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Kaizen vs Kaikaku: Does general practice need big bang or incremental change?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Before I moved into the world of general practice, I used to live in the world of service improvement. It was a strange world, with its own language, traditions and practices. I kind of liked it, and look back on it fondly sometimes as you would when you remember a great place you once visited, like that trip to Sydney in 2003 when England won the rugby world cup, where they put beetroot on their burgers and thought calling me “blue” was hilarious on account of my red hair.

Anyway, in the service improvement world there is an ongoing debate about which type of change is best: should you go for small-scale continuous improvements, or a big bang change? In the world of general practice we are now facing the same question: can we adapt the existing model of general practice through incremental improvements into something different, or is a more radical approach required? Evolution versus revolution.

In the improvement world they use the terms “kaizen” (for evolutionary incremental improvement) and “kaikaku” (for revolutionary radical improvement). In the GPFV, high impact action number 10 is; “Develop quality improvement expertise”. Some believe this is the most important of all the actions because it gives practices a mechanism for making the other changes successfully. It includes techniques such as “plan, do, study act cycles” (or “PDSA cycles”) which encourage rapid cycles of testing of changes to enable successful adoption. This, and the techniques like it, are based firmly in the kaizen school of incremental improvement.

I have recently questioned whether the GPFV is failing to have the desired impact because it is trying to tackle each of the problems individually, rather than creating a clear vision for the future. A number of responses have challenged this, suggesting in particular that if all of the 10 high impact actions were implemented in a single practice that in itself would constitute our required vision.

But would it? If every practice implemented each of the 10 high impact actions, in a structured, incremental way, would the current problems of general practice be over? Certainly life would be better, but would it be enough?

Where they got to in the improvement world is that it is not an either/or. Big bang change is needed to break paradigms and elevate the awareness of people to a higher level of understanding. It is needed in addition to continuous improvement, not instead of it. While some problems can be solved by incremental improvement, others do require radical improvement to start with.

The challenge facing general practice is such that I don’t believe incremental improvement on its own will be sufficient. It needs kaikaku as well as kaizen. While the 10 high impact actions are an important part of the transformation needed in general practice, they are not the totality of it. I understand the GPFV is more than the 10 high impact actions, but if they are the element that provide the vision of the future, my contention remains they are not enough and a more radical transformation is needed.

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Is the Primary Care Home the “answer” for general practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Recently I have been wondering if we have been going about tackling the challenges in general practice all wrong.

We have been focussing on the problems practices are experiencing now, and trying to systematically tackle them one by one. Logical. But it assumes the cuts are only superficial, and once they are patched up individually general practice will be well.

The General Practice Forward View (GPFV) approach is to identify each of the issues general practice is facing, and to come up with “answers” for all of them. So for example workforce is the issue and 5000 more GPs is the answer. Or infrastructure is the issue and the ETTF (estates and technology transformation fund) is the answer. Or workload is the issue and contract changes to stop secondary care increasing general practice workload is the answer.

You could argue the real issue is underfunding, and that more money is the answer. But despite the rhetoric, there never was an extra £2.4bn for general practice (see here for more detail). In 2016/17 not only was funding flat (taking into account inflation), growth was half that received by acute trusts. We operate in the system we operate in.

But whether or not the “answers” are working individually, they certainly are not working collectively. I don’t think it is a failure of implementation. Rather, the approach was wrong in the first place. Wrong because it started with the problems, not the strengths of general practice. It started with individual challenges, rather than a compelling vision of the future. And it started with the premise of offering more within a system that cannot offer any more.

Compare this with the NAPC’s primary care home initiative. I knew quite a lot about it, but what I couldn’t quite comprehend was how it helps general practice meet its current challenges. I spoke recently to Dr Nav Chana, Chair of NAPC, and asked him about this. What I learnt from that conversation was the starting point of the primary care home is not so much the sustainability of the current organisational infrastructure of general practice, but a desire to improve the health of local populations, to bring increasingly fragmented workforces together, and to put the control of resources for that population into one place.

What that then means for GP practices as organisations they don’t know yet. What they do know is they are building on the strengths general practice currently has, they are making the service attractive to those who work there again, and that by focussing on meeting the needs of the local population the most appropriate future form of general practice will emerge.

It makes sense. A model that meets the needs of a defined local population will solve recruitment problems because it will attract staff to work there, will solve financial challenges because it will attract investment and funding, and will solve workload issues by different staff groups all working effectively as an integrated team.

Of course it will need help to get there. But by using a future focussed and population centred approach, the primary care home initiative has much more chance of providing general practice with a realistic route out of its current malaise than the backward looking, issue based approach of the GPFV.

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What GPs should consider if they are thinking about partnership

Posted by IanBlogs, The General Practice BlogNo Comments

If you are a GP who is thinking about becoming a partner, what questions should you ask to be sure you are making the right decision? In this guest blog (his third for Ockham) mergers expert Robert McCartney introduces a checklist of things you should consider to help you make the right choice. You can download and print off the checklist following the link beneath the blog.

We undertake a lot of work assisting practices in developing plans for the future and redesigning systems which strengthen general practice. However, much of this work is undermined by the simple fact that there are insufficient numbers of GPs willing to be partners.

Exploring this with a range of junior, salaried and locum GPs it has become evident that the biggest issue is a lack of understanding about the potential benefits and opportunities partnership still offers.

Work must continue to tackle the issues facing general practice but, at the same time, we need to highlight the positive side and help develop the vision of what general practice could look like if the independent contractor status is secured for future generations.

Feedback highlights that potential GP partners do not know what questions to ask to make an informed choice about the opportunities within practices. The checklist, which we have made available below, has been produced to help those GPs considering partnership for the first time. It is not a complete list but should help structure your thoughts around the type of information you need to know before agreeing to invest in the practice.

As a general point it is recommended that you obtain support and advice throughout the process. The local LMC and trusted GP partners will be able to assist you in identifying when an opportunity is suitable for you.

Entering partnership includes accepting a degree of responsibility for the management and running of the business and you should therefore invest in gaining some simple business skills. It is not necessary to enter onto a MBA course but finding suitable sessions on understanding accounts, HR responsibilities and the principles of leadership will all help you once you enter partnership.

When you are considering the list remember that the final decision will also come down to whether you feel the ‘fit is right’. The culture, relationships and general environment of the practice must suit you or have the ability to develop with you over time. The empirical data collated will give you confidence that you understand the practice but only through spending time and talking with all members of the practice will you be able to make an informed decision.

Download the checklist here.

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

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

Posted by IanBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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

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

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Becoming a GP partner – your questions answered

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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General practice at the precipice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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

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

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Get the skills to support primary care collaboration

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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Guest Blog – My Introduction to Collaborative Working

Posted by IanBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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

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Without GP partners, general practice will lose its Independence

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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Calling All Future GP Partners!

Posted by IanBlogs, The General Practice BlogNo Comments

If you are interested in becoming a GP Partner (or perhaps you are already a new GP Partner) then you will not want to miss our live event in July which aims to answer all of your questions. For all the details see below…

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Six months is a long time in general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

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At-scale general practice must stay independent

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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How to tackle a crisis in your GP Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

What do you do when your practice reaches crisis point, and it is no longer clear whether the practice can even continue? In this presentation Ben Gowland explores the options open to practices, and identifies the avenues practices can pursue who need to consider radical change.

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Tackling growing demand – will GPs be the hero or the victim?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Much of the narrative around GP demand puts GPs and practices into the role of helpless victim, beaten down by the relentless growth in demand without the resources to meet it. But it is more helpful to focus on the practical actions practices can take to gain control over demand, and attempt to become the hero of their own story.

Demand on GP practices is growing. The King’s Fund 2016 study, Understanding pressures in general practice found,

“Our analysis of 30 million patient contacts from 177 practices found that consultations grew by more than 15 per cent between 2010/11 and 2014/15. The number of face-to-face consultations grew by 13 per cent and telephone consultations by 63 per cent. Over the same period, the GP workforce grew by 4.75 per cent and the practice nurse workforce by 2.85 per cent. Funding for primary care as a share of the NHS overall budget fell every year in our five-year study period, from 8.3 per cent to just over 7.9 per cent.”

Natasha Curry from the Nuffield Trust, in her article Fact or fiction? Demand for GP appointments is driving the crisis in general-practice, examined where the rise in demand for appointments was coming from, and found,

“While activity in general practice has increased, most of that increase is amongst staff groups other than GPs. Consultations with GPs rose by approximately 2 per cent, whereas consultations with nurses rose by 8 per cent and consultations with ‘other’ staff (a long list of professionals including pharmacists, physiotherapists, and speech therapists) grew by 18 per cent.”

Introducing new roles is clearly one mechanism practices have been using to manage the growth in demand. Introducing telephone appointments is another. Both have added to the complexity and challenge of the work the GPs actually do see face to face.

What else can practices do? The NHS Alliance considered “potentially avoidable” appointments in their report Making Time in General Practice. They found,

“Overall, 27% of GP appointments were judged by respondents to have been potentially avoidable, with changes to the system around them. The most common potentially avoidable consultations were amendable to action by the practice, often with the support of the CCG. The biggest three categories were where the patient would have been better served by being directed to someone else in the wider primary care team, either within the practice, in the pharmacy or a so-called ‘wellbeing worker’ (e.g. care navigator, peer coach, health trainer or befriender). Together, these three, which could be improved by more active signposting and new support services, accounted for 16% of GP appointments. An additional 1% were to inform a patient that their test result was normal and no further action was needed. A further 1% of appointments would not have been necessary if continuity of care or a clear management plan had been established.”

I recently discussed how “active signposting” works on a recent podcast. It is dependent on creating the alternative routes for patients to follow. Training receptionists will not help, unless at the same time places are established for patients to be signposted to.

Even with the same funding some practices cope well with the level of demand, and some do not. It is not only a function of ability to recruit GPs, or the ability to signpost. I have seen a number of examples where the ratio of GP sessions to patient population is the same or higher, but the ability to cope with the workload is significantly worse. When I have looked into why this is, a key factor appears to be GP generated demand.

GP generated demand are those appointments generated by the doctor (“come back in 4 weeks”) as opposed to those initiated by the patient themselves. While CCGs are working up and down the country to cajole practices into reviewing referral rates (in his paper, Does GP growth in referral link directly to growth in inpatient demand? Dr Rod Jones shows that the answer to his own question is no, and that it leads to a perceived need for higher levels of resource than is really the case), practices might be better focussing their attention on internal GP follow up rates. Rates between individual doctors vary, but the benefits of exploring and managing that variation fall directly to the practice.

Much emphasis, rightly, in general practice is given to continuity of care. Where GPs have their own lists, and know the patients better, they can be much more confident in only bringing those patients back when they know they need to be seen. Where patients simply see the next available Doctor the likelihood of follow-up appointments is higher. So the benefits of continuity of care fall to the practice as well as to the patient.

In practices with high levels of part time working the challenge of achieving this continuity can be higher. Practices in this situation that have managed it well have introduced “buddying” systems, whereby part time GPs work to manage a list together. Practices that have not are often drowning under the weight of the demand.

Use of telephone appointments, introducing new roles, active signposting and managing variation in internal follow-up rates are all actions open to all practices to take control of their own demand. When the status quo is unsustainable, becoming the hero is the only option.

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Case Study: Introducing a “hot” and “cold” appointment split (Part 1)

Posted by IanBlogs, The General Practice BlogNo Comments

In this blog, the first of two from Buckingham GP Dr Rebecca Pryse, she takes us through the practical steps to launching a new appointments system split between Same Day and Any Day appointments. Rebecca will be back later in the spring with a second blog looking at how the change has worked.

So it’s the eve of D Day or “s-D-s Day”: the day we launch our new Same Day Service. We’ve had our final partnership “huddle” at our executive meeting last night; we’ve given the final pep talks to the various teams and here we go.

This has been months in the planning for what feels like a military operation. From the Saturday strategy partners meeting one year ago where I led a “we can’t go on like this /something has to change” discussion around our access and appointment systems; to our lead partner Greg poring over stats, models and spreadsheets at his kitchen table to come up with various proposals; to our management team and IT team testing out these proposals against appointment audits and staffing rotas.

In the middle of all this we went through our second merge, a little more “thrust upon us” than the first merge just over a year before that, making us the only practice in town serving about 30,000 patients. This used up a lot of leadership energy but gave us strength in terms of clinicians (we now have 13 partners, 3 salaried doctors and 7 nurses), staff members (we now have 80 staff), population numbers and a third town centre site to work from. This enabled us to move forward in more exciting ways to change our access system.

So we moved onwards taking a proposed appointment system model to our appointments committee. This is a multidisciplinary group of reps from clinicians, management, staff and several patients who have been meeting over the past 10-15 years since we first changed our appointments from completely open access to an advanced access system – quite novel back then. This group meets intermittently to keep an eye on our access stats and patient feedback and to make constructive suggestions for change. Most recently they helped support and test out the introduction of Patient Access to our patients. The new proposal was discussed over several meetings, tweaked and approved.

Next we took the proposal to our annual “State of the Nation” protected learning afternoon. This is an annual whole staff meeting to which we invite the PPG. The new model was presented to the whole team and this was followed by small group work for each staff group to reflect back their hopes, fears and expectations of the system with some useful and constructive suggestions.

So what model did we finally decide upon? We all agreed that there are broadly two types of access required by patients: I need to see a clinician today and it doesn’t matter who I see and I need to see MY doctor or nurse who knows me best and I can wait for this appointment. We also saw a need for signposting patients first to self-care where appropriate and then to the most appropriate clinician for their problem, which does not necessarily mean a face-to-face encounter.

From these principles we have devised an offer of same day appointments (Same Day Service or SDS) or any day appointments (Any Day Service or ADS). Each service will operate from a different site within the town centre. We have calculated the balance of appointments by looking at the statistics of how appointments are currently accessed, proposing that 60% of our appointments will be made available in the Same Day Service. We have also looked to extend the range of clinicians working from this service to ensure the patients are directed to the most appropriate clinician. This means that the SDS is manned by two GP’s called GP1 & GP2, rather reminiscent of Dr Seuss with GP3 on “special days” that we predict will be busier, one or two minor illness nurses or nurse practitioners, with a paramedic to cover acute visit requests and an HCA to provide urgent diagnostics. All our reception staff have been trained as Care Navigators and patients are being asked to give a brief outline of the problem they wish to bring with an initial question of “could this be dealt with over the telephone” being asked or self care advice given as appropriate. Our paramedic and two of our nurses have just completed the minor illness nurse-training course and two of our nurses already prescribe. We have just appointed a minor illness nurse who fulfills her dream of moving from A&E back to primary care.

In our other two sites the Any Day Service will run: the clinicians here will be offering slightly longer appointments which can be booked in advance by patients who benefit from continuity. There will still be some Same Day availability in this service and these GPs will be offering routine, pre planned visits to appropriate patients. It is planned that all urgent and same day work should be absorbed by the Same Day Service allowing the Any Day GP to plan their day more proactively and offer more complex care as needed without being rushed into 10 minute slots. They will of course keep a view of the SDS and be able to offer support if that system is becoming overloaded. We have recruited a new, additional GP who will start in September. All GPs will work some time in both systems.

In the background all our staff teams have been working hard together to ensure this new system will run smoothly and there is a general buzz of excitement in the practice as sDs-Day has approached, this in itself has felt uplifting to me particularly after they have been through a couple of years of immense change already. So we have all read the protocols and checked the process maps covering all eventualities, looked at the rotas, updated our computer screens ready for tomorrow.

Our practice manager has to be particularly congratulated, as she must be googly-eyed sorting out what has become quite a complex rota. It sounded so simple at the start but when you build in the fact that as well as seeing patients in our three sites, we also run clinics in two boarding schools and one University, we look after 4 nursing homes, we provide one GP session per day to our local community hospital and we are a training practice not only for GPs and practice nurses but for our local Medical school with 2 students in most days seeing patients……… she has politely told us to stop asking if she can sort out any more “tweaks” to her system, just for now, please. But we are keen to work in a PDSA cycle so the snag/learning list will start tomorrow as soon as the front doors open!

Dr Rebecca Pryse is a GP Partner at The Swan Practice in Buckingham. You can contact Rebecca via rebecca.pryse@nhs.net The Practice website is www.theswanpractice.co.uk

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Creating a Training Programme for New GP Partners

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

It is astonishing that despite the huge challenge the lack of GPs wanting to be partners is presenting for general practice, little if any training exists for GPs considering the step up from salaried to partner.

Taking on responsibility for a business, for its staff, for its performance, and for its liabilities, is a big commitment. While in the past GPs took it on because that was the established career route for them, that no longer appears to be the case. Increasingly GPs are opting out of being a partner, and taking on salaried, locum or portfolio careers. Even GPs who had previously become partners are now choosing these alternatives.

This reluctance by some to take on a partnership position, along with the precarious position many practices are now in, is making everyone nervous. Those considering becoming a partner have few places to go to understand exactly what is involved. Dismissing the risks on the basis that others have been able to manage them no longer feels a possibility, and a more considered examination of what is involved is required before such a big decision can be made.

It is into this environment that we are developing a training programme for GP partners. It is for those GPs who are considering becoming a partner, want to understand better what is involved, and want to develop the skills to be a good partner should they choose to make that step. It is also for those GPs who have already made the decision to become a partner, and want training and development to ensure they can be successful in the role.

The programme is in its infancy. We want to develop the programme in partnership with those who need it. Below are all the areas that we are considering including within the programme. What we would like from you is feedback on which areas you think are most important, which areas are not needed, and which areas are missing.

Section 1: Internal – understanding the business

Success Measures: What constitutes success for the practice? Is the practice there to serve patients or to make money? What does independent contractor status really mean?

Partnership: What is a partnership; why partnership agreements are important; what makes a good partnership agreement; building a strong partnership team; “last man standing” and strategies for dealing with it.

People: How to lead people, how to manage people (and understanding the difference!); dealing with difficult people (including other partners!); staff appraisals; staff surveys; team meetings; the importance of coffee.

Finances: Partner financial responsibilities; dealing with accountants; understanding cash flow; how to manage the finances.

Processes: Appointment systems: the good, the bad and the ugly; DNAs; workflow redirection; active signposting. How to implement change within the practice.

Property: Understanding premises; types of ownership of property; leases and rent reimbursement; working with NHS Property Services.

Practice Manager: What to expect from your practice manager; how to get the best out of them; understanding the difference between the role of the practice manager and the role of a GP partner; how to know if you need to change your practice manager and how to do it.

Section 2: External – understanding the environment

NHS: Understanding where GP practices fit within the NHS; the different structures and types of organisation within the NHS and how they impact on GP practices.

Commissioners: Friend or foe? Understanding the GP contract and how it works; understanding the different commissioners; how to build effective relationships with commissioners.

Regulators: The role of the CQC; surviving inspections

Other GP practices: The role of the LMC; why and how to build relationships with other GP practices; overcoming history and other barriers to joint working.

Other external relationships: Should I bother building relationships with other organisations, such as community pharmacy, community trust, local voluntary organisations, local council, local hospital? Who to prioritise; how to do it.

Section 3: Future – understanding the risks

Changing NHS: The changing NHS, including five year forward view, new models of care, STPs.

GP Forward View: What it means now and in the future; how to make the most of it.

Strategic Change: Understanding strategic options for your practice for the future; how to develop them; how to implement them.

Practice mergers: When to consider it, when not to, and how to do it successfully.

Let us know what you think. What do you think the most important training needs are for new GP partners? What would help most for someone about to take on the role? What have we missed? All your feedback greatly appreciated! Please either leave your feedback in the Comment section above or email me ben@ockham.healthcare

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Why £2.4bn is not really £2.4bn

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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General practice organisations explained

Posted by IanBlogs, The General Practice BlogNo Comments

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

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

Posted by IanBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

3. Extended Access is all

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

4. QOF will go, and be “reinvested”

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

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

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

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

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

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

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Putting the pride back into general practice

Posted by IanBlogs, The General Practice BlogNo Comments

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

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

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

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

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

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

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

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

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

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

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

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

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Where has the missing GPFV money gone?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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The Six Stages to Effective GP Recruitment

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In this week’s Blog, guest blogger Nick Mattick demonstrates that GP recruitment cannot be rushed as he outlines the key stages to effective recruitment and spells out the common mistakes practices often make.

It’s a common misunderstanding in GP recruitment that spreading the net as wide as possible and throwing money around will solve the problem. But, in the current recruitment crisis where there are simply not enough GPs to go round, this is unlikely to be the case.

The reality is that your GP vacancy is only likely to appeal to certain people and to attract those people, you need a clearly defined strategy which outlines who they are and how you can target them. The lack of a strategy, or an ill-defined process may not only fail to deliver you any appropriate candidates – it could even lose you applicants who walk away in frustration.

In this blog I am outlining the six key stages to developing such a strategy. They are:

1.Define your candidate – What does the practice want and who is most likely to apply? Focus on who your candidates are likely to be dependent on the type and location of the job on offer. For instance candidates with young families are most likely to want facilities, infrastructure and flexible hours. Whereas those a little longer in the tooth, with the kids off at university, maybe downsizing and wanting to get away from the busy city.

What qualities might a successful candidate possess and how does the practice make itself more attractive to those candidates? Here, you need to consider how the practice will respond to issues such as work/life balance, portfolio roles, specialist training and, perhaps, opportunities to work with other practices to offer more exciting or innovative roles etc.

