Ockham Healthcare: Supporting innovation in General Practice

Guest Blog – My GP by Sarah Smizz

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.

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

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 1st 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!

Funding Federations – The Accountable Care Conundrum

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.

What does “being resilient” mean?

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.

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

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…

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