2.Candidate Attraction – This means getting your defined applicant to see your advert. Your advert is an excellent way to demonstrate what you have to offer candidates. But too often I see lazy adverts which say something bland like; “we’re a friendly team, this is our list size, our IT system and our opening times – come and work for us.” But adverts like those could be for any practice, anywhere in the country. You must find your unique selling point (your USP) and get applicants to become interested in the story you tell about yourself.

For your advert to stand out amongst all the others, you will need to advertise where your defined applicants are likely to be looking, so consider using Google AdWords, LinkedIn and Facebook; these have great tools to really focus on selling your job to the right people.

3.Candidate Handling – How do you deal with applicants once they have expressed an interest? Communication is key. Always acknowledge a CV and give a timeline for your process. Tell applicants what documents you will want from them, and ask them what they want from you.

Have ready all relevant documentation that applicants are likely to need including, as a minimum, the current Job Description and a Person Specification. But also consider CQC reports, Ofsted reports about local schools etc. Offer applicants informal visits and be prepared to help with estate agents or organising house viewings. And don’t forget to ensure your practice website is up-to-date.

4.The Interview – The interview is not just about candidates selling themselves to you; it is your chance to sell yourself to candidates. So be organized on the day and pre-plan questions; agree who will ask what questions when.

A clean, uncluttered, open and light room will put your candidate at ease. Try going informal – don’t sit behind a desk. Offer a tour of the practice and introduce them to colleagues – but most of all, however you do it, make them feel welcomed.

5.Negotiation – Once you have found your candidate you are aiming to achieve a Win: Win. You probably won’t get exactly what you are looking for and you probably aren’t exactly what the candidate is looking for either; so consider how you will “close the deal” and get both parties as close as possible to what they are looking for. Agree in advance what are “red lines” and what’s up for discussion. Many people, when recruiting, think it’s all about the money – but in most cases it isn’t. Find out what’s really most important to a candidate.

6.On-boarding – This is about getting your candidate to the start line and to hit the ground running. It’s more difficult in GP recruitment because of the long notice periods that lock GPs into jobs – usually for 3-6 months; so make sure you continue to engage with your candidate during this time.

Invite them to practice meetings or social events, offer help with finding somewhere to live, get all the paperwork and compliance done in advance and offer them an induction session before starting. Keep up the communication and start forming relationships early.

If you’re looking for an urgent start consider “buying them out” of their notice period. On Day One make sure you are ready for them to start with email and log-ins available, a list of who’s who and housekeeping issues clear such as how the phones work and how to get refreshments; and even think about, as a particularly nice touch – a welcome gift!

In essence then the key lessons for GP recruitment are:

Recruitment is not something that can be done over a sandwich at your desk – it requires a lot of effort, work and planning.

Don’t expect to place an ad in the BMJ and have candidates queuing at the door; you have to work for them.
It will take some compromise.
Don’t be locked into a mindset of replacing like for like recruitment is an opportunity to change, to freshen things up.
Recruitment is all about up-front planning, a clear process, adapting and communicating.
Above all – you need to sell, sell, sell!

Nick Mattick is an expert in Clinical Recruitment & Recruitment Strategy. Nick has worked for NHS and private healthcare service providers and recruitment agencies. You can contact Nick:

Call 029 2051 2517 or email Nicolas.mattick@me.com

www.OliverRose.net

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mar

1 0

Transforming general practice: The CCG Dilemma

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

CCGs face a choice. They want to support GP practices to make the changes necessary to get out of their current malaise and to play a more active role in change across the wider system. To do this there are two approaches CCGs can take. Their dilemma is which one to choose.

The first approach is the easiest choice to make. CCGs focus on changes that will impact on all practices. So for example this might be creating incentive systems for practices to get involved in things like managing the complex frail elderly. It may even look like offering services for practices working together, for example to offer extended access. The £3 per head for general practice is divided up evenly for all the practices, and everyone gets their fair share. The proposals are acceptable to the practices, the LMC is happy, and they are deemed equitable by all.

The problem is no actual transformation happens. Practices continue to struggle, emergency admissions continue to rise, and the distance between general practice and the rest of the system does not really change.

The second approach is more challenging to implement. CCGs focus on supporting the small number of practices most likely to drive transformation. They do not make funding and development opportunities available to all. Instead they identify the most dynamic and progressive practices, the ones with a track record of making changes, who are actively seeking to grow, and who have leaders who can make things happen. The CCGs invest in these practices. They ask them what support and resources they need, and they provide it. They work with them to develop solutions that work for general practice as well as the whole system.

It is not an approach that will be popular. The majority of practices will be against it because they will see an uneven share of resources flowing to the “favoured few”. CCG board members whose practices are not part of the selected group will be against it, and they will become representatives of practices who not only are struggling but are now not receiving any further investment. LMCs will be against it because they have a responsibility to represent the wishes of all practices.

But popularity of an approach is not a great indicator of its chances of success. The question for CCGs is do they want the changes in general practice to happen at the pace of the quickest, or the pace of the slowest? The problems in general practice require radical change; changes many practices are not prepared to take. Working with those most likely to make these changes is a far more sensible strategy than it might first appear.

Practices who can make change happen can work with CCGs to overcome the initial resistance. The natural GP leaders are by definition already in these practices. With support they can bring the rest of the practices along. It can still be an inclusive strategy – it just has a different starting point.

The stark reality is the transformation of 7800 GP practices will not happen at the same pace. We are already seeing a small number of practices embracing the need for change and making the most of the opportunities that exist to make themselves fit for the future. But many practices are stuck, unable to find a way forward or to overcome the internal resistance to making the necessary changes. I would argue that hanging on the coattails of those who are moving forward, and focussing support, time and energy into them, is the only approach that will actually deliver results.

mar

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10 Surprising Lessons from over 50 Podcast Guests

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I had just finished an hour long interview (by Skype) for the podcast. The conversation had gone well, and I was excited by the quality of the content. As usual, I started to upload the recording for editing. Only nothing was happening. Panic started to well in the pit of my stomach, as I pressed buttons and searched for the audio file. But the file wasn’t there. The conversation hadn’t recorded.

I am not a technical person. I don’t have a background in radio or recording. I started the podcast as a platform for great practice, new ways of working and innovation in general practice to be shared. Learning how to use the kit has probably been my steepest curve, but I have learned other things (about GPs, about general practice, about podcasts as a platform for sharing) from the many guests I have had the privilege of interviewing. Here are the 10 most surprising:

Very few GPs use Skype. With all the chat about Skype GP consultations this wasn’t a problem I predicted, but I would say over half of the GPs I have spoken to had to set up an account (or ask their teenage children to set up an account for them).
Academics are rarely given a platform to discuss the implications of their research. When academics produce research they become very clear about what it does and doesn’t prove or say. However, here in the real world we are interested about the application of their research to our daily lives. Some academics have loved the opportunity to explore this, but most feel well outside of their comfort zone!
The non-GP general practice workforce doesn’t feel heard. When we talk about general practice most of us immediately think GPs. But there is a whole other “hidden” workforce out there of nurses and other clinical staff, as well as the practice managers and administration teams. These groups do not feel well represented, and the podcasts involving these groups have had tremendous support from their peers.
Physician associates can add real value. A year ago when I discussed new clinical roles in general practice with GPs many were quite open to the idea, except for physician associates; the mere mention of whom usually provoked a withering look. However, our occasional podcast series exploring their impact has shown they can add tremendous value to practices.
Locums are not all bad. An even less popular group than physician associates are GP locums. Last year we explored why GPs become locums, and the concept of GP locum chambers, and learned in a world where there are not enough GPs we need to find ways to make the most of this critical resource.
It is not just GP practices that are independent, it is also those providing support to GP practices. We all know there are c7800 GP practices who contract independently with the NHS. Less well known is that what this in turn leads to is a sporadic and independent group of individuals and small companies that provide support to general practice. You won’t find many commissions for the big four consultancy firms from individual practices!
The changes with the biggest impact are not necessarily the most complex. The change that I have seen with the biggest impact is “workflow optimisation” or, alternatively, “keeping the post away from the GPs”. It can save up to an hour of GP time per day.
Great editing can perform miracles. Not everyone who comes onto the podcast is a fluent orator. But listening to the podcast you wouldn’t necessarily know it. On the other hand I have finished recording interviews and wondered whether there will be any tape left that we can actually use, once the stumbling and disjointed sentences have been removed. But out of the editing suite come these coherent, intelligible productions that make both me and the guest sound great.
Being on the podcast creates opportunities for guests. I am not sure I anticipated how positive an experience being on the podcast could be for those being interviewed. For example, I recently received a note from previous guest Mia Skelly who said, “People’s general feedback has been very complimentary and it’s given me some wonderful opportunities to continue to promote general practice nursing”.
The Ben Gowland podcast is not the best name for a general practice podcast. When I came up with the title I thought it sounded good(!), and I have been surprised to learn that 1) the title in no way explains what the podcast is about, and 2) people not knowing what it is about can make it harder to access. As a result, we are going to go for the slightly clearer but less narcissistic title “The General Practice Podcast” from April.

Maybe only some or even none of these things surprise you. But they all surprised me, and I am looking forward to continue being surprised by the second year of the show. Thank you for all your support over the last year, and if there any changes (other than the title!) you think we should be making, please do get in touch.

feb

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Why making change in general practice is difficult

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I wanted to leave my job as a CCG Chief Executive for a long time. But it took many months until I finally handed in my notice. I was nostalgic about the past, and clung to memories of a time when I had loved the job. My attachment made leaving difficult. Despite the relentless, day to day pressure there was always this nagging concern; if I left I would no longer be needed in the same way. And I was not 100% clear what my new future would look like. In many ways a bleak certainty was easier to cope with than the uncertainty of the unknown.

I don’t think I am alone. Letting go (of control, of certainty, of routine) is difficult for all of us. Unfortunately, nearly all of the things that can make a difference for general practice seem to involve GPs “letting go” in some guise or other. So, for example:

Practice mergers. These involve GPs “letting go” of the control of their (smaller) practice for a lower amount of control in a bigger practice.
Introducing new roles. Bringing in clinical pharmacists, paramedics, physician associates and the like involves GPs “letting go” of some of their workload so others can take this on.
Workflow redirection. If you have not come across this yet you should (listen to this), but effectively it involves GPs “letting go” of their post, and trusting much of it to be handled by others.
New models of care. Okay, not yet a common solution but a designated national direction of travel, and it involves GP partners “letting go” of their independence and becoming salaried employees or, at best, board members in an NHS organisation.

This is why making change in general practice is difficult. It is why practices don’t merge, don’t introduce new roles, don’t make changes to how they operate, and don’t jump into bed with the local hospital just because they are under pressure. The changes may be logically sensible to an outsider, but if they are not underpinned by a strong desire to take whatever action is needed they won’t be implemented.

The big mistake made by those trying to lead change in general practice is starting with the solution, with a description of the change that is to be implemented. Taking the desire to actually make the change for granted, on the basis of the parlous state of general practice, is a fast track to failure.

Professor John Kotter, regarded by many as the leading contemporary expert on change, believes[1] assuming people know they are in trouble and need to change, and focussing instead on strategy and solutions, is what kills most change efforts. He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change.

Ultimately I made my decision to leave based on a strong desire to create a new future for myself. After many months of anxiety, frustration, and (frankly) inaction, I reached a point of determination to make a change, however hard it would be. It was only then I was able to actually resign. To be successful, those leading change in general practice must first focus on establishing a sense of urgency for change, before ploughing into the details of the uncertain future they want to create for their GP colleagues.

[1] A Sense of Urgency, Kotter J.P. Harvard Business Review Press, 2008

feb

0 1

Why the new GP contract is disappointing

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

There has been a cautiously positive reaction to the GP contract. But for at least one enthusiast for general practice, it doesn’t live up to its promise. Here, Ben Gowland explains his huge disappointment…

The GP Forward View was published in April last year. It promised an additional recurrent investment of £2.4bn into general practice. But for all its rhetoric, the finances have been hard to pin down. After a raft of national pots of money that have all translated into very little at local level, all hopes were pinned on additional money arriving in the core contract.

And has it? Well in 2015/16 the contract was uplifted by £220m, the equivalent of 3.2%. That was pre-GPFV. So what was the outcome of the 2016/17 contract, the first one after the publication of the GPFV? An uplift of £239m, or 3.3%. An almost identical award.

What does it mean for the promised additional £2.4bn? Well at the current rate of uplift, which does not like it will change, an additional £1.3bn will have been added by 2020/21. The global numbers sound a lot, but the reality is last year’s contract award did little to assuage the problems faced by general practice, and there is no reason to believe that similar uplifts next year and for three years afterwards will have a greater impact. The rises continue to be offset by a parallel growth in costs.

The tinkering with the elements of the contract, and moving money from one part of the contract to another, really only acts as a smokescreen for the overall failure to invest. It creates opportunities for people who don’t understand general practice to complain about specific elements (e.g. funding the cost of CQC registration), and leads to odd behaviours (e.g. locums increasing their fees by 2% because of the indemnity reimbursement).

The only significant recurrent additional funding in the GPFV, on top of the contract awards, is the funding for additional access. This is £500m, and we know it translates into £6 per head of population. But it is not funding for individual practices. The sites involved in the prime minister’s challenge fund, which receive the money recurrently from April onwards, have to bid for a large single contract. So it is only really available to large organisations. Plus, individual practices just don’t want to do it. As one GP explained to me, if a practice receives what amounts to £115 per patient for 8 – 6.30 Monday to Friday, why would they extend that to 8 to 8 7 days a week for an additional £6 per patient?

So where is the rest of the GPFV money? £2.4bn has been promised. £1.3bn will be in the core contract. £500m is for extended access. Where is the other £600m? I have not yet met anyone who can answer this. It begs the question as to whether it will ever arrive.

Worse, NHS England are predicting a £70m underspend on primary care and public health budgets this year. An underspend that will offset an overspend in the acute sector. Changes to the tariff have pushed many CCGs into financial difficulties, and it seems unlikely all will be able to meet the requirement to provide £3 a head to general practice in the next 2 years. And it is not official, but I am yet to meet someone who does not believe the promised £900m capital fund (the Estate and Technology Transformation Fund, or ETTF) has been cut.

The GPFV made specific promises about putting funding into general practice. This year’s contract award was the last chance for NHS England to demonstrate it was going to meet these promises. But the contract disappoints, and instead reinforces a growing belief these promises are never going to be met.

feb

0 0

GP Mergers – A Blessed Union?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In the first of a short series of guest blogs, Robert McCartney warns that the marriage of two practices will only be a success when there is a healthy pre-nuptial agreement between both parties.

Mergers are the ultimate form of marriage between GP practices. When they include the consolidation of the contract into a single patient list it becomes incredibly difficult, maybe impossible, to separate them again. As a consequence, the parties must understand the commitment they are entering into as there is no easy divorce.

During my recent podcast with Ben Gowland at Ockham Healthcare I stated that spending the time understanding and sharing a common vision of the future is essential. This applies to the relationship analogy. The most successful marriages are built upon a shared vision for their future, an understanding that there may be challenges but they will be overcome together and a trust that your partner will support you despite the occasional disagreements.

If the ‘soft’ merger elements linked to developing the relationships, like creating a shared vision and building a framework for the future of the partnership are rushed, the ‘hard’ formal merger steps may still happen but it increases the likelihood that the merger will fail.

Practices are currently under immense pressure and time is not a luxury many GPs have. Whereas a corporate merger may take months or even years to achieve, GP practices are looking to complete the process within a few months.

Fortunately, unlike a marriage there are some firm, definable objectives that all practices will be working towards. By ensuring that the parties focus on these at the earliest possible opportunity the ‘dating’ process can be accelerated with a reduced degree of risk.

The parties need to be willing to be forthcoming and ‘lay their cards on the table’ at an earlier stage than they may otherwise want to do. This openness is essential. In the past year, I have seen proposed mergers fall apart for a range of reasons based on people not being open until far too late in the process. This includes; forgetting significant funding repayment plans on properties; an unrealistic expectation as to equivalent sessional pay; and, despite comments to the contrary in the initial discussions, a complete refusal to consider using allied health professionals.

I have found that practices considering mergers have benefitted from having an independent third party facilitate and structure these discussions. This is especially important where time is of the essence. They are the pre-marriage counsellors focused on ensuring the merged practice is built on firm foundations.

For more information or if you would like support in any merger process you are considering or undertaking please do not hesitate to contact me.

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

feb

0 0

The Future of GP Visiting

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In his latest blog Ben reflects on attempts to set up an outsourced GP visiting service and what it taught him about the way GP practices innovate.

A few years ago, when I was working in a GP federation, we set up a GP visiting service. The basic premise of the service was that, because GPs were so busy, they were not able to meet all the patient requests for visits. As a result, we hypothesised, patients were being admitted to hospital when an admission could potentially have been avoided if a visit had taken place. So we funded a pilot in which the out-of-hours service provided a GP to carry out visits during the day that they would not otherwise have been able to carry out.

Do you think it worked? It didn’t. The service was not fully utilised (despite only one GP being available for 30 practices). Uptake was limited to a relatively small number of practices, with many of the practices rarely, if ever, using the service. It was not possible to produce any correlation between the service itself and emergency admission rates (which instead stubbornly continued to rise), and, unsurprisingly, the pilot was stopped.

Contrast this with a practice I visited recently. There they have paramedics for 6 sessions a week, who carry out 5 or 6 visits a day, for a practice that in total undertakes between 7 and 10 visits a day. There are clear parameters in place for visits the paramedic will undertake and those that are best carried out by a GP, e.g. palliative care visits. The practice is extremely happy with the service and is soon to increase the number of paramedic sessions from 6 to 8.

In Shropshire the local out-of-hours provider Shropdoc has developed an Urgent Care Practitioner role in which staff with a paramedic, nursing or physician associate background are trained to be able to offer (amongst other things) home visits for GP practices. The role is proving extremely popular both with staff and practices alike. You can see a video of the service here.

A visit for a GP, with all of the travel involved, is a time consuming activity. While average consultation times may average 8-10 minutes, the total time required for a visit is at least double that, and often much more. Practices vary considerably in the number of visits they undertake. A recent comparison across five practices working in the same town revealed a fivefold difference in visit rates – varying from an average of 0.2 visits per 1000 patient population per day, to 1 visit per 1000 patient population per day.

So where did I go wrong with the GP visiting service we instituted, and what are others now doing right? I think I failed to fully understand visits are an integral part of the service a GP practice offers. Any attempts to change the way they are carried out must be fully owned and bought into by the GPs in the practice. Trying to “outsource” visits to a separate agency that does not know the patients is unlikely to work. A more successful approach is to use other roles, as long as they operate under the guidance of the GPs and not separate from them.

Equally, success in the redesign of GP visits cannot in isolation be measured by the number of emergency admissions. It is the continuity of care GP practices offer that will ultimately support patients to manage their conditions effectively. Freeing up scarce GP time to be deployed where it is needed most (which, paradoxically, will sometimes be in a patient’s home) is now a critical factor in enabling this, and would have been a much better measure of success.

It is hard to replace the long hours GPs work (at no extra cost) with a paramedic or nurse practitioner in a small, cash-strapped practice. As practices become bigger they have more freedom and more flexibility to experiment with different systems for triaging requests for visits, with the introduction of new roles, and with new ways of working for visits.

In my attempts to set up a visiting service I should have remembered that most successful change in general practice is generated within the practice itself, not imposed from outside. Changing the system for practice visits proved to be no exception. In future, as practices become larger they will have more capacity to test different ways of working and that is one of the reasons I established Ockham Healthcare; to support and promote the many innovations that will inevitably result.

jan

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The New Multispecialty Community Provider (MCP) contract and CCGs

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In his second summary of the new MCP contract Ben looks at the likely impact on CCGs – and finds it is a case of “out with the new and in with the old”…

What does the new MCP contract mean for CCGs? Well, for all the range of documents published only two target specific groups: general practice (which was not surprising); and commissioners (which was). This was the first major clue that major upheaval is at hand.

The second clue was the way the document on MCPs and the commissioning system starts, “the new models… will not remove the established boundary between commissioning and provision. CCG statutory functions will not change”. You know trouble is coming when a document begins with what is not going to change.

The document then basically says while the statutory duties of CCGs will remain (so no acts of parliament required), most of what they actually do can (and will) be discharged through MCPs. It provides a list which states the only activities CCGs can undertake that MCPs can’t is: produce an annual commissioning plan; develop outcome measures and monitoring for MCPs; take responsibility for the overall performance of the local health care system; and create a contract to spread risk between the MCP and the CCG, as well as have responsibility for providers outside of the scope of the MCP. I.e. not much.

Interestingly it is in the finance document not the commissioning document where it is explicitly stated that management funding will transfer from the CCG to the new MCP: “an assessment will be made of current CCG and CSU spend on activities carried out by the MCP that will support commissioning. The value of this spend will transfer from CCG admin budgets to the MCP whole population budget”.

As a consequence we will need less CCGs, so the residual statutory functions can be carried out at lower cost. To really understand the following quote, insert “will have to” for “may want to” (it is only existing legislation that precludes the document from being more directive), “CCGs may want to consider whether the establishment of a new care model means that it would be appropriate to pool functions and management arrangements with neighbouring CCGs. This may be the case where an MCP or PACS cover the entirety or bulk of the CCG area; and where key CCG staff and capability will transfer to the new provider. In some cases the CCG may want to consider merger with another CCG.”

Even then CCGs won’t operate separately from the MCPs. “CCGs and new care model providers should maximise opportunities for making shared use of administrative resources. For example, creating and operating successful new care models will require a new set of information management and analytical approaches by both CCGs and providers… CCGs and new care model providers should look at how they might work together to develop a shared business intelligence capability rather than invest in potentially more costly separate functions. The same applies to other back office functions e.g. payroll.”

Of course, in the “virtual” MCP model, the changes are not so drastic. When I was looking at the draft of the alliance agreement for the virtual model, at first I was confused by the inclusion of commissioners on the alliance leadership team. Isn’t the point of an MCP that it is an integration of providers, deciding together how to deliver services? But, the document explains, they are included because their role is to make changes to underlying service contracts as a result of agreements within the alliance.

This makes sense in the context of MCPs taking over the lion’s share of what is currently considered commissioning. The only difference is in the virtual model the staff are still employed by the CCG and have not yet transferred their employment. In the partial and fully integrated models these staff will transfer and be responsible for “sub-contracting” between the MCP and its linked providers.

So MCPs carry out a range of commissioning functions, directly provide community services, include public health, and have a relationship based on section 75 agreements with social care. Is there something familiar here? Indeed, there is. The partially integrated model in particular is extremely similar to the (pre-transforming community services) primary care trusts. Everything above, plus a separate national GP contract but an ability to create local enhanced services, GPs as part of the management team (remember PECs?), and a clear role as system leader (integrator). For all the packaging of the new models of care as new and exciting, the new partially integrated model in particular will have to work hard to explain how it will be different from that particular version of the past.

In summary, the impact on commissioners of the formation of a local MCP is the end of a local CCG, and the creation of larger (more distant) CCGs focussed on a much narrower range of functions, and the creation of MCPs as integrated organisations that will undertake many of the existing commissioning functions, and which may or may not look like the old PCTs.

jan

1 0

The New Multispecialty Community Provider (MCP) Contract

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

Just before Christmas NHS England published a draft of the proposed new MCP contract, along with a set of supporting documentation (15 documents in all). In this latest Blog Ben Gowland considers the implications of these documents, and what it all means for general practice.

First, it is important to clarify this is not a new GP contract. The documentation clarifies it thus, “The (MCP) contract itself is not a contract with GP practices. GP participation with the MCP would be underpinned though an alliance agreement or the integration agreement in addition to the existing GMS/PMS/APMS contract, or through moving directly to work as employees for, or sub-contractors to, and MCP”. We will come to “alliance” and “integration” agreements shortly, but for now all talk of a “new GP contract” is misleading, because that is not what this is. Rather it is a contract with a new entity, an “MCP”.

So what is an MCP? It is a new provider, that brings together (“integrates”) existing providers. The range of these providers can vary, but it can include general practice, community trusts, social care, public health and specialised services. There are three different levels of “integration”, and the greater the integration, the greater the loss of independence for the participating organisations, and the greater the autonomy for the new MCP organisation. Along this spectrum there is a virtual MCP, a partially integrated MCP, and a fully integrated MCP. I will explore each of these in more detail below.

Virtual MCP. In this model no new organisation is actually formed and an MCP is not actually created. The existing contracts between commissioners and individual providers remain. The key difference is that an “alliance agreement” is put in place between the providers (including with the GP practices). The aim of this agreement is to “establish an improved financial, governance and contractual framework for the delivery of services”. There is a legal framework for the agreement supplied in the documentation (over 30 pages long), and it contains more specific actions than simply agreeing working together is a good idea. The more interesting things to note about it are: 1) the responsibility for establishing the alliance agreement in the first place lies with the providers wanting to create the virtual MCP; 2) an “alliance leadership team” is required, with representatives from all of the participating organisations that will make decisions in relation to the alliance; and 3) it can allow for GP practice participation in any local gain/loss mechanisms agreed for activity outside of the MCP (i.e. with the acute trust).

So while an MCP is not really created, the alliance agreement is still potentially powerful, as it creates a mechanism for collective decision making binding upon the members of the alliance, and as such represents the first step away from independence for participating GP practices. Equally it enables GP practices to positively benefit from gains made by the different organisations working together.

Partially Integrated MCP. In this model the contracts of the providers, with the exception of primary medical services, are brought together. So this time a new organisation, an MCP, is actually created, but separate contracts are held with general practice.

But it is not quite as simple as that. It is only the core contracts that are held separately from the MCP. The MCP contract requires it to ensure that its services and GMS/PMS are operationally integrated, to deliver seamless care for patients. Non-core income is clearly a mechanism to enable this, a point which is addressed thus, “We recognise that some GPs are concerned about the potential to lose non-core income and whether local enhanced services would be included in the MCP contract scope to ensure that their delivery is managed in an integrated way with other MCP services. If they are, local agreements could well see GPs delivering these, or additional services, as sub-contractors to the MCP. Local discussion will need to take account of these issues as GP participation in the model is agreed, including the maintenance of appropriate practice income”. So where there is a partially integrated MCP, practices will get core income from their existing commissioner (CCG or NHS England depending on level of delegation), and non-core income as a sub-contractor of the MCP.

Other financial impacts on practices are that practices can be offered an alternative to QOF to align practice incentives with that of the MCP. There may also be the opportunity to participate in the gain/loss share arrangements the MCP develops, which are essentially for levels of acute activity. Noteworthy here is that at one point the guidance states, “GPs in some areas are exploring the possibility of agreeing a gain-only agreement with the MCP”.

In this partially integrated model there is what it is described as an “integration agreement” between all the providers who are coming together to form the MCP, including the GP practices who are receiving core services via a separate contract. This is a much more directive document than the alliance agreement in the virtual model. This is because the document exists to ensure there is sufficient involvement of primary care, and what it does is create a framework for shared governance and decision making with the practices, and sets out the primary care contribution to the MCP model. A template integration agreement is included in the set of documents, and it contains elements such as, “all share in the savings generated by reduction in acute activity”, “GPs work towards reducing variation and unnecessary admissions (where appropriate) by agreeing a common set of protocols with the MCP”, “practices will make their booking system accessible to the MCP under local agreed protocols”, and “GPs will work with the MCP to achieve local primary access requirements”.

The partially integrated model therefore marks a further step away from the level of independence practices currently enjoy. The agreement is governed by an “integration leadership team”, on which all participating practices are represented, but which can decide and monitor how integration takes place. And again, “it will be for the MCP contract bidder to demonstrate that agreement has been reached with local practices on the Integration Agreement”.

Fully Integrated MCP. The third and most radical model is a new MCP organisation that includes core general practice, either via termination or a suspension of the current contracts. Immediately the whole ‘right to return’ question for existing GMS/PMS contracts raises its head, and this is dealt with in the document. Practices can reactivate their contracts either at expiry or termination of the MCP contract (which will be 10-15 years in length), or at regular two year intervals throughout its lifetime. The only sting in the tail is that, “A GP considering a return to GMS/PMS will need to articulate how the care the patient will receive from the new practice will compare to the care provided by the MCP”.

GPs and practice staff become salaried employees of the new MCP organisation, the terms of which they must negotiate directly with those leading the new MCP. They will receive rent for their premises via the funding that is first transferred to the MCP, and it will be up to the GPs to agree with the MCP the terms on which these payments will be passed on. The guidance states, “For GPs there may be an option to explore the sale of their premises to the MCP on mutually acceptable terms, though we would expect this to only take place in limited circumstances where there was clear value for money”. And in the fully integrated model indemnity cover for GPs and practice staff will be paid for by the MCP as the employing organisation.

A point to note on the fully integrated model is that the draft contract is based on APMS conditions. This means practices who choose to join will be giving up their existing GMS/PMS conditions and in the new model will be bound by APMS conditions. While you can argue it is the new MCP provider that is technically bound by these terms, the reality is that the expectations of provision of services of the GPs within the new organisation will be the delivery of what is in effect an APMS contract. Now the documentation does have a side note, stating, “In due course all such provisions will be amended to reflect or refer to the appropriate provisions of forthcoming Directions specific to MCP/PACS contracts”. I suspect the development of these terms may be a critical factor in the attractiveness or otherwise of the model, and a process GPs will very much want the GPC to be part of. As this process unfolds it will be interesting to see the extent to which the development of the fully integrated model actually represents a move away from a nationally negotiated GP contract.

So the fully integrated option means the end of independent general practice as we know it. While, as one of the documents states, “some GPs will prefer to move to the MCP as employees to improve their work life balance”, others are undoubtedly going to need some significant persuading.

Even those most evangelical about MCPs recognise the engagement of general practice is both critical and yet at the same time difficult to secure. A dedicated document is included on GP participation in an MCP. It comes up with the following reasons as to why GPs should consider it:

It can give GPs a more manageable and rewarding workload
It provides a contractual framework to share work between practices
It creates wider development opportunities for GPs that enable greater job satisfaction, including the opportunity to influence the wider system
It gives GPs greater influence over financial and staff resources, and over community services, and allows resources to be put where they are most needed
It gives access to a broader, more in-depth range of services in primary care settings
It will enable multidisciplinary team working that reduces handoffs for general practice
It has the potential to increase recruitment and improve retention for general practice by providing a structure for a larger primary care team

But with the promises of what the formation of CCGs could offer practices still ringing hollow in the ears of many GPs, and a commitment for much of this to happen anyway through the GPFV, none of this strikes me as overly convincing. It is either going to have provide a way out for practices who have had enough, or a route to really channelling additional resources into general practice if take up at any sort of significant scale is going to happen.

One route that would potentially give GPs more confidence this is going to happen is if the MCP organisation itself is owned by the GPs. This is referenced as an option, as a company limited by shares or a limited liability partnership. But new MCPs will need capital for start-up costs to deliver the infrastructure, working capital to pay salaries etc ahead of receipt of revenues, and contingency reserves. In the cash-strapped environment of the NHS it seems highly unlikely that many, if any, GP-owned models will emerge, as the incentives to put up this type of capital do not seem strong enough. Much more likely is that an existing NHS organisation will own or host the new MCP organisations. At best, we might see joint ventures between GP and NHS organisations.

The documentation refers on a number of occasions to “mixed economies”, where different practices from the same area choose different levels of sign up to the local MCP model, in particular with some choosing the partially integrated relationship and others the fully integrated. Where this happens it will be interesting to see the impact it has on the power of the voice of general practice, and whether it will be diminished. Even where local practices want to move together, it is not hard to envisage a situation where any failing practices or ones that return their list are “fully integrated” by commissioners at the earliest opportunity, meaning mixed economies are created anyway. Once the wheels are in motion, they may become difficult to stop.

GPs, then, will be considering the potential benefits on offer, and deciding whether the MCP route, with its associated costs to independence and the glimpse these documents provide to a future weighed down under the burden of NHS bureaucracy, is the best one for delivering them. Whilst there has been a growing disillusionment with independent practitioner status in recent years, support for it remains at well over 50%. My sense is the energy behind the primary care home movement, and the current shift towards collaboration and federation of practices, may represent not a step towards MCPs, but the creation of a more acceptable alternative to it, one that enables practices to build system relationships, take on new roles, change the way they manage demand, but at the same time maintain control over their own destiny.

Next week Ben will look at the implications of the new contract for CCGs

jan

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Top Five Countdown – Our Most Popular Podcasts of 2016

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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…

dec

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Recent Developments in General Practice: Autumn 2016

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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!

dec

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Welcome to the club – the rise of Leg Clubs

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Guest Blog by Amanda Brookes, Locality/Projects Manager – Bradford-On-Avon and Melksham

Anyone working in general practice cannot fail to be aware of the misery that leg ulcers bring to their patients; regular attendances and multiple medications, legs wrapped like the Michelin man, the discomfort and the smell. No wonder so many patients end up with depression and social isolation.

But, as I discovered, it doesn’t have to be that way.

In 2008 the practices I worked for established a provider company and won a bid to provide the Level 2 Leg Ulcer Contract to sixteen practices in West Wiltshire. As we developed our specialist team of nurses and HCAs it became clear to me that the treatment of leg ulcers was a neglected area and that patients were suffering unnecessarily; there had to be an alternative. At the same time, with my Business Manager head on, I was concerned with the costs of multiple attendances and the rising cost of specialist bandaging.

Although I am not a clinician, in 2010 I attended the annual conference of the Lindsay Leg Club Foundation and was immensely inspired by Ellie Lindsay OBE and the model for Leg Clubs which she had developed in the mid-nineties.

Ellie was an ex-District Nurse and had set up around 25 Leg Clubs, led by District Nurses who invite housebound, potentially socially isolated patients into a social setting for care and chat. Her results on healing and recurrence rates were excellent. I invited her to talk to our Leg Ulcer team and we were so impressed we began talks locally on how this model might be made to work in primary care.

For those who don’t know, a Leg Club is an evidence-based initiative which provides community-based treatment, health promotion, education, ongoing care and social activities for people of all age groups who are experiencing leg-related problems.

Following a merger with two smaller practices, our original patient base of 14,000 grew to over 20,000 which resulted in more patients with leg ulcers and a lack of space. This was the ideal push we needed and we began to pursue the Leg Club model in earnest.

The doctors and nurses I worked with were incredibly enthusiastic but it was difficult to gain interest from those who held the purse strings. So we began a very time-consuming and frustrating hunt for sources of money. It was at this time, after running a number of community events with charitable organisations, that I came to the realisation that leg ulcers are not sexy!

It became bit of a running joke with colleagues, every-time I met anyone who could help or would listen, I talked Leg Clubs! I’m afraid I became mildly obsessed and evangelical but it paid off in the end when the Friends of Bradford on Avon Community Health Care gave me £12,000 of funding. Others then followed.

And it turns out the model can very much be made to work in primary care. General practice nurses provide the drop-in clinical support (through six stations) in a local community hall and we have a Doppler machine as part of a patient’s first assessment. A committee made up of Leg Club members is in control of the social side which includes activities such as a Balance and Falls Class, structured short walks program, an arts group, access to a podiatrist, support from a care co-ordinator, dementia advisor and ad hoc speakers such as Carers Support and Age UK – all of which remain accessible to members even once their legs are healed.

We estimate that members coming to the Leg Club have saved the practice around 20 appointments a week. The well-leg regime has no funds attached – but as our recurrence rates fell over two years from 75% to 25% there is evidence that it is a cost effective model. Membership is at 600, and legs are now healed in an average of 12 weeks, whereas in 2014 it was 19-24 weeks.

It is a constant battle to raise funds for the social side but we have regular fund raising events and local industry partners are very important.

The patients love attending the Club and the nurses love it also because they are not constricted by time; consequently the atmosphere is positive and fun. The practice likes it because it has reduced the number of times this group of patients come to the surgery and in many cases, their mental wellbeing has improved.

If you are thinking of setting up a Leg Club yourself then I strongly recommend you contact the Lindsay Leg Club Foundation (information at www.legclub.org– and you’ll see us on there!)

There is a lot of planning, fundraising and awareness-raising to be done before a Leg Club opens. There needs to be a Champion or Lead with the passion to take this project forward; it’s hard work and needs on-going support once the club opens. Nurses need to be trained in the infection control standards for community based care as well as admin staff to learn how the patient record and audits are produced. The Leg Club Foundation carries out an audit once a year by an independent clinical consultant and keeps a check that all the standards are being met and are safe. The Club submits weekly audits and any corrections are fed back to us to rectify.

I know I have become evangelical about Leg Clubs, but for a reason. They do work clinically, they make business sense and they provide a better service for patients. But if you are still not convinced you can either watch our short video on the subject here or contact me via email at amanda.brookes@nhs.net

nov

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Where to start with CCG GPFV plans

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The crisis in general practice has led to individual practices making changes, on their own at first and then increasingly together. CCGs should be facilitating this process through their GPFV plans rather than introducing big picture change, argues Ben Gowland.

There is something going on in general practice. Change is afoot. While nationally all of the talk and rhetoric is around STPs, new models of care and operating at scale, practices seem to be taking a different approach. CCGs should take note.

At the risk of stating the obvious, general practice is not one organisation. It is 7800 independent, individual business units, all operating in their own way. While the contract they deliver against is (essentially) a national one, how they choose to deliver against that contract is up to them. And it varies significantly. No two practices work in the same way.

Despite its obvious drawbacks, this variation has created a huge opportunity. For every single practice there are better ways they could be doing at least some things. For some practices there are better ways they could be doing most things. And as the crisis in general practice has started to bite, the response has been (as is the way of general practice) pragmatic. Practices are starting to focus on how they do things internally. “How we have always done things around here” is no longer good enough, because it no longer works.

What is starting to emerge are changes with quite astonishing results. Hours of administration time removed because of changes to the way documents are handled. Huge reductions in DNA rates because of changes to the way appointments, and cancellations, are handled. Swathes of clinical work moved from GPs as a result of the introduction of different types of clinician into the practice team. New types of appointment creating more efficient ways of meeting the ever increasing demand. The lives of the duty doctors being literally transformed by internal re-shaping of how appointments are handled.

Making the first real change is always the most difficult. But once achieved it often creates a thirst for more. Practices that were previously impenetrable islands suddenly let the drawbridge down, keen to share their success with others, and are newly open to learning from the success of others. This sharing brings mutual success, builds trust and strengthens relationships that had grown cold through the winter of the crisis.

And out of this trust and these relationships further improvements and changes are found to be possible. Accountancy fees, indemnity fees, regulation costs (and more) are starting to be reduced by practices working together. More new roles are introduced. GP-led multidisciplinary teams enable practices to tackle the workload in different ways, freeing up GP time for the patients who need it most. Once the rock is moving, it develops pace, energy and impact, and more and more is achieved.

All around the country (but not everywhere) this is starting to happen. The hard bit is the first step – recognising there are other ways to do things, and then making the first change happen inside the practice. Talking about big picture change in locality or CCG meetings is not what is important. Arguments about the rights or wrongs of MCPs won’t help. It is only doing something differently at the individual practice level that has an impact, that can get things moving.

Which brings me to CCG GPFV plans. General practice is still in crisis. Don’t turn the plan into a strategic template for the introduction of MCPs, or a way to fulfil a requirement for 7 day working when 5 days is currently out of reach, or the creation of complex bidding processes for limited pots of money in the name of “equity”. Instead, use the plans to help practices take the first step, or if they have taken the first step the second, or the third, or whichever is the next step to build the momentum local practices need to find a way out of their current predicament.

nov

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What the Changes to General Practice Mean for Primary Care Premises

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The secret to what will happen in the future to primary care premises lies in the past. Understanding the current crisis in general practice provides vital clues as to the impact the new models of care and the like will have on estates.

The growth in demand on general practice (the number of consultations per head of population has more than doubled in recent years, in addition to the overall population growth) has not been matched by a similar growth in resources. The general practice estate is no longer big enough. Worse, the growth in regulation and the shift to NHS Property Services means the existing estate is becoming more and more of a cost pressure. Even though new, bigger premises are desirable, they are not necessarily affordable.

There are also less and less GP partners. In the last 10 years the number of GP partners has dropped by 9% while the number of salaried GPs has increased by 260%. As GP partners have become harder to recruit, many places have had to look at how to drop the requirement to buy into the property in order to attract new partners. As a result, GPs and GP practices are increasingly looking to “cash in” their property.

To cope with the pressures, general practice is making changes to the way it operates. New roles, such as pharmacists, physiotherapists and paramedics are being introduced to the practice; but only, of course, where they have the space. Less commonly, but increasingly representing the overall direction of travel, a number of places such as St Austell, Plymouth and Hampshire, are operating an urgent care “hub” – a single site where all of the on the day demand is seen by a multidisciplinary team, freeing up space on the other sites for longer planned and follow up appointments. And bigger practices are considering whether consolidation onto a smaller number of sites is possible in future.

But surely the Estates and Technology Fund has been put in place to address the estates problems in general practice? While the reduction in the match funding requirement is welcome (down from 33% to 0%), few practices so far have been able to benefit from the fund, especially compared to the number who spent hours completing the paperwork to bid for it in the first place. Revenue consequences of new builds remain a problem for practices and CCGs alike, and the old notion that these simply have to be “absorbed” no longer washes.

The challenges general practice is experiencing mean some are looking to partner with other organisations to more effectively manage the demand. We are seeing more examples of practices joining up with volunteers and voluntary groups to offer more holistic care, and of practices trying to build links with community services. But space is a real barrier for many. Partnership working inevitably means some degree of co-location, and practices are not sat on empty rooms, waiting to be filled.

It may be that as a result of the new Sustainability and Transformation Plans (STPs) we have a reversion to some sensible join up of strategic estates planning, which will incorporate primary care premises. But it will need to happen quickly. In the meantime, the reality is that the new multispecialty community provider (MCP) and Primary and Acute Care Services (PACS) models offer a way out for general practice. When we dig underneath why GP practices are signing up to these new models, it is largely because these new contracts are offering to buy them out of their premises. Without this incentive, it is hard to see much movement towards them.

The pressure on general practice is such at present that if an attractive way out is presented, many are likely to take it. In the future, the trend will be to an increasing split of “hot” and “cold” GP sites, accelerated by the funding on its way for additional GP access. The move to operating at scale will ultimately lead to a reduction rather than an increase in the number of GP practice sites. And the development of MCPs and PACS models will see the estates increasingly owned by the community and acute trusts, within these new organisational forms.

nov

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The one new role every single GP practice should adopt

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In all the work I have done on new roles in general practice, the role I have probably paid least attention to is that of “medical assistant”. They are tucked away within the Releasing Capacity in General Practice programme, under high impact change number 4, “Develop the team”, bullet point 5. It is small wonder they get overlooked!

Plus they are not really new roles. It is actually training for existing administration staff, specifically those who code, to be able to read, code and action incoming clinical correspondence according to agreed protocols, as opposed to passing everything on to the GPs.

But the impact is huge. I visited a practice recently who had implemented this system, and they were evangelical about the benefits! According to them the new system was saving each GP up to an hour a day. When the biggest pressure on GPs is workload it is not hard to understand why a change that can make a difference like this is so popular.

Not only is the GP time saved, but coding actually improves, and the administration staff undertaking the new way of working enjoy it and feel like they are contributing more to the practice.

Here is how it works. A lead GP from the practice is put in charge of working out how the different mail coming into the practice can be processed. The starting point is a set of protocols, worked out from practices where this has already been introduced. They really just require tweaking to reflect the specific needs of each individual practice, and then reviewing over time to continually refine them. The aim is to reduce the number of letters that need to be processed by a GP.

So for example if there is a letter informing the GP a patient has failed to attend a mental health appointment, the agreed action could be “book telephone appointment with the GP”. Instead of the letter going backwards and forwards between the clerical staff and the GPs, the action is implemented straight away. If the practice wants a different process to be followed for this particular pathway, it can set its own rules for the clerical staff to follow. Meanwhile letters that the GP absolutely needs to see, such as a safeguarding issue or a serious or complex diagnosis, are passed straight on to a doctor.

The other key difference is that instead of the letters going to the GP to outline what needs to be coded, and the letter then coming back to the coders, the clerical team will code directly from the letter. After the initial training, the lead GP audits and checks and feeds back very regularly at first, but then increasingly infrequently, as the clerical team develop the skill set. The wasted GP time is cut out of the loop.

The practice I visited, who had been refining the system in their practice over 3 or 4 months, estimated a reduction of 70 to 80% in the correspondence now going to GPs, compared to before the introduction of the scheme.

This new way of working, which I have seen termed “workflow redirection”, “workflow optimisation” and “document handling”, depends very much on the oversight, governance and audit within the practice from the GP lead for it, and the new skills and new way of working of the administration team, or “medical assistants”. The practice I visited did feel that it increased the administration burden on the clerical team, and they had to increase capacity to absorb the additional requirements. The team in Brighton who first developed the change suggest it requires an additional 3.5 admin hours per day per 5,000 patients. You can see the video they have produced about the change here.

Introducing medical assistants might not be the sexiest of changes developed to support the challenges facing general practice at present, but it may well prove to be one of the most useful. If you are struggling to make any change at all in your practice, I would highly recommend you start with this one. Start with just one GP’s letters. Measure the benefits. Others will soon become interested!

nov

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Who Can Represent General Practice Locally?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

To ensure they are adequately heard in the development of STPs, GP practices need a strong and clear voice. But who will represent them? In his latest blog Ben argues that there are a number of options but ultimately local GPs must decide this for themselves.

There is not always strength in numbers. While there are 7875 GP practices, there are only 154 acute trusts, yet the influence of the latter appears far larger in the development of the 44 local Sustainability and Transformation Plans (STPs). Worse, the numbers work against practices: while it is possible for every acute trust to be represented on STPs (there are an average 3.5 acute trusts per STP), the same is not true for every GP practice (there are an average 179 GP practices per STP).

Does this matter? Is representation important? General practice has left many of these things alone in the past and in the main has avoided what would have been a colossal waste of their time. But the world is shifting. Alongside the ever growing pressure on resources, providers are being asked to come together and decide for themselves how what little money there is should be spent. Instead of a series of bilateral agreements between the different providers and a system arbiter, the STPs are looking for a single agreement across all parties.

In the past general practice could ignore local developments, protected by a single, nationally negotiated contract. But now the NHS is shifting to a series of bespoke, local agreements. Much of the promised additional £2.4bn for general practice is coming outside of the core contract. New, local, multispecialty community provider (MCP) contracts are emerging, with much more room for local negotiation than was ever possible with the national GP contract. It is a brave GP practice that will allow the other providers in the system to determine how much funding, and with what strings, they should receive.

So if we accept it is not possible for 179 practices to all represent themselves in local discussions, even if only for practical and logistical reasons, who should represent them? Insufficient thought and effort has so far been put into resolving this question, not only by local systems but also by practices themselves. In many cases the local system has decided how general practice is to be represented. But if I ran a practice, I would want to make that decision myself, along with my fellow practices.

There are a number of options available. First, the CCG could represent its practices. It is after all a membership organisation and each practice is a member of its local CCG. The problem comes because the remit of CCGs extends across all providers, and they continually have to go to extraordinary lengths to demonstrate they are not favouring their member practices. It is more or less impossible for CCGs to both carry out their role as CCGs and simultaneously represent general practice effectively.

Second, the RCGP could represent general practice. The RCGP has appointed RCGP ambassadors for each of the 44 STP areas, whose role (according to the RCGP website) is to “maximise investment in general practice at a local level, track developments, and make sure that GPs have a very strong voice in the GP Forward View across England”. The RCGP is supposed to focus on improving patient care, clinical standards and GP training, and while I am sure the RCGP ambassadors are a good thing for general practice, it is hard to see them having the mandate or infrastructure to be able to adequately represent practices in local negotiations.

There are two more realistic options. The first is the local LMC. Their explicit purpose is, after all, to represent general practice. There is often resistance to their inclusion, as they are seen more as a trade union than as a reasonable representative of GP practices. Their leaders are rarely viewed, for example, in the same way that an acute trust CEO might be viewed. But they are statutory bodies, funded by a statutory levy on practices. Tracey Vell, leader of the LMCs in Greater Manchester, argues it is essential LMCs talk for GP practices in STP discussions, and also recounts how it was only through grit and determination that she was able to ensure they gained a voice around the table in Manchester.

Second, the local federation(s) could represent general practice. This is tricky because federations vary so significantly in the way they are set up and what they have been established to do. Where their role is to generate and deliver additional services across a group of practices, local practices can become resentful pretty quickly if the local federation leaders are seen to overstep the mark and assume they can talk on behalf of their member practices. But equally where one of the reasons for the local federation is to strengthen the voice of the member practices then this can work really well.

Nothing of course is stopping GP practices setting up a federation just for this purpose. If they don’t feel (for whatever reason) that the way they are being represented is satisfactory, they can create a federation, appoint a spokesperson, and all they would need to fund between them is the cost of that person’s time.

It is also not unreasonable for there to be more than one voice for general practice. If the 3.5 acute trusts in each STP area each have their own voice, then general practice can reasonably expect to have more than one voice. In Manchester they have a “GP Advisory group” which contains the federation and LMC leaders, and then this group has a voice on the main board, mirroring arrangements for the acute trusts.

We are at a point in time when local representation of GP practices, and the establishment of a strong voice for those practices, is more important than ever before. Unusually, GP practices need this representation more than the system needs it. If effective representation has not yet been achieved, it is GP practices themselves who now need to take responsibility for making it happen.

nov

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Inspired by Indemnity (seriously)

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Occasionally you talk to people who are inspiring, and I am very lucky that through the podcast I have the opportunity to speak to inspiring people more frequently than most. Recently I spoke to one such individual – Tawhid Juneja, founder and director of Primary Care People, who got me excited about professional indemnity for GPs. I know! You can hear the conversation here

Indemnity is one of those issues you either understand because you have to (ie you are a GP) or you simply consign to the “too complex and not interesting enough to spend time understanding” box. But for anyone involved in general practice it is becoming increasingly difficult to ignore. Costs are spiralling. The average cost is up from £5200 in 2010 to £7900 in 2016, a rise of over 50%. This in itself masks the real rise as in that period GPs have reduced their number of sessions. NHS England in its 2016 GP Indemnity Review estimated the real inflationary cost is 10% per year. As costs rise GPs reduce their sessions further, the profession becomes less and less attractive, and the staffing crisis will continue to deepen.

The NHS England report was disappointing in that it accepted the claims of the three medical defence organisations that cover 99% of GPs, who argued there is sufficient competition (based on the fact that 40% of GPs have switched between the three in recent years), and concluded the only real long term solution is operational measures to reduce negligence claims in primary care. The cost is the cost etc.

But having spoken to Tawhid, I don’t agree. He has spent the last couple of years establishing his own commercial indemnity support scheme for the GPs working for his organisation. He has been able to reduce the cost of indemnity by employing interims rather than locums (ie GPs prepared to sign up to a minimum of 6 months with one organisation), guaranteeing a certain number of GPs to be covered under the scheme, agreeing an excess that he then pays on behalf of the GPs he employs, and introducing certain quality standards both to the GPs he employs and the placements to which he assigns them to reduce the risk of claims.

Tawhid pays for the indemnity of the staff he employs and places. As a result, he can make it cheaper for the practices, enable the GPs he employs to have a greater take home pay, and turn a profit for his own organisation. He has singlehandedly demonstrated that something can be done!

Think of the possibilities this creates for general practice operating at scale. What is to stop super-practices from developing their own scheme, just as Tawhid as done? They could operate the same conditions: minimum 6 months with one organisation; guarantee a certain number of GPs to be covered; and agree quality standards and placement standards across their practices with the underwriters to secure a better deal for their members. It could be for all the salaried doctors across the practices to start off with, or the ambition could even be for all the GPs.

It won’t be easy. GPs, instead of having cover anywhere for anything, would be covered only for working in specific locations. Because of this some will dismiss it out of hand, but it is no different from indemnity secured by an NHS organisation for its staff through the NHS Litigation Authority scheme. It will require GPs adhering to certain standards of practice, such as minimum consultation times, maximum numbers of consultation per session – but is that such a bad thing? And if that in itself accelerates the introduction of changes to general practice (overflow hubs and the like), again isn’t that exactly what the profession is crying out for?

We have entered a vicious spiral of decline, whereby the worse the working conditions for GPs, the greater the chances of claims, the less GPs will work, and the worse the conditions will become (and so on). The only option is to break the cycle. We can use indemnity to make it happen. Insist on the standards. Reduce the claims. Decrease the cost of cover. Use the absolute requirement to adhere to the standards to accelerate the changes in general practice.

Disruptive entrepreneurs like Tawhid may not be everyone’s cup of tea, but individuals like him are what is needed to shake the profession out of its current predicament. Instead of avoiding indemnity it is time to tackle it head on, and use it as a lever to drive through the changes that no one disputes are necessary.

oct

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Make General Practice your CCG’s Priority

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What will the GPs working in CCGs leave behind when clinical commissioning has been dismantled? Ben Gowland argues that now is the time for them to consider this legacy and to act swiftly and single-mindedly…

This week Simon Stevens exhorted GPs on CCG Governing Bodies to ensure the money promised to general practice reaches its intended destination. He condemned the compounded impact of a decade of disinvestment in primary care, and reaffirmed the necessity of changing the trend to one of investment above the rate of the rest of the NHS. Mr Stevens declared the final destination of the GP Forward View money the responsibility of GPs.

At the same event Professor Steve Field, CQC Chief Inspector of Primary Care, declared an inspectorate for general practice is only needed because local GP leaders have not done their job properly. The CQC is a necessary evil caused only, according to Professor Field, by the failures of local GP leadership.

These declarations will rankle with GPs. CCGs in many areas do not have, and never have had, responsibility for the commissioning of general practice. They are castigated on an almost daily basis for their failure to monitor conflicts of interest thoroughly and effectively, and for allowing their particular part of the system to slide into financial imbalance. And now suddenly we have bewilderment expressed at a national level as to how GPs in the form of CCGs could have been given the purse strings and at the same time allow general practice to fall into its current parlous state.

At the same time, clinical commissioning is being discreetly dismantled. STPs, local accountable care organisations, and devolution are working together to diminish the role of commissioning. Ever since the shift from competition to integration with the publication of the Five Year Forward View, power has been stripped from those attempting to use contractual levers and plurality of provision to effect change. Unachievable financial pressures have been added to CCGs to “even up” the playing field between commissioners and providers, so all can “share the pain equally”.

What is a GP on a CCG Governing Body to make of all of this? What should they do?

It is time to think legacy. It is time to look forward 5 years and think what impact did I have on local general practice? What did I do that made a real difference?

The door has been opened. Simon Stevens and Steve Field are telling you, explicitly, it is your job and your responsibility to support general practice. Take them at their word. Do everything in your power to ensure the GP Forward View money reaches general practice. Reverse the trend of disinvestment and ensure funding for general practice reaches 10 or even 11% of local NHS expenditure.

Hold your own CCG to account for increasing its investment in general practice. Use delegated commissioning to shift the focus of the CCG away from the acute trusts and onto the stated national priority of general practice. Be single minded. Use the opportunity.

Time is limited. You are now being berated at a national, as well as (I assume) a local, level for not using the situation you are in to make a difference to general practice. Stop listening to those who are persuading you the right thing is to forego investment for the sake of financial balance, or that the CCG can’t afford to create its share of the £171m earmarked from core CCG allocations for general practice.

The time for self-sacrifice is over. It is not serving you or your local population. However uncomfortable it feels to say to a room of stakeholders, all desperate for commissioner money, that you have weighed up all their needs and have decided to give it to yourself and your colleagues, that is what you have to do. Putting general practice, primary care and all of out of hospital care first is a national priority. Make it yours.

oct

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How I Discovered the Future of General Practice

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Looking at solutions for the problems facing general practice and learning from those who have already got it right inspired Ben Gowland and his team at Ockham Healthcare to write a book. In his latest blog Ben explains why the resultant book should be essential reading for anyone with an interest in general practice.

General practice is a difficult problem to solve. Few now dispute the profession is in crisis, and yet despite the publication of the General Practice Forward View (GPFV) we seem no nearer to a consensus on what the future of general practice will look like.

When I left my role in the CCG I started by trying to really understand the problems general practice was experiencing. I visited a range of different practices and spoke to many GPs and found the problems were even worse than I had imagined. You can watch the TV documentary I made about this here.

I then started talking to people; to GPs, practices, and sometimes whole areas, who had found a way through the problems. There are nearly 8000 GP practices in England, and while many are struggling, some have found a way through and are thriving. I wanted to learn from what they had done, and I wanted to share that learning with others. In February this year we started publishing The Ben Gowland Podcast every week – short recordings of conversations I have had with those who have found a way through the problems general practice is experiencing.

As I listened to the experiences of both those who had found answers and those who were struggling, I was struck by the realisation in many cases both had tried to do the same things. Practices who were struggling had joined a federation but it had made no difference. Practices that were thriving had formed a federation and it had had a transformative effect. I realised there is no simple “answer” to general practice, no single solution that can be applied to solve the current crisis. How an answer is implemented is often more important than the answer itself.

So to find a way forward, a future, for general practice, I believe the best place to start is those practices that have made the future a reality already. Rather than starting with a hypothesis and testing whether it will work in general practice, it is better to start with what has worked already and try and capture the learning of how this happened for others. And to this effect we decided to publish a book, one that took real life case studies of what has worked in general practice, and then used those case studies to extract the learning for others.

In the book we have been able to capture the experiences of those who have made operating at scale work, and use these to identify 10 practical steps for other practices to follow. These steps are the difference between practices losing £20,000 each of investment in a new federation that never goes anywhere, to being able to reduce costs, grow income and manage workload better. They are not rocket science. They include things like, for example, ‘being upfront about the commitment needed for each practice’ and ‘ensuring the right motivation’ of each practice who you are going to operate at scale with, but they are critical to ultimate success.

Equally the book contains the same for introducing new roles, introducing new models of care, and it even considers how CCGs and commissioners can have a transformative impact on their local practices. The book starts with the case studies, analyses what they have in common, and distils the learning so that others can do more than find an answer – they can learn how to make the answer work for them.

The Future of General Practice: Real Life Case Studies of Innovation and New Ways of Working is out today (Monday 10^th October). You can buy your copy here. The future of general practice requires more than an understanding of what solutions can help. It needs an understanding of how to implement these solutions in a way that will enable a new future to be created. The book provides both.

oct

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Community Engagement and Social Prescribing in General Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In a guest blog this week, Sheinaz Stansfield, a Practice Manager from Gateshead, gives an insight into how community engagement and social prescribing is making a real difference in her practice. If you want to read more about Sheinaz’s practice they appear as a case study in our new book “The Future of General Practice; Real Life Case Studies in Innovation and New Ways of Working”. The book can be purchased here

It was snowing in Gateshead at 9am on the Friday before the bank holiday. On leaving the surgery I bumped into Jez, a homeless patient, recently released from prison. I was late for a meeting and he followed me out, cold wet and hungry, when he burst into tears. I gave him some money for breakfast and asked him to wait for me in a local café. By this time, I was also cold, wet and very late – but I had a warm car to escape to.

Working jointly with the 3^rd sector, the practice had just won some funding to manage people with complex need; those who were too complex for us to manage in primary care, but not complex enough to fit the criteria for other local services. We have many such patients; those who have GP appointments several times a week, because of social issues impacting on their health and cannot possibly be addressed through the health system alone. People who have nowhere else to go.

At Oxford Terrace and Rawling Road Medical Group in Gateshead, our social prescribing is led by two Primary Care Navigators (HCA’S). Having developed an extensive “dynamic” directory of services, they are well respected and known to all of the statutory and non-statutory services within our GP catchment area. Jez and others like him are also known to them and we have worked with a local charity Fulfilling Lives, and won transformation funding (from the local Authority) to test a new model of care. We were meeting that morning to develop a mobilisation plan.

The meeting was attended by our practice based complex care team, who take a patient-centred approach to case management. The team consists of our frailty nurse, care navigators, occupational therapist and community matron. Between us we were able to identify the first half dozen patients for Alex, the co-ordinator. Jez fitted the bill perfectly. I introduced Alex to him as her first patient!

A core component of this service will be to identify peer mentors as volunteers for befriending and support. Fortuitously, my next engagement was a training session for Practice Health Champions. We have 39, who work with us as volunteers leading various groups including knit ‘n’ natter, reading, walking and others. They also host events for patients including a flu fair, summer health fair and an annual Christmas dinner on Christmas day. A new event for this year will be a veteran’s engagement event and a full WW2 re-enactment on 11^th November! Such is the power of unleashing energy to connect patients’ skills and passion with staff commitment.

This morning we were welcoming 10 new volunteers into the fold. The training was developed and led by other champions, facilitated by the practice, hosted by a local charity. Therefore, there was no additional cost to the health and wellbeing system. We were connecting local resources, building alliances around patient need and supporting each other to help the most vulnerable and dispossessed people in our community. There is no funding in the GP contracting mechanism for us to do this work, we do it because we care, it adds value and we are passionate about our people.

We have many Practice Health Champions with enduring mental health problems running these groups. Two champions, recovering alcoholics, run the men’s group and the Practice Facebook page. With training and support, they will become our first two peer mentors, for this new service.

My afternoon was spent back at the desk, trying to navigate my way through the tangled bureaucratic mess that is the transformation fund (GP Premises). I was interrupted by a phone call from a neighbouring Practice Manager, wondering how she was going to manage demand with two partners retiring and no applicants for the vacancies. We talked about social prescribing and the complex care team.

At this point I decided to call it a day. At 6pm as I left the practice, one patient was waiting in the waiting room, the sun was shining. Reflecting on my day, I smiled at the patient on my way out, looking forward to the long weekend ahead. My day job as a Practice Manager is full of “bad” NHS rules that block and frustrate most of our attempts to care for people the way they need to be taken care of. Today though, we had made a difference to at least one person, who might have otherwise spent the long weekend on a park bench, tired, cold and hungry.

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sep

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What does the NHS Planning Guidance mean for General Practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Every year CCGs receive planning guidance from NHS England, which tells them what needs to be included in their local plans for the coming year. In his latest Blog Ben Gowland explains in detail what this latest round of guidance means and why this year is different – and not all good news.

This year there have been a few changes to the Planning Guidance. The guidance has been produced earlier, in September, and plans and contracts are to be complete and signed by December, and cover 2 years instead of one. Each CCG has to produce a local GP Forward View plan by 23^rd December (regardless, it seems, of whether they have chosen to take on delegated responsibility for the direct commissioning of general practice or not).

So what can general practice learn from the newly published guidance? The detail it contains (along with the subsequent local plan) was only ever going to be one part of a 3-piece jigsaw – the other two parts being the national GP contract award and the local STP plan. Combined these three will give us a really good picture of what the real impact of the GPFV is going to be in the coming years. But a few things stand out.

For a start, the headline £2.4bn uplift, so prevalent and heavily featured in the GPFV, does not get a mention. In some ways I understand this as the £2.4bn was set for 2020/21 and the guidance is only until 2018/19, but nonetheless it is a concern.

This concern is exacerbated when the starting point for investment is the NHS England 5 year allocations for primary care. The final per capita growth in 2017/18 is 2.41% (compared to 3.16% in 2016/17), an amount that varies considerably across the country (from 0.45% in NHS South Norfolk CCG to 10% in NHS Islington CCG). In 2018/19 it is lower still, at 1.75%. Across the 5 years these allocations create a £1.1bn recurrent investment in General Practice, which on its own will not be enough to increase the general practice share of total NHS expenditure nor keep up with inflation of expenses in general practice.

That isn’t of course the end of the story. What was exciting about the GPFV was the other recurrent £1.3bn that would make up the £2.4bn, as well as a promised £508M non-recurrent package of investment in the meantime. The new guidance contains more details of both of these.

£500m of the additional recurrent £1.3bn was always going to come for access. What the guidance says about this is that in 2017/18 and in 2018/19 the GP access fund sites (formerly the Prime Minister’s Challenge Fund sites) will receive £6 per weighted head of population. The CCGs without GP access fund sites will receive £3.34 per head in 2018/19, and £6 per head from 2019/20. This isn’t great news for 2017/18, because according to the GPC £6 per weighted head of population is less than the GP access fund sites currently receive, and if you are not a GP access fund site you won’t be receiving any additional access money until the year after.

For this money, CCGs have to commission services 8am-8pm during the week, and at weekends, “provide access to pre-bookable and same day appointments… to meet local population needs”. At least 8-8 on Saturdays and Sundays has been avoided. In capacity terms they must provide an additional 30 minutes extra consultation capacity per 1000 population, rising to an extra 45 minutes.

Where the remaining £800m of the £1.3bn is going to come from is still something of a mystery. The guidance says further investment will come from:

Increases in funding for GP trainees funded by Health Education England

Increases in funding for nationally procured GP IT systems

Increases in the section 7A funding for public health services, which support payments to GPs for screening and immunisation services

3,000 new fully funded practice-based mental health therapists to help transform the way mental health services are delivered

But none of that feels like real money coming into practices. It will be interesting to see whether money will come to practices to directly employ mental health therapists, but if that was the plan I think more would have been made of it by now. But maybe this gap provides an opportunity for investment into the core contract, or into general practice via the STP plans. We will need the other two pieces of the jigsaw to find that out.

This still leaves the promised non-recurrent investment of £508m. The headline here is that CCGs have to find £171m of it from their core allocations (i.e. they haven’t been given any extra money for it), and this equates to £3 per head. This money is to, “stimulate development of at scale providers for improved access, stimulate implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice”. CCGs can choose whether to give this to practices in 2017/18 or 2018/19, or spread it across the two years. The guidance also says CCG funding to general practice should increase beyond the level of their core allocations (2.14% in 2017/18 and 2.15% in 2018/19), but I can’t imagine for one minute cash-strapped CCGs will be able to fund this on top of the £3 per head.

This non-recurrent fund also contains a number of other smaller pots:

Online general practice consultation software systems – £15m available in 2017/18 and £20m in 2018/19, specification yet to be shared.
Training care navigators and medical assistants for all practices – £10m available in each of 17/18 and 18/19, specification yet to be shared
General Practice Resilience programme – £8m available in each of 17/18 and 18/19 (compared to £16m this year)
Time for Care national development programme – nationally funded, CCGs to identify a senior local leader

At the same time NHS England will be investing (non-recurrently) in international recruitment of GPs, clinical pharmacists in general practice (3 years funding for practices), and expansion of physician associates, medical assistants and physiotherapists. The bids put forward for capital investment are also being considered.

And that is it. The significant investments are essentially those for access and the £3 a head by CCGs. What we are left with is a sense that the two year planning timeframe could work against practices in areas that don’t have a GP access fund site, and so won’t be receiving any additional access money next year, and whose CCG chooses to invest its £3 per head in 2018/19. For them, unless there is significant assistance coming via the STP plan or the national contract negotiation, 2017/18 could well be an even more difficult year than the one we are currently in.

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sep

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5 Steps to Introduce Innovation in a GP Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Knocked back at every turn when you try to introduce innovation into your practice? You are not alone. But, in his latest blog, Ben Gowland clears a bit of wood so you can see the trees and presents five steps to introducing change…

Everyone in general practice agrees things need to be different, but as soon as specific changes are mentioned barriers go up. Words from Sir Sam Everington declaring the need for Skype consultations to become the norm in general practice send shivers down the spine of most GPs. Likewise declarations that the traditional partnership model is dead, and that “super-practices” and their ilk must become the new norm.

GPs readily admit the need for change, for innovation, but not Skype consultations or super-practices. Or telephone consultations. Or physicians associates. Or social prescribing (whatever that is).

How do practices wanting to make change overcome this particular problem? In the flat decision-making structure that makes up most GP partnerships, overcoming this type of resistance is especially challenging, because not everyone wants to take risks, not everyone is on board, and focus on the bigger picture easily gets lost.

Let’s take an example: the employment of a clinical pharmacist by a GP practice. Let’s say one partner is particularly in favour, and puts forward the case. Some partners are not going to want to take the risk. They are going to see the (definite) financial outlay with an only probable financial return. Some will be against the idea on the grounds that a pharmacist can’t possibly do the job of a GP (I know they are not trying to, but you can picture the discussion).

The discussion goes on. The longer it goes on, the less it is about tackling the problem of unmanageable workload, and the more it is about whether taking a risk on a pharmacist is a good idea. The vision is lost, and the focus is on the detail. Eventually, after a long discussion by the partners, the practice decides to pass on the opportunity to employ a pharmacist. Everyone still agrees innovation is needed, just not this one.

It is not always like this. I have spoken to a large number of practices that have successfully introduced innovations and changed the way they have done things. I have asked them how they did it, and how they managed to overcome the barriers others could not. I have grouped what they said into 5 steps to introduce innovation in a GP practice:

Don’t start with the solution, start with the problem. Any practice looking to make changes will be doing so for a reason. If the workload is unmanageable, the workload is unmanageable. Focus the initial discussion on this as the problem, and establish a sense of urgency that something must be done. Be clear that no change is not an option.
Develop options. Giving a choice of options empowers decision makers. Listening to the arguments of those against an option can help develop even better options. In our pharmacist example we could offer a range of different roles, or reduced drawings to fund extra GP sessions, or merger with another practice as ways of coping with the unmanageable workload. Keep the focus on solving the problem, not on any specific solution.
Create a critical mass of support. There will nearly always be someone in any GP practice who is against whatever the change is. Once it has become clear which is the best option it may be that those most in favour of the change need to do some work outside of the meetings to firm up support for the change. It is all too common for one all powerful voice to continually veto the introduction of any meaningful change. Where this is happening others need to work together and plan how to get the final approval required.
Create a worked up solution that reduces risk. A good way of getting the change to happen is to provide a way out, whether that is a review after 6 months or a short term contract before offering a permanent one. At this point the work of those in favour of the change is only beginning. They need to mentor and support the new recruit, manage their introduction into the practice, support their professional development, and problem solve with them. The experience of those who have done this is that 6 months later the practice can’t imagine how it ever coped without the new member of staff in place.
Use one successful change to enable further change. When practices agree to make one big change, and have a positive experience of it, they are much more likely to take a risk on the next one, and make further and further innovations. It is no coincidence that practices who introduce new roles are often larger, building whole system partnerships, and looking for ways to make the new models of care work for them.

Identifying innovations is relatively easy. Getting them to happen in your practice is not. The innovation problem in general practice is not a lack of ideas, but the difficulty of adoption, and of changing the behaviour that goes with it.

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sep

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On the Day Demand

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

We don’t really understand demand in general practice. The big message from the Kings Fund report earlier in the year, Understanding Pressures in General Practice, was the need to create the ability to measure this demand. The West of England AHSN published Measuring Demand in General Practice which found,

“A lack of research in this area and a lack of continuity in national projects aimed at supporting GP practices to understand demand… Work with GP practices revealed no definitive or widespread approach to measuring demand in primary care. However, it confirmed that practices and CCGs were struggling to cope with apparently increasing demand and were very keen to engage in further activities that might help understand and manage it better.” p3

We do, however, know some things. We know the population is growing. We know people are living longer and morbidity is increasing. We know people are becoming more demanding. We know there is a GP recruitment crisis. We know 71% of GPs identify workload as the top factor negatively impacting on a career in general practice. We know waiting times for an appointment are going up.

Clearly there are no straightforward answers to the challenge growing demand presents, but is there anything that can help? In the past we had ‘advanced access’ (you can find the evaluation of this here), then came telephone appointments, and more recently based web-based systems, Skype and e-consultations.

I always find starting with the answer to be a mistake. Better to understand the problem as best we can, and develop solutions from there. There is a limited capacity (and shortage) of GPs, which cannot meet the totality of the demand. Demand is rising faster than the population or its underlying morbidity, which means demand is presenting now that previously patients would have managed themselves. There is a growing cohort of patients with complex multimorbidity. Continuity of care is needed for some patients but not for all, but is particularly important for this complex group. All this suggests efforts to access additional or different capacity to meet the less complex demand, and free up GP time to focus on the more complex demand, are those most likely to be successful.

The other place to look is to see what others are doing. The practices I have seen that are dealing with the pressures best all seem to split demand into two. They split the demand that presents on the day (on the day demand) from the demand that comes from the management of patients with ongoing chronic conditions, some of whom are highly complex (ongoing demand). They find demand for the former constitutes a large proportion of the demand on a practice, and they have found different ways of creating capacity to meet this demand.

Some have introduced new roles in to practices specifically to help meet this demand. Some have gone as far as creating a multidisciplinary team, led by a GP, for this specific purpose. Some have used joint working with other practices to enable a collective approach. They have set up ‘urgent care hubs’ or the like to manage on the day demand across multiple practices in one place, with an extended team and a range of roles. Some have used partnerships with the local community trust, ambulance service or acute trust to access the additional skills and capacity they need to help meet this demand.

Many of these sites have found by making these changes they have been able to free up more GP time for the ongoing demand, for the more complex patients, and some have been able to increase appointment times for these patients to 15 minutes, or even longer.

Changing how on the day demand is dealt with can do two really important things. It can ease the overall pressure on the practice, and it can create more capacity for GPs to focus on the ongoing demand and provide continuity of care where it is most needed. The specific changes individual practices choose to make will always need to be tailored to the individual local circumstances. But the principles behind the changes remain the same: consider on the day demand and ongoing demand separately, find new ways of creating capacity to meet the on the day demand, and this in turn will free up more expert GP capacity to meet the ongoing demand.

sep

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Recent Developments in General Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

You are now up to date! If you want to keep it that way, become an Ockham subscriber and we will send you (free) weekly updates so you don’t a miss a thing.

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Locality Hubs: The Perfect Opportunity?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The BMA has produced a new document, ‘Safe Working in General Practice’. Now you might assume, particularly if you have read the accompanying headlines, this is simply a call for a limit to general practice workload and to establish 15-minute appointment times. But you would be wrong.

The document is actually about the introduction of what it terms ‘locality hubs’. These provide additional primary care capacity in a locality, delivered through multidisciplinary teams, and are created as a result of collaboration between practices. They operate as a place where triage can be managed centrally, and on-the-day demand can be managed across multiple practices in one location using a much wider skill mix.

The concept is not new. It was introduced in the General Practice Forward View (GPFV), where they were described as primary care access centres. The BMA say,

‘The sole initial purpose of locality hubs is the stabilisation and sustainability of general practice. Hubs are not walk-in centres: each hub would help manage demand across a number of practices and their respective patient lists, ensuring that patients in excess of safe working limits can still be seen by a GP or the wider primary care health team.’ p5

While the presentation by the BMA is in terms of a protection of core general practice, the reality is the model they are supporting is highly progressive. It incorporates all the key features of ‘modern’ general practice: the introduction of new roles; general practice operating at scale; the integration of practices with the wider health and social care community; and the development of the new models of care.

There is an unusual alignment in that the profession itself needs exactly what the wider NHS needs, manifested in these locality hubs. At the same time as providing support for core general practice, the system receives better access, more responsiveness, and an ability to deliver more joined up care, particularly between community services and general practice.

The sticking point is normally the funding. But as the BMA rightly point out, the funding has already been identified. The GPFV promises a further £500m per year recurrently from 2020/21 for extended GP access, and £171m between now and then from CCGs to support the development of this capacity. There is no obvious other route for this capacity to be delivered. There are no more GPs. Existing practices cannot take on any more work. This has to be the answer.

In what could be viewed as a once in a lifetime event, the stars are perfectly aligned. The profession wants the hubs, NHS England wants them, they fit perfectly with the introduction of the new models of care, and the funding is already in place. Opportunities like this are exceedingly rare, and must be grasped with both hands. While making the locality hubs a reality will still require conversations, trust, joint working, leadership and hard work, now is the time to do it. Seize the moment, because it may be a long time before another one like this comes along.

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GP Locums – dispelling the myths

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

Locum GPs, are they a low quality and overpaid drain on resources or an underutilised pool of agile talent? Ben Gowland seeks to dispel some of the more prominent myths.

The debate about locum staff has raged for years, but the recent strain on NHS finances has brought it into even sharper focus. GP locums have not escaped: NHS England attempted to introduce practice reporting on any payments made over an ‘indicative maximum rate’ as part of the 2016/17 contract. In response the LMCs passed a motion which rejected ‘any attempt to cap the fees charged by GP locums’, asserting the real problem was the GP recruitment crisis.

Is the use of NHS monies on GP locums a waste of scarce resources? Or is it a valid expenditure, pivotal to enabling a fragile system to continue to operate? I recently debated this with Dr Richard Fieldhouse, Chair of the National Association of Sessional GPs (NASGP). He took the opportunity to dispel a few myths.

Myth 1: GP locums are destroying continuity of care. The reality is very few us will see the same GP each time we visit our local practice. For at least half of us, it doesn’t matter which GP we see. For those where it does, practices are rarely organised to enable this. When a practice employs a locum GP, they are just as likely to be asked to see patients where continuity of care would have made a difference to those where it would not. You can’t blame locum GPs for how practices organise care.

Myth 2: GP locums deliver lower quality care. For a GP to be effective they need to be able to access a range of information, including patient histories, test results and local patient pathways. Practices rarely provide locum GPs with the information they need. It is not that locums deliver lower quality care, it is that practices prevent locums from performing and often make it impossible for them to function effectively.

Myth 3: GP locums earn more than most GP partners. GP partners, who sign the cheque for the invoice, see the gross amount the locum receives. They then compare this with the net amount they take home, and, inevitably, the gross amount is larger. This does not mean the take home pay of the locum is greater! And when a locum GP is employed through an agency, the cost includes a 20% or 30% agency mark up. Money to the agency is not money to the individual locum.

Myth 4: GP locums are a small, greedy minority of the profession. The number of locum GPs stands in the region of 17,000, and represents about a quarter of all GPs. It is not one or two GPs out to make a fast buck. It is an increasingly popular career choice, and, as our recent podcast series has shown, attracts a range of GPs with a range of different motivations. Characterising locum GPs as a drain on resources serves to disempower a substantial, and growing, portion of the total GP workforce.

In future, all GPs may be locums. If the profession does eventually follow through with its threat of mass resignation, local locum GP chambers represent one of the most likely future employment scenarios for GPs. Even if GPs resist the temptation to press that particular nuclear button, the growth of multispecialty community providers (MCPs) may also see a rapid growth in local locum GP chambers, as the historically independent-minded profession seeks to resist a salaried fate.

The time has come for the debate to move on. The focus should no longer be on the validity of locum GPs, but rather on how the system makes best use of what Richard describes as “the rich pool of agile talent” it has at its disposal.

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A new lease of life for APMS Contracts

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

General Practice has never really liked Alternative Provider Medical Services (APMS) contracts. This is because they are the only GP contracts that can be negotiated with those who are not NHS GPs, such as foundation trusts and commercial organisations. But, writes Ben Gowland, they may be about to experience a resurgence…

APMS contracts were introduced really as a mechanism to enable NHS commissioners to market test General Practice against the private sector. But fears the APMS contract was going to lead to the privatisation of General Practice proved unfounded. Research by The King’s Fund^{^[1]} found use of APMS contracts by PCTs was limited and very few APMS contracts had been awarded to independent providers.

There is no specified maximum contract length for an APMS contract, but they were typically awarded for a five-year period. This is in stark contrast to the unlimited contract length of the main GMS and PMS contracts. This drew criticism from the profession as providers would not make long term investments, or tackle long-standing problems such as premises leases. A 2015 study published in the Journal of the Royal Society of Medicine found APMS practices provided worse quality care than practices on GMS or PMS contracts, even when demographic differences such as age and deprivation were taken into account.

But change is afoot. A hospital foundation trust in Chesterfield has been awarded a 15-year APMS contract to run three GP practices serving more than 20,000 patients in Derbyshire. 15 years, and with an option to extend for a further 3 years! The APMS directions do not specify a maximum contract length and a contract exceeding 5 years can be agreed locally, but even a few years ago this would have been unheard of.

Now, as with all aspects of integration, using the APMS contract in this way creates issues for commissioners. The 2013 APMS directions[2] state the APMS contractor is required to be a member of the CCG. So by deduction Chesterfield Royal Hospital must now be a member of the local CCG. Equally, when the APMS contractor makes a decision to refer a patient it must ‘do so without regard to its own financial interests’. Choice and integration are not easy bedfellows.

But North Derbyshire CCG are not alone. Other CCGs, e.g. Blackpool CCG[3], have also been considering APMS contracts of 10-15 years (interestingly the same length as the new multispecialty provider, or MCP, contract). Clearly, something has changed.

The world has shifted since 2004, when APMS contracts were first introduced. Then the focus was on competition and market testing. In our post-Five-Year-Forward-View-world there is a new game in town: integration. APMS contracts are changing from a tool to enable competition to a tool to enable integration. Hence the sudden shift from short to much longer term contract durations. Blackpool CCG explicitly stated that ‘longer term contracts offer stability and an incentive for providers to participate/engage in CCG strategy, new models of working and integration in neighbourhoods’.

Suddenly APMS contracts have a new lease of life, as an enabler to integration. The 15 year APMS contract award in Chesterfield was met with local LMC approval. General Practice antibodies to the APMS contract appear to be dissipating (although lingering concerns over the contract value relative to GMS/PMS inevitably remain). Extending the term of the APMS contract, keeping it within the NHS ‘family’, and using it as a building block for the new models of care, mean it may be about to become much more prevalent than ever before.

[1] Walsh N, Maybin J, Lewis R (2007). ‘So where are the alternative providers in primary care?’ British Journal of Healthcare Management, vol 13, no 2, pp 43–36.

[2]https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183370/apms_directions_2013_acc.pdf

[3] http://blackpoolccg.nhs.uk/wp-content/uploads/2015/10/Item-6-APMS-Paper-Oct-PCCC.pdf

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How to find the GPFV money

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

The money that sits behind the General Practice Forward View (GPFV) is proving elusive. We seem to be in a place where lots of money has been promised, and in a very British attempt not to appear ungrateful no one is really asking where it is. Instead we are just hoping it will materialise. I have now asked a range of people about it, some in practices, some in CCGs, and some in national roles, and not a single one is clear when or where this money is coming.

So here at Ockham Healthcare towers, we have identified 5 things to watch out for if you want to find the missing millions promised in the GPFV:

Watch out for the 2017/18 core contract rise. This might sound obvious, but this is actually going be the most important announcement for General Practice, as we will get our first sense of how much of the promised additional £2.4bn will actually arrive into core contracts. In NHS England’s business plan published in December last year they had indicated a 4.0% uplift for next year, so that would be a good benchmark to monitor the actual rise against.
Watch out for the publication of the local Sustainability and Transformation Plan (STP). NHS transformation money has been given to the STP areas, and in the guidance sent to them it said the allocated funding included money for, “taking forward the programmes set out in GPFV and delivering extended GP access”. This means GPFV money has been given to the STP areas, and it is their job to say how they are going to use it.
Watch out for how much extra investment goes into the new MCP contract. We now know the multispecialty community provider (MCP) contract is not for General Practice alone, it is for all the providers of community services in an area. If investing in the MCP contract is used synonymously for investing in General Practice, there is a high risk that only a proportion of that money will find its way through to individual practices.
Watch out for your CCGs commissioning intentions and plan for next year. The RCGP are optimistic about this. They believe that over the next 5 years CCGs will invest 10%-20% more in General Practice, reaching somewhere between £184 and £368M by 2020/21. Very crudely that is £1-£2M extra per CCG, which would mean growth of £200k-£400k each year. So review next year’s plan, and see if you can find it.
Watch out for next year’s Better Care Fund (BCF) plan. Again, this was trailed in the GPFV and the RCGP have picked up on it, thinking that more money will come from that fund into General Practice. Next year’s BCF plans will indicate whether the RCGP’s faith in them is justified.

Details from each of these areas will be released in the next 6 months, which means soon (hopefully!) we will know exactly how the money is going to come to General Practice. Then we can make a better assessment of the impact it is going to make.

One tip for practices looking to maximise their own share of the money. There are a lot of different pots of funding. As a minimum we know that practices can potentially access pots of funding for: practice resilience programme; clinical pharmacists; practice manager development; practice nurse development; CCG practice transformational support; on-line consultation implementation; releasing time for patients programme; mental health workers; and further capital allocations. Get together with other practices and identify or employ someone whose job is to look out for pots of money that become available and write bids for all the practices. It won’t take long before they have already paid for themselves!

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The new MCP Contract Framework: more important than the GPFV

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The recent NHS England document, “The Multispecialty Community Provider (MCP) emerging care model and contract framework” (which you can find here), is in Ben Gowland’s view a more important document about the future of General Practice than the General Practice Forward View (GPFV). He explains why.

The document describes how NHS England sees the future of General Practice. At the same time, the document is not written specifically about General Practice. This is because it is about MCPs, and an MCP is not a form of General Practice. Rather it is a new organisational form that includes General Practice. As such, it potentially represents the end of the independent contractor model of General Practice.

That’s a lot to take in, but I don’t think I am overstating it. I read the document expecting to find out more about the new voluntary GP contract that the then Prime Minister David Cameron had unexpectedly announced last year. But it turns out there is no new GP contract. The new contract is for MCPs, a new form of organisational entity,

“An MCP is what it says it is – a multispecialty, community-based, provider, of a new care model. It is a new type of integrated provider. It is not a new form of practice-based commissioning, total purchasing or GP multi-fund, or the recreation of a primary care trust (PCT). An MCP combines the delivery of primary care and community-based health and care services – not just planning and budgets. It also incorporates a much wider range of services and specialists wherever that is the best thing to do.” p5.

General practice will become only one part of this new bigger organisation. What the document does is work through some of the detail of the new MCPs, and in particular how they will be contracted. While the primary focus of the document is not General Practice, the implications for General Practice are huge.

Now, before panic sets in, the model is entirely voluntary for General Practice. The document clearly states, “Under no outcome would GPs lose their right to continue to provide primary medical services against their will” p29. But that said, what exactly does the document say about the relationship between the new MCPs and General Practice?

First there is what looks like a ‘pre-qualifying’ phase. General Practice has to operate at a population level of at least 30,000, which, the document says, “is a natural first step towards an MCP, for example via super practices or GP federations” p20. It then says, “Working in groups of at least 30,000 patients enables general practice to be commissioned to take on new services and funding set out in the General Practice Forward View. These could include the provision of additional access, co-funding for the introduction of pharmacists within general practice, or infrastructure investment.”

I don’t know what to make of this. It hints the new investment in General Practice is only going to be available to groups operating at this scale, but maybe I am reading too much into it.

There are three types of contractual relationship GPs can have with an MCP. The first is through a “virtual” MCP contract. Here, the existing individual contracts of the GP practices and other providers of community services remain separate, but are then overlaid with what is essentially an agreement between all of them in which, according to the document, they “could establish a shared vision and a commitment to managing resources together, as well as clear governance and gain/risk sharing arrangements, together with an agreement about how services will be delivered operationally” p20.

The second type of MCP contract is described as “partially integrated”. Essentially all provider contracts are brought into a new single MCP contract, except the GP contracts. It could include elements of the GP contract, e.g. QOF, DES’s “by agreement”. These agreements could, “break down barriers and commit GPs to new ways of working (e.g. by working at scale, redesigning the workforce, and developing operational protocols)” p27.

The third and final type of MCP contract is “fully integrated”. All the provider contracts are brought into a new single contract, including the GP contracts. The contract will be 10-15 years in duration, and the DH has been asked to change legislation to create an option to enable GPs to return to G/PMS arrangements (p27). It will have a performance element that replaces QOF and CQUINs of approximately 10% of the contract value. The contract will be for the existing value of the commissioner spend for the services included for the population served. It will have gain/risk share arrangements that are yet to be determined.

Can GPs own and run an MCP organisation, and hold a “fully integrated” MCP contract? It would appear this option will be to open to very few. An MCP can in theory be a Limited Liability Partnership (LLP), a Community Interest Company (CIC), or a limited company. GPs could be partners or shareholders in these organisations, and as such be direct owners of the company. But not on their own, “it is quite likely that many existing organisations that deliver part of the proposed MCP service scope will be unable in isolation to be credible holders of a fully integrated MCP contract, and they will need to forge new partnerships” (p25). Only “stronger” federations or super-practices, the document says, “could then seek to develop into credible bidders” for MCP contracts (p20). The clear implication is very few GP organisations of any type will even be eligible. The document itself concludes, “Given that MCPs will be responsible for out of hospital services, the natural application of this option would be with existing Community Trusts or FTs” (p26).

And in this scenario (established in the document as the most likely) what happens to the GPs? Well, they either become employees of the new MCP, or subcontractors or independent contractors operating under a clinical chambers model. And what will their salary be? That will be up to the MCP, because, “there is no single new “contract” for individual GPs wanting to be part of an MCP arrangement” p28.

At present 8% of the country is covered by MCPs (although it should be said that 0% is currently covered by any sort of MCP contractual agreement). By next year the document states that national coverage will expand to 25%. The expectation is that a quarter of the country, and therefore a quarter of General Practice, will by next year will at least be moving towards these new contractual agreements.

As with any radical new proposal, the document generates more questions than answers. But the overriding question I am left with is where do the incentives lie for General Practice? Remember it is voluntary, so it needs incentives. Maybe the model of an MCP, with its focus on population health and freedom to innovate, will be attractive enough for some. Maybe for others it will provide the way out they have been looking for (“GPs participating in an MCP may leave their current contractual arrangements permanently. They might contribute their existing GP partnership for a share of the MCP partnership or equity” p27). Maybe there will be freedom within the new contractual arrangements for each practice or groups of practices to create an outcome that is beneficial for them. Maybe it will be the only way to access the additional £2.4bn General Practice has been promised and needs to survive. Maybe I have missed something…

The document presents a new future for General Practice, as part of a wider team delivering care for a local population through an MCP. But it is a dense and difficult document, not targeted specifically at GPs – written instead I would say with GPs in mind. General Practice may only be one part of an MCP, but an MCP potentially represents the whole of the future for General Practice, which is why this document is so important.

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How CCGs can partner with locum GP Chambers

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In the third of our series of articles on CCGs and local locum GP chambers, we explore how CCGs can work with the local chambers once it has been established, and how the partnership between the two can benefit local practices, patients and the wider healthcare system.

Once a chambers has been established locally, CCGs can partner with them to put together a programme to offer training and other services to local practices. This programme can include:

Practice Improvement. The chambers can collect regular feedback on each practice from its GP locums and sensitively provide constructive feedback to help practices improve their working relationship with its clinicians. It can also play an active role in identifying local best practice and spreading it to other areas (e.g. appointment systems, DNA policies and procedures etc.)

Backfill to create GP time for CCG business. GPs often cannot attend CCG meetings because no locums are available. Local locum GP chambers can work in partnership with the CCG and use their local workforce intelligence to ensure these meetings are organised at a date and time when backfill can be arranged.

Practice Manager Training. The Chambers can put on workshops for practice managers on how to make the best use of locum GPs, including elements such as getting their feedback on your practice, how to make sure locums want to keep working at your practice, avoiding risk and complaints, and spreading best practice.

GP Locum Training. The chambers can provide training for locums to include elements such as high quality referrals, improved prescribing, supporting continuity by writing better notes, being involved in clinical governance, increasing effectiveness as a locum by giving better feedback, engaging with the practice, risk management and clinical handover.

Workforce Planning. Commissioners and the chambers working together proactively can ensure an effective use of the local GP locum workforce to help manage and avoid workforce issues, including holidays, sickness, winter, out of hours and weekends.

Service Provision. As with other GPs, many GP locums have specialist skills e.g. women’s health, dermatology etc. As locum GPs these skills are often under-utilised, but within the chambers model, these skills can easily be deployed across the CCG when and where they’re needed.

Direct locum Involvement in CCGs. CCGs and local locum GP chambers can work together to better involve the dedicated pool of flexible locum GPs so that they are more involved with commissioning, especially building on their experience in working in lots of different practices across the patch.

Some local GP locum chambers may be prepared to go a step further, and consider a scheme for the chambers to support local General Practice. In such a scheme the CCG would contribute the administration costs of the running of the chambers (rather than this being paid directly by the locum GPs themselves). In return the locums would offer to meet specific needs the CCG has. The table below provides an illustration of some of the potential elements of this scheme.

GP locums open up their availability five months in advance	Often, GP locums will only make themselves available one month in advance. Incentivising them to open their availability to 5 months would enable better and longer term planning by local practices.
Practice-blacklist amnesty	A locum agrees a trial of returning to work in a practice they have otherwise chosen not to work in. Appropriate safeguards are agreed in advance, and feedback is given after the assignment to identify issues and solutions.
At busy times (Christmas, Easter etc), enter into a ‘holding pattern’	Typically, well organised practices book well in advance, and struggling practices book when they are ‘desperate’. The ‘holding pattern’ would entail a commitment by the GP locum to work, but the location is only announced when local practices have been assessed on a needs basis by the commissioner.
Minimum commitment	Locums agree to a minimum level of service e.g. four sessions per week.
Time ringfence	A commitment is made by the locum to give first choice to the sponsoring CCG up until a set time period, after which the locum can make themselves available elsewhere.
Backfill	If a practice is in crisis, local experienced partners can be deployed to the failing practice, whilst the chambers deploys a group of chambers locums in the donor practice to reduce loss of continuity.
Attendance at clinical governance meeting	Already a requirement of many chambers, regular attendance at internal clinical governance meetings to discuss significant events, complaints and feedback about practices.

Whilst such a scheme is not currently in existence, the Chairman of the National Association of Sessional GPs (NASGP) Dr Richard Fieldhouse believes the potential of such a scheme to be huge. He says, “As a system we consistently fail to make the most of the opportunity that locum GPs provide. The Chambers model enables effective partnerships to be developed between commissioners and locum GPs, and a scheme like this is the logical next step”.

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Does the PACS model mean the takeover of General Practice by the local hospital?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

When the new models of care were first introduced in the Five Year Forward View, there was concern in some quarters of General Practice that the PACS model (Primary and Acute Care Systems) could herald the takeover of General Practice by local hospitals. Ben observes that this is far from what is actually happening…

When I read of the Symphony Programme in Yeovil, one of the PACS vanguards, it looked like this indeed was what was happening. A number of local practices – initially 3, then 6, and potentially 10 – were reportedly joining a company, Symphony Healthcare Services, which is wholly owned by Yeovil hospital.

I contacted Dr Berge Balian, a GP and the Chair of the South Somerset Symphony Programme Board, to find out whether the rumours were true, and if so why the local GP practices were allowing this to happen. We spoke, and what I discovered was surprising. He kindly agreed that we could use the conversation as a podcast, which you can find here.

The first surprising point is the focus on General Practice, and developing it to play a leading, sustainable role in the delivery of care, through an enhanced primary care model. This includes incorporating health coaches within practices, as well as extending the care team to include mental health, pharmacy, and therapists.

The second is the starting point for working together: both General Practice and the acute hospital are experiencing the same pressures, of demand, recruitment, and finances. There was a realisation in conversations between the two that by combining they could more effectively meet these problems. As Berge puts it, ‘The ultimate outcome is that the hospital is going to shrink’, as it focuses on doing only what it absolutely needs to do. Working together provides the mechanism for moving resources, whether money or personnel, from secondary to primary care, in ways that could alleviate pressure on both sides.

Berge was an LMC chair. He knows General Practice inside out, and has its best interests at heart. Inspired by the vision of the Chief Executive at Yeovil Hospital he took on a role there as Associate Medical Director for Primary Care. Together with the Chief Executive they began building bridges between the hospital and the local practices. Berge knew change in General Practice starts by building trust, and he recounts 18 months of conversations that they had with all of the local practices, strengthening relationships and ironing out problems. A key part of the battle, Berge recounted, was convincing the practices this was not a clandestine way to negatively impact General Practice.

What happened next was most interesting. A number of local practices became so overwhelmed with their own problems they approached the hospital directly wanting to formally merge with them. The hospital considered this, but Berge wanted to ensure the valuable G/PMS contracts, which are contracts in perpetuity, were protected. As a result, they set up a complicated set of arrangements (under the banner of Symphony Healthcare Services) that means the existing contract is preserved, the organisation is at arms-length from the hospital, it is led by primary care clinicians, and the lead partners have a ‘right to return’ to their original contracts in future.

Impressed by the hospital’s commitment to making this work for General Practice, another 6 or 7 practices have expressed an interest in fully integrating with the hospital through Symphony Healthcare Services. And not just the ones in trouble. As Berge says,

“About half are motivated by some challenges they are having, but another half really just see the future of General Practice being in a different model to the historical smaller partnership model.”

The integration of the practices with the hospital is built on what are described as “three pillars”: to preserve the individual identity of each practice; to share administrative and back office functions across the practices and the hospital; and to redesign the healthcare system, through the enhanced primary care model and shifting how care is provided for patients.

When asked about the future, what Berge sees as key is keeping primary care at the centre. His focus is on ensuring that those practices that have chosen not to ‘integrate’ with the hospital will stay at the centre of this work, shaping how resources are shifted from secondary to primary care.

At the end of the conversation I was not left thinking the local hospital had taken over local General Practice. Rather I was impressed by the way the hospital had enabled integration to take place by working to meet the needs of the local practices, and ensuring practices remain in the driving seat.

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Three steps to CCGs supporting the development of local locum GP chambers

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Ockham Healthcare is running a series of podcasts and blogs on local locum GP chambers because of the impact they can have on an area struggling with GP recruitment. In this second blog in our series Ben Gowland calls on CCGs to do what they can to support their development – but warns against trying to control them.

The idea of having a local locum GP Chambers in the patch can be very attractive for Clinical Commissioning Groups (CCGs). The advantages are clear (see my previous blog “10 reasons why your area needs a local locum GP chambers” here.), and it is a tangible way in which CCGs can be seen to be actively supporting local practices cope with the shortage of GPs.

The challenge comes because the establishment of the chambers lies outside of the control of the CCG. It is not as simple as deciding one is needed, and then charging someone within the CCG with setting one up and persuading a few locum GPs to join to get it off the ground.

This is because the chambers will only work if they are owned by the locum GPs themselves. And for them, the CCG-led model is not attractive. GP locum Dr Caroline Chill puts it like this, “If chambers are controlled by CCGs it makes being a locum less attractive, because it almost becomes a zero-hours contract with the terms and conditions being dictated by the practices using the service”.

All, however, is not lost! The idea of local locum GP chambers is attractive. It is attractive to some existing locum GPs who feel isolated and unsupported, to newly qualified GPs wanting to become a locum, and to GPs working in GP practices who for whatever reason do not want to continue in a specific practice but do not want to stop practicing as a GP altogether.

In all of our conversations with locum GPs working in local chambers, they described how they knew they wanted to be able to locum with peer support, but if they did not already know an existing local chambers they had to search to find out about the model. Unless one already exists locally, most GPs still do not know about them.

Step 1: Publicise the model locally. To start off with, you are unlikely to know who the potential GP members of the chambers will be. The aim is to connect those GPs who would like to be part of a local locum GP chambers (but might not know it yet!) with the idea of it. Publicising the model, and presenting it as something that gives locums control (rather than taking it away) will help make that connection.

Creating something from nothing requires a certain type of person. While some like to join something that already exists, there are those whose preference is to create something new and build it from scratch. It requires a certain level of drive and energy, and from our conversations with members of local chambers it is clear that this generally comes from one individual to start off with, who then draws in others along the way.

Step 2: Identify a leader. In order for the model to take off locally, the CCG will need to use all of its networks and contacts within the GP community to find a locum GP who wants to lead its development. Dr Mark Sage, a GP locum who set up the West Kent chambers, suggested the place to look would be either, “the well-established locums in an area, or the more recently qualified doctors, who are looking for a group they can affiliate with”. He suggested Programme Directors on VTS courses are important contacts, as they know the plans of the GPs leaving the course.

To be clear, this individual is not creating the chambers for the CCG, but for themselves. However, setting up something new is difficult as it requires a leap of faith that it is going to work, and can be challenging for someone who has never done anything like this before.

Step 3: Provide support for the leader. When we spoke to those who set up new chambers about the support they needed or received, this was not financial but rather moral support in terms of encouragement that the new model is going to work. The only practical action they described was help with the business case, in particular establishing the level of demand for locums from each of the local practices so that the newly formed chambers could be clear there would be sufficient demand for their business. Every chambers has since found that demand far exceeds the capacity they can provide!

In conclusion, it is clear from our research that, whilst successful locum GP chambers cannot be set-up nor controlled by a CCG, every CCG has a role to play in creating the environment in which they can flourish.

jul

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The future of General Practice is a jigsaw – will all the pieces fit?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I am worried. I worry that the General Practice Forward View (GPFV) does not fit with everything else that is going on. I worry that while on the one hand there is a small national team desperately trying to do the right thing by General Practice, most people haven’t even read the key document.

Recent events (and not just the obvious) have compounded my fears. Two things have happened. First the new CCG assessment and improvement framework has been published. It is not a fun read. The upshot of it is that there are 57 indicators across 29 areas by which CCGs are going to be assessed. One of these 29 areas is primary medical care, and it has a total of 4 indicators. These are:

Management of long term conditions: unplanned hospitalisation rates for patients with chronic ambulatory care sensitive conditions.
Patient experience of GP services: weighted percentage of people rating their experience of GP services as “fairly good” or “very good”.
Primary care access: percentage of practices within a CCG where patients have the option of accessing pre-bookable appointments outside Monday to Friday 8.30am to 6.30pm. Access may be through a hub or federation rather than the individual practice.
Primary care workforce: number of GPs and practice nurses (full time equivalent) per 1000 weighted patients by CCG.

I won’t waste the next 500 words explaining just why these in no way reflect the ambitions for General Practice outlined in the GPFV (but feel free to get in touch if you want the debate!). Suffice to say the measures by which CCGs are to be judged do not reflect the GPFV stated intentions around investment, workforce, workload, infrastructure and care redesign. Instead it is two steps backwards with tired measures that feel increasingly distant from the reality of most GP practices.

Second is the growing role of Sustainability and Transformation Plans (STPs). Recent guidance on STP allocations stated that this funding, “represents the full amount of funding expected to be available for local health systems from all sources in 20/21. They include an indicative fair share of the sustainability funding, primary care access and transformation funds, and other transformation funds including technology…. This includes taking forward the programmes set out in the General Practice Forward View and delivering extended GP access.”

The guidance goes on to say, “STPs will be the single application and approval process for being accepted onto programmes with transformational funding from 2017/18 onwards. Phasing of funding by areas in years 2017/18 – 2019/20 will be subject to consideration of STP plans submitted and subsequent decisions on how to target and deploy funding”.

The implication is that the financial plan for investment in General Practice actually sits within the local STP plan. While this contains a certain logic, the risk of the General Practice funding not finding its intended target becomes much higher. There is already guidance about the requirement of STP money to be passed through to acute providers, alongside a paucity of core General Practice provision representation in the development of STP plans in many areas.

The GPFV can’t sit in splendid isolation. It needs ownership across the system. It has to be the basis for how CCGs and primary care commissioners are assessed. It has to become the framework for local investment in, and the development of, General Practice. It has to materially impact local STPs. When we see the STPs we will find out exactly how reflective they are of the GPFV, and I really hope I will discover I have been worrying over nothing.

jun

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We need a Financial Plan for the GP Forward View

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Increasing GP cynicism about the Government’s Forward View is understandable, argues Ben Gowland and, without a clear financial plan, the criticisms can only increase.

There is a growing temptation for many GPs following the recent criticism of the GP Forward View (GPFV) to dismiss it completely. However, the GPFV is a published policy document by NHS England. It makes many promises. Regardless of whether or not you believe the promises to be sufficient, they are real, written down promises. As such they need to be identified, monitored and those who made them held to account for keeping them. Especially the financial ones.

The complexity of the GPFV makes unpicking these promises, in particular the financial ones, very difficult to do. The RCGP has recognised the importance of this task, and has taken steps to establish what financial promises have actually been made to General Practice, and in particular how close these come to the RCGP’s campaign for General Practice to receive 11% of NHS funding (you can find this here).

What financial promises have NHS England actually made? What can we monitor and hold NHS England to account for? Ultimately there are only two that I think we should focus on: the promise to increase recurrent expenditure on General Practice by £2.4bn a year by 2020/21; and the (separate) promise to create a £508m “Sustainability and Transformation Package” that will be invested between now and 2020/21.

It is stated in black and white headline terms that recurrent funding for General Practice will increase from £9.6bn a year in 2015/16 to £12bn a year in 2020/21. It is not, however, broken down. The financial plan is missing. This I suppose provides room for manoeuvre, but at the same time is leading to confusion, mistrust and the growing lack of enthusiasm for the whole document.

The text does not help. One headline says that the £2.4bn “includes capital investment amounting to £900m over the next 5 years”. How can it? The capital funding is non-recurrent. The promised £2.4bn is recurrent. Even the one year share of the 5-year capital pot in 2020/21 would presumably have to be replaced or matched the year after anyway in order for it to be classified as recurrent.

And what do you make of this statement on p12, “The additional investment we are making in introducing new care models will benefit general practice too – and this will ensure investment rises at least in line with the plans set out above, and potentially even more.”? Does it mean any extra money from the transformation fund is part of the additional £2.4bn, or is it in addition to it? The RCGP sought clarification on this very point and were told by NHS England that it is additional. By the RCGP’s calculations this means General Practice will be receiving an additional amount between £561m and £842m extra (depending on whether you think General Practice will receive a “conservative” 20% of the Transformation Fund or an “optimistic” 30%) by 2020/21. For clarity, this is on top of the additional £2.4bn.

Suddenly the RCGP’s enthusiasm for the GPFV becomes a bit clearer. The money that is needed has really been promised.

But will it materialise? Really, will it? We hear talk of a national ‘reset’ of NHS finances. The funding problems in General Practice are often lost in talk of huge acute provider deficits. Every day we hear reports about the impact of continuing PMS reviews and cuts, alongside the ongoing removal of MPIG. If this level of extra funding was really coming, wouldn’t the approach shift to one of reduced growth payments as opposed to actual cuts? CCGs, even those with the most delegated of primary care commissioning budgets do not know when this funding is coming, how this funding is coming, or what this funding will look like. Can you blame practices for not sharing the enthusiasm of the RCGP?

We need the financial plan. NHS England would not accept a plan from a CCG without the financial plan attached, and General Practice must insist on seeing the financial plan that underpins the GPFV. NHS England needs to do this to build confidence that it will deliver what it has set out in the GPFV. General Practice needs it so that it can hold them to account for doing just this.

jun

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General Practice Needs a Route Map

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We know General Practice is in crisis. We know NHS England has published the GP Forward View. We know more money is on its way (despite arguments about how much!). But the curious thing is there is no clear direction for GP practices to follow.

I spoke recently to Dr Maureen Baker, Chair of the RCGP, (you can listen here) and asked her whether GP practices should now be looking to operate at scale. Her response? “I don’t think all practices will have to get bigger”. But some, presumably, will. It depends.

I asked her whether GP practices should be looking to take an active role leading the integration agenda or simply participating as others (such as the local community or acute trust) take a lead. Her response? “I don’t think it matters too much whether GPs are doing it or whether GPs are coming on board… It doesn’t have to be GPs that design it, lead it, run it.” Again, it depends.

Indeed, Dr Baker’s own summary for GP practices was they must look first to their own survival, but then consider that, ‘There is a range of ways of doing things… there is not a best way to do it”.

The GP Forward View (GPFV) in many ways reflects this. There is a huge reluctance to impose change upon General Practice, but at the same time a recognition that change is necessary. From an individual GP practice perspective, it has ended up almost as a smorgasbord of ideas and opportunities that can feel both overwhelming and lack the collective coherence necessary to create a clear plan for the practice.

GP practices have to sit, poised, ready to respond to expected announcements about deadlines for estates proposals, about funding for pharmacists and mental health workers, about the programme for online consultation systems, and about any local investments in extra capacity. Information drips through about each individually, as local commissioners await guidance from on high.

Without doubt, the GPFV brings opportunities for GP practices. But these opportunities do not sit together in a coherent narrative. There is no clear direction, no route map for practices to follow. It just depends.

I was working through with the GP partners of a practice recently to understand how they could tackle the challenges they faced, and what their plan should be. It was hard. The problems facing General Practice have not gone away, and continue to worsen. Next year looks more challenging than this year for the practice. Opportunities exist, but they feel intangible, opaque, and like they are within the control of someone else and outside the control of the practice.

The partners reflected in the past making these decisions had been easier. There had been clarity from the PCT, or the Health Authority, or whoever the commissioner of the day was, as to the proposed direction for General Practice and what they wanted each practice to do. This does not exist today. Even within the same geographical area GP practices face challenges to lesser or greater extents, and the required response varies. It depends.

But no-one is helping practices work out what their individual response should be.

You could argue the lack of a clear direction is a good thing, as it provides choice and freedom for practices, and empowers practices to be masters of their own destiny. I wonder, however, whether we have taken this too far, and as a result have created an almost impossible task for practices who lack the headroom and time to navigate through such difficult terrain. My sense is many GP practices want and need leadership – someone to say this is the route you have to follow, and if you do this it will be ok. General Practice needs a route map.

may

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Integration and Little Green Fairies

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

Ben Gowland muses on the potential roles for GPs in the integration agenda and finds himself away with the fairies.

I recently asked a GP whether she felt that GPs should play a leading role in integration across the system. She peered at me through her half-rimmed spectacles, and said, “I don’t even have time to go to the loo let alone get involved in Integration. It sounds great in theory but there is more chance of little green fairies doing a magic dance at the bottom of my garden than there is of me taking on any more work.”

So that was me told. The RCGP have produced a new report entitled, ‘The Future of GP Collaborative Working’. You can find it here. The report, as far as I can tell, has two key messages. One is that GPs, as the expert medical generalists, have a key role to play in the integration of services around patients with increasingly complex needs. The second message is that this central role of GPs is often not recognised and that any additional funding generally either falls short of what is needed, or is not maintained over the longer term.

So we are left with something of a conundrum. This is the ‘little green fairy’ problem; GPs now exist under such extremely severe time constraints that the prospect of them taking on more and more system responsibility seems, to many, simply preposterous. There are not enough GPs and no prospect of there being enough any time soon. But, at the same time, the system requires GPs to play a greater role in bringing services together around the needs of patients.

The RCGP Report contains a number of really interesting examples of how GPs have taken a leading role in integration. They are worth a closer look. They fall into three groups. There is one whereby a new service has been created that employs GPs directly into a new service, for example the @home scheme in London and the Memory Assessment Service in Brighton. There is a second whereby a small number of GPs are upskilled in a specific specialty and then work in partnership with a specialist centre to improve the General Practice offering, e.g. the child health hubs/clinics in London and in Lerwick in the Shetland Isles. The third is one whereby the GP practice team is expanded, for example the addition of a prescribing pharmacist as a partner, or employing a mental health therapist.

The analysis required is of the impact of these developments upon General Practice overall. Integration does not replace the need for core General Practice. Rather, it aims to fill the hole that often exists between core General Practice and secondary care, and indeed other services. But filling that hole at the expense of the core General Practice service would clearly be a mistake (a point, I fear, that is missed by some new-models-of-care enthusiasts).

This isn’t wholly scientific, but here is the little green fairy analysis of these three groups of examples:

Group One could either attract new GPs into the profession by creating a new range of options for newly qualified GPs to choose from, or it could pull from an already too small pool and make it smaller. Little green fairy verdict: I’m dancing.

Group Two can enable a small number of GPs to develop an interest, receive proper support, and enable that to be monetised by the practices of those GPs to recruit replacement capacity. At best the impact on GP practices is likely to be neutral. Little green fairy verdict: now you see me, now you don’t.

Group Three involves reshaping core General Practice by incorporating new roles and responsibilities as a driver for integration. This enables core General Practice to develop alongside integration initiatives. Little green fairy verdict: I’m toast.

We need integration; not as a replacement for General Practice but as well as General Practice. GPs have a key role to play. The only way this is going to be realistic at any sort of scale is if the integration work helps, rather than adds to, the delivery of core General Practice by GPs. If it doesn’t, then we would be better off looking at the end of our gardens for the elusive magic dance of the little green fairy.

may

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We need new roles to enable change, not to replace GPs

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Whatever may be inferred from the introduction of new clinical roles into General Practice, Ben Gowland argues that GPs are irreplaceable; no other health professional working in primary care has the depth and breadth of experience and training like a GP. However, the introduction of these other staff groups is, he suggests, a way of ensuring the survival of General Practice.

There is, unquestionably, a shortage of GPs. Practices need to be able to recruit GPs to fill the vacancies they have, and to avoid the financial burden of dependence on high cost locums. But practices with a full establishment of GPs still have a workload that is becoming increasingly unmanageable, and are also facing financial challenges as income has fallen and costs have risen over recent years. They cannot afford more GPs.

The new GP Forward View places the development of new clinical roles centrally alongside renewed efforts to attract and retain more GPs. As a result, the message that many GPs have heard (and rejected) is that somehow lesser-trained, lower-paid clinical professionals can carry out the work of a GP. But that is not why we need new clinical roles in General Practice.

We know that demand from patients has gone up to unmanageable levels and that clinical and non-clinical staff cannot cope with the daily onslaught. A recent study from the Kings Fund showed that the number of consultations has risen by 15% in the last 5 years. Patients are not just getting older, they are becoming much more demanding.

But if demand is up, and capacity (i.e. the number of GPs) cannot be increased to meet this demand, then something else has to change. This is at the heart of the introduction of new clinical roles.

The GP practices getting most on top of this are the ones that have embraced change in tackling on-the-day demand by, for instance, bringing in a multi-disciplinary teams of advanced nurse practitioners, paramedics and pharmacists. They have created in-house ‘urgent care centres’, or the like, that manage the telephone triage and act as the frontline for the practice.

Some GP practices have got together and created these ‘urgent care centres’ across different practices, to make them more affordable. Some have even merged so that they can do this more effectively. Some have teamed up with their local community trust so that they can access the nursing and physiotherapist workforce that they can supply.

The question practices need to address is not, ‘Can other clinical specialties carry out the role of a GP?’ Rather, the questions they need to ask are:

How can we re-shape the way that on the day demand is managed, using the skills, experience and expertise of other staff groups that are uniquely placed to be able to do this?
How can we meet the challenge that the new profile of demand presents for our practice?
How can we make best use of the GP time that we do have, while still meeting the needs of our population?’

If the aim is simply to replace ‘missing’ GPs with other staff groups, then attempts to introduce these staff groups to General Practice may well negatively impact the service practices can offer. But if the aim is to redesign the model of General Practice to better meet the shifting pattern of demand, then new roles can have a transformative effect on everyone working in a GP practice, and for the patients they serve.

may

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Time for Action

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Enough with the analysis and breast-beating, pleads Ben Gowland! As the system finally wakes up to the crisis in General Practice he posits that there is at least one reasonably easy solution which no-one has yet tried.

The Kings Fund have published a new report, entitled ‘Understanding Pressures in General Practice’. The immediate reaction in General Practice I am sure will be a weary shrug. They know what the pressures are. Their frustration lies in the amount of time it has taken the system to recognise it, and a prevailing sense that further analysis of the problem does not seem to lead to help and support that makes coping any easier.

There could be a real benefit to the quantification of the problem. There has been a 15% rise in consultations from 2010/11 to 2014/15, based on analysis of over 30 million contacts. This is driven by an increase in the number of consultations per registered patient per year from 4.29 to 4.91 over the same period. The benefit would be if this led to an increase in the funding per registered patient.

But the money has already been promised, through the General Practice Forward View (my take on that here). This report comes two weeks too late. For GP practices, the time now is not for further analysis of the problem, but for the development of solutions. We already know what money is available and what the policy makers are offering.

Ultimately it is now down to GP practices themselves. The GP Forward View is out, and it is decision time. But, realistically, how can GP practices possibly take a grip of this agenda? How will they find the time? When some GPs respond to surveys putting the need to be able to take a toilet break at the top of their wish-list, it is hard to imagine practices being able to create the necessary capacity.

There is one place that help could come to General Practice from. There is a group of GPs who understand the challenges General Practice faces, who know how the system works, who have relationships with different healthcare organisations across the system. These are the GPs working in CCGs.

These GPs work in CCGs because the CCGs pay them to do it. If they returned to General Practice they would lose both the funding and the protected time to really help. So right now the GPs that general practice needs are crusading the cause of CCGs, tackling the problems of the system. But while they are away, home is burning. At this rate, there may be nothing left to come home to.

The time has come for a really practical step. CCGs need to identify a core group of GPs that they will second back to General Practice, and fund these secondments. The job of these GPs will be to work with local practices to help them navigate a way through the post-GP Forward View landscape, and support the development of a strong local General Practice.

If General Practice really is at the heart of local Sustainability and Transformation Plans, it is a perfectly reasonable step for CCGs to take. If GP leaders in CCGs really want to make a difference, then it is time to focus on General Practice itself. Not from within the confines of the CCG offices, but out, hand in hand, with the practices who need the help.

The pressures in General Practice are now understood and documented. It is time for action. As Benjamin Disraeli said, “Action may not always bring happiness, but there is no happiness without action”.

apr

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Unpicking the Finances of the GP Forward View

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

Ben Gowland has read the new GP Forward View a number of times – despite its length! The question on his and everyone else’s lips is “Is there real coffee underneath the froth?”

The new GP Forward view is full of headline promises, but at the same time it is a marathon read (60 pages), repetitive and unwieldy.

Everything hinges on the money. The headline is an additional £2.4bn investment in General Practice. But what is that money, and is it really ‘additional’? How much will practices actually receive? You have to work hard to unpick this from the document, but here is how I think it breaks down:

This year’s GP contract (previously agreed) contains an uplift of 3.2%, totalling £220m. If this is replicated over the next 5 years General Practice will end up with a total funding rise of c£1.1bn. Remember, following the government’s 5-year funding settlement for the NHS at the end of 2015, NHS England had already promised investment in General Practice of 4-5% each year until 2020/21.

Capital investment of £900m. Capital investment promises to General Practice are hard to track. In 2014 £1bn was promised over 4 years from 2015/16 to 2019/20 as the General Practice Infrastructure Fund. This then became the Primary Care Transformation Fund, and then the Estates and Technology Transformation Fund. It looks like £100m of this was spent in 2015/16 (my assumption), and that the existing fund (£1bn less the £100m) has been re-announced as £900m with the deadline extended until 2021. We await the new name…

Recurrent investment of £500m for extra primary care capacity. This money is essentially for 7 day working, and is not for everyone. Hidden away in the document it explains this funding, “will be tested with the current GP access fund sites during 16/17”, meaning (I assume) it includes the funding NHS England has already promised to continue the services at the existing Prime Minister’s Challenge Fund sites. It will be “linked to” investment in 111 and out of hours, raising questions as to whether the money will even make it to core General Practice. This money is only accessible for “groups of local practices and other providers”.

These three pots together make a total uplift of £2.5bn, by my calculations. The promise is for £2.4bn, and the difference must therefore mean that the core expectation of GP practices should be that the annual rise in core contract value will be slightly less than that received this year, over the next 5 years. The only recurrent money that is ‘new’ is the additional funding available to those who pursue the government’s 7 day working agenda. More froth, it seems, than coffee.

This funding “will be supplemented by” a £508m sustainability package. This is essentially non-recurrent funding that will be invested over the next 5 years. It breaks down into 3 distinct pots:

£56m of what is essentially crisis support: £40m to continue the £10m investment that was made into vulnerable practices in 2015/16 for another 4 years (bizarrely it is going to start with £16m investment in 2016/17); and £16m for specialist services for GPs suffering burn out and stress.
£206m for ‘workforce measures’: the part funded pharmacist programme will be extended (£112m); a new Pharmacy Integration Fund (described as “£20m in 2016/17 and rising by £20m each year”) which is essentially for community pharmacy; a £15m practice nurse development programme; a £6m practice manager development programme; £3.5m in “multidisciplinary training hubs” to develop a wider workforce; plus an unspecified investment in GP recruitment and retention measures. 3000 new mental health therapists were also announced, but the document is silent on the source of funding for these.
£246m to ‘support the redesign of services’: £45m to stimulate the uptake of online consultations; a £30m national development programme ‘Releasing Time for Patients’ for all GP practices; plus CCGs to come up with £171m to stimulate providers of extra capacity, to implement the 10 ‘high impact changes’ for General Practice, and to improve in-hours access.

So there you have it: the uplift in core funding over the next four years will be equal to or less than that received this year, the £500m of additional recurrent funding is not really available to the average practice, and at least half of the non-recurrent funding will be focussed on improving access. The lack of clarity in the document I suspect was designed to make the promise of funding look greater than it actually is, and on first reading it did exactly that. Once the reality of what is actually on offer sinks in, there may well be more heartache ahead for both General Practice and the Government.

apr

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What planet are you on?

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

After years of studying General Practice, Ben Gowland has achieved something that has eluded many great scientists: he has found empirical evidence that parallel universes exist…

I have recently discovered evidence of a new universe, centred on Planet Alpha. Planet Alpha appears, to all intents and purposes, very much like our own planet. The inhabitants breathe an oxygen/nitrogen-mix, the humans are bi-pedal and no-one can fully explain the attractions of Donald Trump.

But Planet Alpha demonstrates some marked differences from Earth. It is overly endowed with policy wonks and Whitehall mandarins, a disproportionately large percentage of its movers and shakers have never held a real job and, tragically, many of its citizens suffer from selective deafness.

It is in Planet Alpha‘s approach to General Practice that we can really see the differences between them and the planet inhabited by you and me. On Planet Alpha the problems of General Practice are that it is not available 7 days a week, that not every GP surgery is offering Skype appointments and, therefore, not ‘embracing technology’, and that it is not uniformly operating at scale.

On Planet Alpha the push is to “modernise” General Practice using an army of robotic entrepreneurs with unlimited private equity that is hanging around just waiting to be invested in primary care. On Alpha there are huge efficiency savings to be made by using other professionals to support GPs and, ultimately, make them redundant. But, frustratingly for the policy-makers, many of the Alpharian GPs won’t get their acts together by offering more modern services such as 24/7 access to primary care through supermarket-like chains of super-practices stretching across the country.

Things are very different on Planet Beta (also known to scientists as Planet Reality). Beta is inhabited by GPs and practice managers with very different problems. On Beta demand has skyrocketed to unmanageable levels. Staff are leaving and there is nobody to replace them. Indemnity costs, regulation costs and locum costs are forever rising, while PMS reviews and the withdrawal of MPIG protection have stolen income away. Many staff on Planet Beta are at breaking point.

GPs on Beta know their premises are too small, are not DDA compliant and they constantly worry about the future. They look for the queue of investors waiting to sign cheques for them – but it never materialises. Increasingly sick and demanding patients arrive in their surgeries with sheets of conflicting information downloaded from the internet. The GPs want to make changes, but they don’t have time to meet the other GPs in their own practice, let alone anyone from the outside world.

Parallel universe Alpha is a much happier place because Health Ministers there are currently working to manufacture 5,000 new all-singing, all-dancing GPs to populate their alternate world and bring joy and relief to all concerned.

My research has left me reflecting; isn’t it a good job that parallel universes remain parallel and never intersect? Aren’t we lucky that the hard-pressed GPs on our own planet won’t ever have to meet the top-down loving, one-size fits all, single-minded-against-all-the-evidence autocrats on Planet Alpha? Wouldn’t it be truly awful if the Alpharians set the strategy and made the policy decisions for our own GPs to follow?

apr

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A move to the dark side?

Posted by Ben GowlandBlogs, Life After the NHSNo Comments

When Ben Gowland left the NHS to set up his own company he was publicly accused of immorality. He himself questioned whether he would be able to retain his public service values in the “outside” world. Here he reaches a conclusion.

Are people who work in the NHS more value-driven than those who work outside the NHS? This is a question that came quickly to mind when I decided to resign my role as Chief Executive of a CCG and establish my own company. When my decision to quit was announced in the local media, the message board on the Northampton Chronicle and Echo website erupted into life with furious comments condemning me as a villain and a leech. The tone is summed up by this one:

“Ben Gowland has no better morals than the bankers & corrupt politicians of late that we all have witnessed…When are politicians and the media going to wake up and expose these people? Their only desire is to milk us dry and take even more money for themselves…I wish every failure for him and his venture. He’s wrecked our services now he wants to set up a company supplying services back to us to cream off even more monies from the public purse!”

And this was one of the more moderate comments. I must admit to being surprised by the reaction. I wasn’t expecting a ticker-tape parade and dancing in the streets of Wellingborough when I left but, like anyone who has worked hard for a long time, I thought I might just leave with a warm glow and appreciation of a job well done. How naïve!

At the heart of my decision to leave the NHS had been a growing disillusionment with my ability to effect real change from within the Service, and a belief that the freedom of working for myself would make this more possible. Shifting from being paid directly by the NHS as a salaried employee to working alongside the NHS, contracting services in, didn’t feel like a decision to move to the “dark side”. But was it? Had I now become, as owner and only employee of a private company, a person lacking in morals as the comments suggested? Did my new position inevitably place me as a self-interested capitalist, no longer interested in social values?

I found even the suggestion that this might be true to be difficult. It took me several months before I could even read the comments written in the paper in full and they made me variously cringe and become indignant. Deep down I knew that, whatever others might think, I personally could add more social value from outside the NHS than from within it. I understood it was going to take time to prove this to others, particularly those who don’t know me but my whole career has been driven by my values – so prove it, I would.

I started by writing down the mission of Ockham Healthcare, and published it on the website. It finishes like this,

“Ockham Healthcare is here to create practical steps to a better future for healthcare: to support those who embody the ideas of the NHS but that the NHS seems to work against; to help those who want to create a new future for the values underpinning the NHS; and to enable change and innovation in a system without incentive to change.”

The opportunity I now have is to use my position outside of the NHS (and the freedom this brings) to provide help where I think it is needed most, and to focus on areas of my choosing -rather than those chosen by others. Now it is up to me to embrace that opportunity.

The whole experience has actually made me far clearer about my own personal values and about what I am trying to achieve with my life and my career; far clearer than I had been for many years operating within the NHS.

Can one enter the cut-throat world of commerce and remain value-driven? Using my experience as a sample of one, the answer is “yes”. Not only is it proving possible to be value-driven in the private sector I find that, by being single-minded about what I believe in and without the distracting influence of other agendas, my values have led my actions in Ockham Healthcare even more forcefully than when I was in the public sector. And long may that continue.

apr

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How do you solve a problem like General Practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Who has the answer to the crisis facing General Practice? Ben Gowland argues that it is not the politicians, or indeed anyone who believes in an imposed, top-down intervention. The solution has to come from General Practice itself.

We all know General Practice is in crisis. What we seem to be lacking is a sensible plan for how to tackle it.

The Government’s approach is relatively straightforward. They have promised more money (4-5% each year until 2021), more doctors (5000 more by 2020) and less bureaucracy. They are going to encourage GP practices to operate ‘at scale’ by offering a new voluntary contract for practices that cover a population of 30,000 or more. And in return they want 7-day access to GP services.

Sounds simple. But there is a fundamental problem with this approach – we know it is not going to work. The financial problems in General Practice are NOT going to be solved by the additional funding (less than half of GPs think it will have a significant positive impact on the problems they are currently facing). The recruitment problems are NOT going to be solved by the extra GPs: GPs are leaving, retiring and emigrating far faster than new ones are joining. And a huge 90% of GPs think that the introduction of 7-day working will only make their problems significantly worse.

The current crisis in General Practice will NOT be resolved by a new contract, a 10-point plan, or a series of ‘interventions’ from on high. Offering more money to GPs for working harder or longer hours when they are already at breaking point is just likely to send them over the edge. Shouting louder at practices that are struggling or increasing the number of inspections or applying stricter and stricter contract penalties are NOT going to work – they will simply make the situation worse.

So what WILL work? However dire the current situation you can’t just force or manipulate General Practice into changing. A completely different approach is required. It needs leadership that will inspire those working in General Practice (who are variously tired, frustrated and burnt-out) to believe that change for the better is, in fact, possible. The group interest of General Practice (and thus their patients) needs to be set as the priority, as a means of stimulating followership. Change needs to start with, and build on, the values, ideals and needs of General Practice. And it needs a focus on innovation, on doing things differently and doing different things – rather than the execution of someone else’s plan that no-one really believes will work.

Where this type of approach has been used, we have seen the green shoots of success. I spoke recently with Mark Newbold, the Managing Director of Our Health Partnership, the new ‘super-practice’ formed from 32 previously existing practices in Birmingham. Inspired by the vision presented to them, the member practices committed to the new model. They dissolved their old partnerships and created a new one. The model is working because the organisation has created trust between the leadership and the members. This is because its primary focus is on the needs of the members and their patients and because it is striving to deliver on its promise that the benefits of operating together at scale will outweigh the loss of independence and start-up costs. In Mark’s words, it remains a “grass roots movement”.

But it would be a foolish Whitehall mandarin who interpreted this as meaning that super practices must be the “answer”. What this example demonstrates, though, is that the “answer” must come from locally-led change, focussed on listening, collaboration and leading by example. The plan for General Practice can’t start with the answer. Imposing change on General Practice will make things worse. But a plan that strives to build trust, to create an environment that encourages new ways of working, and to enable and empower GP practices to transform themselves, is the one most likely to succeed.

mar

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A Life Without Meetings

Posted by Ben GowlandBlogs, Life After the NHSNo Comments

Ben Gowland considers what happens when the meetings stop and you suddenly have time to think.

I was having a drink with an old colleague recently and he asked me what life was like, now that I am working for myself. Frankly, I replied, there are a lot less meetings.

There is something about working in the NHS that draws you into this culture of meeting after endless meeting. I remember a new Finance Director joining an organisation I was at who proudly placed a framed quote on his desk that read, ‘People who enjoy meetings should not be in charge of anything’. Within a few months he was complaining about the meetings just like the rest of us, and the quote mysteriously disappeared.

At a different hospital, when a new HR Director started she announced she would not be having any meetings before 9.30am. That is going to be tough, I thought to myself, given the consultants would only meet you at 7.30 in the morning (or earlier – there seemed to be some sort of competition amongst the general surgeons as to who would arrive the earliest). I remember meeting her six months later, at about 7.45am on a dark winter’s morning in the half mile queue for the coffee shop in the main hospital concourse, and I asked her about her initial pledge. She looked like she had aged 10 years in that time. She had dark circles around her eyes, and that constantly distant look that comes with one too many employment tribunals. She just stared at me and denied all knowledge of anything so idiotic. ‘Double espresso to go’ she barked at the hapless barista…

I have to admit there was a transition, moving from a diary packed from dusk to dawn with meetings to one with virtually none. What do you do? How do you stop yourself checking whether Supermarket Sweep is still on in the mornings? I searched the web for advice. It turns out it requires discipline: only look at emails for half an hour twice a day; focus on the ‘one big thing’ you want to do each day before you do anything else; and don’t, whatever you do, turn on the TV.

Now I like it. Admittedly it took me a while to get used to it, but now I really enjoy being able to spend my time working on the things I want to do. It has meant I was able to ensure that Ockham produced its first White Paper, ‘5 Years to the End of General Practice?’ in February, that we could generate a suite of tools for the ‘Practical Steps’ programme for GP practices, as well as have the capacity to write two regular blogs – this one and one on general practice.

Life without meetings has its own challenges, but in the quest to make a difference it feels like a step in the right direction. And (I know you are wondering) there is currently no sign of Supermarket Sweep anywhere…

mar

3 1

Why scale isn’t the answer for General Practice

Posted by Ben GowlandBlogs, The General Practice Blog3 Comments

Ben Gowland argues that working at greater scale is not the panacea for General Practice that some would have us believe.

To many outside observers the problems facing General Practice seem quite straightforward. There are nearly 8000 small businesses, many of whom are finding their current business model to be unsustainable. Clearly what is needed is for there to be a consolidation of the businesses, so that there are fewer, each of a bigger size, with greater operational and financial resilience.

But is this really the answer? Reports have emerged recently about a federation in Doncaster going into administration after running into financial difficulties. Not only did operating at scale in this instance fail to provide the answer to the current pressures for this set of practices, but it also cost them as much as £20,000 each to find this out.

Operating at scale can help practices. But it is not a solution in itself. Rather it enables other solutions to be put in place. It means the practice can cope better with staff who want to work part time, it creates the critical mass to introduce new roles, and it enables the provision of sufficient management capacity for further change. Larger practices can access more capital, invest in buildings and technology, and play a much larger role in changes across the whole system.

But these benefits are not automatic. They are not delivered simply because the practice is now operating at a greater scale. If two or three practices merge or form a federation these benefits will not necessarily follow.

This is because the journey is often not straightforward. As one GP put it to me recently, “(these changes) have the potential to help the practice but if they are introduced badly they could also make things worse… Working as a group could definitely improve things if developed well, but could also drain effort and resources without giving enough benefits in return”.

Ultimately it is the way the change is made that is important. Not the practical legal governance issues (these are straightforward enough), but the engagement of hearts and minds, the development of a shared set of values, and the setting of common goals that will determine success or otherwise for those parties deciding to get bigger together.

The right question is not to ask whether operating at scale is an answer for General Practice. Rather it is to ask; are practices capable of changing the scale at which they operate? Does the expertise exist in General Practice to ensure the benefits of getting bigger outweigh the effort and resources required to get there?

In pockets the answer is yes but in general it is no. Some practices can, and have, made changes that have delivered huge benefits for them. But many practices are stuck in a vicious circle of increasing workload and worsening finances, and haven’t the capacity for a discussion about whether to make a change, let alone to implement anything significant. Telling them to operate at scale, or even employ a pharmacist, or introduce web-based triage simply is not going to help. And using a contract to try to force the change misses the point: the issue is capacity and capability to change, not resistance to trying something new.

Operating at scale is an answer for General Practice, but not the answer. The answer is headroom for practices to make changes to the way they operate; it is help with the process of identifying and making these changes; and it is resources to make these changes happen.

mar

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Will Anyone Listen to a Healthcare Podcast? or How Chris Moyles Changed My Life

Posted by Ben GowlandBlogs, Life After the NHSNo Comments

I was gutted when they announced Chris Moyles was to be axed from the Radio 1 Breakfast Show. He was appealing to the wrong demographic. Radio 1 is apparently supposed to attract 18-25 year olds and yet “old” men in their forties, like me, were clinging onto their youth and still enjoying the daily banter from the larger-than-life Yorkshireman.

So where to go then? I tried Radio 2 (despite his devoted audience Terry Wogan was never going to be for me), Radio 4 (made listening to the radio feel too much like work), Radio 5 Live (all over the place), and even local radio (couldn’t cope with the adverts). It was then that I first came across podcasts. Podcasts are basically pre-recorded radio shows, but the beauty of them is that you can choose exactly what you want to listen to and when. I discovered that on iTunes there are literally thousands available.

So I found ‘Coffee Break Spanish’ and started to learn Español. I discovered The Fantasy Football Scoutcast to feed my unhealthy addiction to fantasy football. And I really enjoyed ‘The Tim Ferriss Show’ because I love his books (‘The Four Hour Work Week’ changed my life, but that’s another story…), and he interviews some fascinating people.

I also looked to see whether there were any good healthcare podcasts. There is Radio 4’s Inside Health and a number of other examples from the “pills and piles” school but I couldn’t find anything for someone like me working in healthcare.

When I started up Ockham Healthcare one of the things I really wanted to do was see if we could create such a podcast: one about the delivery of healthcare specifically targeted at people working in healthcare. I wanted it to provide examples of good practice that could go into more depth than a written summary, which could really get underneath how people were able to make the changes they did, and overcome the resistance that they inevitably faced along the way.

But where do you start? Is making a podcast easy or difficult? Well, it turns out there are various technical challenges, but nothing insurmountable. Yes, I have found myself on the end of a frustrating Skype call with someone miming ‘I can’t hear you!’, and yes I have had to record a 30 minute call in 5 minute bursts because I didn’t realise the ‘free’ version limited you to 5 minutes of recording. But, as it turned out, there was plenty of freely available information on the internet to get me through.

On February 9^th 2016 we published on iTunes the first episode of ‘The Ben Gowland Podcast’ – a name which, unsurprisingly, I came up with myself. We publish a new episode every week and I have had the privilege of speaking to some fantastic people along the way. These have, so far, ranged from a practice manager in Gateshead explaining how their work with the local community saw her organising Christmas dinner and a tea dance, to finding out what is going on behind the scenes in the development of the largest ‘super-practice’ in England.

Will anyone listen to a healthcare podcast? It is early days but it is beginning to look like they will. More and more people are listening every week. Have a listen here and let me know what you think. Be brutally honest with me, I want it to get better and I can take it. Plus if you think there is anyone I should be interviewing on the podcast let me know.

In the end I think the controllers of Radio 1 did me a favour when they axed Chris Moyles. It was clearly time for me to recognise I am no longer in my twenties, and to “update” my listening behaviour. If they hadn’t I am not sure I would have even discovered podcasts, let alone have my own show. You could say it changed my life…

mar

2 1

General Practice or CCG: Time for GP Leaders to switch?

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

I recently tried to persuade a GP leader (Dr S) to leave his CCG and spend his time helping core General Practice instead. Here is how the conversation went:

Me: The time has come for you, and GPs like you in leadership roles in CCGs, to step down from your CCG role and instead use the skills you’ve developed over the last 6 years to lead General Practice out of its current crisis.

Dr S: I can’t begin to tell you how bad an idea I think that is! First off, I don’t think it is my job to change General Practice.

Me: So whose job do you think it is? Seriously, if it is not your job, whose job is it? NHS England do not think it is their job, and you certainly cannot believe it is the Government’s! Only GPs really understand General Practice. You are now a trained system leader. General Practice needs you.

Dr S: But I‘m needed where I am. CCGs have to be clinically led, and need GPs like me to stay in place. Otherwise they will become just like PCTs.

Me: You yourself are always telling me how serious the crisis in General Practice is. If it really is in such a bad way, why are you not switching your efforts? What is more important, the badge of clinical leadership for CCGs, or the future of General Practice?

Dr S: I have invested a lot in the CCG. I want it to succeed. I don’t want to let down all those I work with in the CCG. I would feel like I am abandoning them.

Me: I understand how you feel, but at the same time you are letting down your GP colleagues, current and future, by not focusing your efforts on General Practice. It is the system’s job to look after the CCG – it is, after all, a statutory body. It is no-one’s job to look after General Practice.

Dr S: But I can do more benefit for General Practice here in the CCG. I control the money here and I can make real change happen.

Me: First, the CCG bureaucracy around conflicts of interest means the change you can effect in General Practice from within the CCG is extremely limited. Second, contractual change is not the answer General Practice needs. It needs to change from the inside, with leaders like you working across practices, winning hearts and minds, finding a way forward.

Dr S: Even if I wanted to leave I couldn’t because my practice needs the CCG money. I won’t get anything for working with General Practice. If I left the CCG I would just have to go back to full time clinical work.

Me: You are right that the incentives in the system encourage GP leaders to remain in CCGs rather than support General Practice to change. At Ockham Healthcare we make the case that the money you earn in the CCG should be transferred with you if you want to make this move, so that you are paid the same for carrying out work to support the development of local General Practice as you are in the CCG. (You can read the report here)

Dr S: But we are talking about over £70K per year. How would this work in practice?

Me: Your CCG could choose to fund you, or indeed any of the GP leaders in your CCG, to work in General Practice by seconding you on full pay on the basis of the benefit this would bring to the system as a whole. You don’t need anyone else other than the CCG itself to agree it.

Dr S: But in the CCG I have a clearly defined leadership role, and everyone understands what it is. What would my role be if I If I left the CCG? Would there even be a role?

Me: There won’t be a marked out role, but there is a huge leadership challenge. You will have to establish your role and gain acceptance from your peers for it. No-one said this would be easy!

Dr S: The problem is I have burnt bridges with many of my colleagues as a result of my CCG role. I am not sure my GP colleagues want my help!

Me: First and foremost you are a GP. You understand General Practice. The fact you have made tough decisions in the past and stood by them in the face of peer resistance shows you are a leader of courage and integrity. You are exactly what General Practice needs. General Practice has to make some difficult decisions about how it is going to change and adapt going forward. Some are not going to like it and the challenge is going to be taking everyone with you.

Dr S: That is very generous, but I am not sure however hard I try that I will be able to persuade my GP colleagues to change.

Me: If you don’t believe that General Practice can get out of the situation it is currently in, do not expect anyone else to. Everyone can change with the right leadership, resources and support. If anyone is capable of helping your colleagues to change, it is you.

Dr S: But where would I go? What would I do? I am not sure I would even know where to start.

Me: You could do worse than following the advice of John Kotter. You would start by listening to your colleagues and really understanding their problems. You would share the experiences and ensure everyone understood the urgency of the situation and the need for change. You would create a change team around you. You would build a vision for the future. You would make sure everyone bought into it, and you would communicate it over and over and over again. You would move to action, creating quick wins to develop momentum. You would build on early successes and make bigger and bigger changes. Eventually you would embed these changes in the way that General Practice operates, completing the transformation.

Dr S: Maybe the idea is not as ridiculous as I first thought! I am not sure what to do

Me: Either General Practice is in trouble or it isn’t. If it is, it needs your help. Don’t leave it to others. Don’t take the easy route of staying put. Take up the challenge. Make the move. Use the skills that you have developed in the CCG to give General Practice a chance. Don’t do it for yourself, do it for your colleagues, do it because you believe in General Practice and the role it plays in the system and the difference it makes to patients. Do it because it is the right thing to do.

Should GP Leaders be leaving CCGs and supporting core General Practice? Let me know what you think: email ben@ockham.healthcare or via twitter @BenXGowland

mar

0 1

An Adventure Outside the NHS

Posted by Ben GowlandBlogs, Life After the NHSNo Comments

Some of you might know me, but some of you won’t, so let me introduce myself. After working for 20 years in the NHS, in April 2015 I resigned from my job as Chief Executive and Accountable Officer of a Clinical Commissioning Group, and ‘left’ the NHS. I started up a new company, Ockham Healthcare, which is part think tank, part consultancy. But is it possible for someone like me, ‘born and bred’ in the NHS, to build a successful company outside of the NHS?

A colleague said to me a few years ago that public sector executives are not, and never can be, entrepreneurs. He said we lacked whatever it is that is required to make a new company successful. His rationale was that we have all become too indoctrinated by the public sector mentality of days filled with quality committees and audit committees and the like, and of doing whatever we are told from on high, to ever be able to build something from the bottom up.

Maybe he is right. I don’t want to believe it, and in many ways what I am doing now is an experiment in proving the validity (or otherwise!) of his hypothesis. I don’t mind being the guinea pig!

One thing that I can say is that I now earn a lot less money. There is a frightening statistic that 50% of new businesses fail in the first year, and 95% fail within 5 years. So far outgoings have indeed exceeded incomings, but I am told that if I can end the first year even with a small loss I will be doing well. But for me this isn’t the point. The challenge I have set for myself is whether I can put my energy and effort into creating something that I am proud of, that feels like a force for good, and that makes a positive difference to all those that it touches (whether they are staff, clients, partners or patients).

That said, I still have to make a living. I had saved enough to make it through a year. Whether I can make it through two remains to be seen! I plan to share my adventure into the unknown through this column, to share whatever I learn about life after the NHS, and to discover whether it is even possible for me to stay outside the NHS.

My starting point is general practice. I am trying to find ways of providing support that can help general practice get through the genuinely difficult position it is in right now. Whether or not general practice wants my support is another matter, but I am putting together tools to help GP practices who are in real trouble and need to make big changes. If you know GP practices that could benefit from my help please put them in touch – help me make a difference!

My next column will be in two weeks’ time. In the meantime, if there is anything you want to know, experiences that you can share, or advice that you think can help, please get in touch via ben@ockham.healthcare.

feb

0 2

Give us our daily bread

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I am a bread maker. I know which ingredients I need to make the perfect loaf. I know how long it takes. I know how much the ingredients cost, how much of my time I need to put in, and how many loaves I need to sell at what price to make a living.

As a bread maker, I know my customers. I know if I make really great bread I can sell at a price higher than that in the supermarkets because my customers appreciate great bread. If the cost of the ingredients goes up, I can raise my prices and my customers might not like it but they will understand. I can still make a living.

In the NHS the life of a bread maker is much more complicated. When I sell my bread to the NHS, I am not selling it to my customers (the people who eat my bread). I am selling it to “commissioners”, who are buying that bread on behalf of patients. The job of commissioners is to make sure patients get the best possible value for the money invested by the government in the NHS, and they take this very seriously indeed.

Problems arise when the cost of my ingredients go up. I say to the commissioners, “the cost of flour has gone up, and so I will have to raise my prices”. But according to the commissioners this is my problem. They insist that I make more bread for less money, despite the rise in the cost of ingredients.

So what do I do? I can either make lower quality bread, putting less care and attention into each loaf. Or I can work longer and longer hours making bread, and pay myself less and less money to offset the rise in the cost of ingredients. Eventually, I have to do both.

I go back to the commissioners and say that I can’t carry on. My bread is no longer of the same quality and I am close to burnout.

Finally, they listen. They say they understand the problems I am facing. They say they are going to give me more money for my bread. On one condition: that I make bread 7 days a week. Patients should have fresh bread 7 days a week they tell me, and that is what they want in return for the extra money.

I say, “But I need the extra money because my costs have gone up. My costs will go up even more if I have to make bread 7 days a week. My business will still be in trouble”. “Money is tight for everyone” the commissioners reply, “we need a return for the extra money we are investing”.

I don’t understand this logic. If flour costs more, I need more money to make bread. I cannot absorb the cost and still make great bread and still make a living that will support my family. Sometimes costs go up. Sometimes people have to pay more for the exact same thing. When I sell directly to customers they understand this.

I agree with commissioners that patients should have fresh bread 7 days a week. I am happy to work with my fellow bread makers to work out a way that we can do this between us, and as long as we are reimbursed for the costs of doing it then we can provide it. But not now. Not while my business is facing such severe challenges. If commissioners paid more money so that I could meet the costs of making bread, and I could get my business back on track, then I would be at a point where I could work out how to make fresh bread available 7 days a week. But not right now.

I would be happy to agree to change the way I make bread in return for extra money. I would be happy to explore how I could find different types of labour, work with other bread makers and other organisations, and find ways that would enable me to still make great bread at lower costs. If the commissioner would invest extra money to help me make these changes I would be up for the challenge.

But if nothing changes, I do not think I will be able to make bread for the NHS any more.

feb

0 1

Life after the NHS

Posted by Ben GowlandBlogs, Life After the NHSNo Comments

Why I Resigned as CEO of a CCG

This article was first published in the Guardian on the 23^rd June 2015

At 4pm on Tuesday 13^th January this year, less than two weeks after the Christmas break, I walked nervously into the Chair’s office and resigned.

A few hours later, I was sat in a bar with some friends, their faces etched with disbelief, being interrogated about what I had just done. After finally exhausting the ‘and then what did he say?’ questions, one of the group asked, ‘But what I still don’t understand is why? You are the Chief Executive – why would you walk away from such a well-paid job, with its final salary pension, when you don’t have to? Why?’

The last time I had encountered that degree of questioning from them was twenty years earlier, when having graduated from Oxford I decided to spurn the advances of the city and instead pursue a career in NHS management. My answer then was that I didn’t want to wake up when I was 40 (40 seeming very old at that point) and discover that what I had achieved was simply earning a pile of money. I wanted to do something more with my life. I wanted to make a difference, and working in the NHS felt like an opportunity to positively impact on the lives of people who need help most.

I have worked in the NHS for 20 years. And in that time I have met many front line staff who work every day under exceptionally difficult circumstances, and who do, truly, impact upon the lives of patients and their carers. I have always felt my job is to do what I can to make their lives easier, to create systems that work better for them, and to try to solve as many of their problems as I can.

There have been times when I have felt that this was exactly what I was doing, for example when I was able to facilitate the introduction of a Community Elderly Care Service, that had been the brainchild of the local Elderly Care consultants who could see that their expertise was needed more out in the community than in the hospital.

But there have been other times when I have felt like I am not making any difference at all. The endless meetings, the incessant reporting, the answering to the latest political diktat. The NHS operates from the top down, but what makes sense in Whitehall rarely makes sense to the staff on the front line.

I vividly remember driving home at 8pm one evening when the phone rang. It was the local regional manager, who wanted information for her manager for 8am the next morning (because he had a meeting with Secretary of State). I arrived home, called a number of staff and between us we worked until midnight pulling the information together. But for what? We weren’t adding any value, simply feeding a system that demanded it.

So how can I make a difference in the NHS, when this is the environment? This was the question I had been grappling with for some time. Finally at Christmas I decided the only way to be free from the directives and the diktats, the imperatives that are well-intentioned but in reality stifle local innovation and prevent change from happening, was to quit.

This is what I explained to my Chair back in January. He listened, sighed heavily, and said, ‘I can see I am not going to change your mind’. And he was right. I want to focus on supporting the changes that matter, to provide genuine support to those working on the front line. To do this, I have come to understand, I need to be working with the NHS not in the NHS.

feb

0 0

Is the noise from General Practice rhetoric or reality?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

What is really going on with general practice? Is the noise we hear from GPs every time we turn on the radio or pick up a paper rhetoric or reality? Are GPs simply feeling the same pressure we are all feeling, or is something more going on? I decided to find out.