Guest Blog – the NHS long term plan, a GP at-scale view

You’ve seen the summaries of the NHS Long Term Plan but now, thanks to a guest blog from Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) we offer you a more in-depth look from the particular perspective of general practice operating at-scale…

I’m a long-term cynic when it comes to NHS long-term plans.  They’re usually unnaturally narrow, overly prescriptive and with the flexibility of a Soviet Five Year Plan.  This new one is different: it’s broad (scattergun broad in places), with vision statements instead of hard plans, and enough scope for local areas to interpret this in a way that makes it work for their area.

Be open when you read it, if you don’t like one part then don’t write off the entire plan.

The sections below are my commentary on each chapter in the plan, concentrating on Chapter 1 and putting a very strong at-scale bias on it.

CHAPTER 1 – SERVICE MODEL

The changes to the existing NHS service model in this plan are generally well thought through and represent some good innovative thinking.  There is substantial work needed, though, to turn it from vision into actual plans.  For at-scale General Practice, the Plan has plenty of changes:

The focus around Primary Care Networks (PCNs) is interesting as it’s a deliberate step away from discussing “providers” and into defining geographically bound GP-led organisations.  There is almost no other way they could have phrased this without allowing a way-in for out-of-area and private company poaching of work.  How this is funded is a different question, as it’s vague.  I would prefer a capitated block budget with a deprivation supplement (see Chapter 2 notes).  It will be interesting to see how this will work with looking-out GP Federations mixed with looking-in PCNs.

Additionally, it refers to CCG procured “enhanced” services.  This is a particular issue of mine as cash-rich CCGs can afford lots of these enhanced services while cash-poor ones can’t.  It’s a built-in inequality that directly impacts the way clinicians can offer patient care. It would be good to see a national index of enhanced services offered in each area.  Maybe this is something for NHSE to do, enabling GPs and providers to hold CCGs to account for the reduced capabilities they have.

A very welcome change in this Plan is the addition of “shared savings” where GPs and PCNs will be rewarded by getting part of any savings made in other care settings.

There is now a focus on “digital first” for GPs.  I think this partially misses the point as it does not account for the system-wide savings through continuity of care in General Practice. Neither does it work for the “have-nots” of society who can’t or won’t use technology. This is where GPs must step up and be the patient advocates for the have-nots, especially in deprived areas.

I would recommend a priority for GPs is to address this themselves to protect their own service.  For example, it’s allowable in this for patients to be offered telephone appointments OR online conference ones.  Show that you offer patients a teleconference option and change your model to prioritising it and you’ll be half-way to meeting this objective. Do it yourselves or you’ll find it mandated and patients going elsewhere under promises of remote unicorns of same-day GP appointments by phone.

The outpatient redesign part of this chapter concerns me as, unless it’s done properly, it’ll result in General Practice being dumped with patients overly quickly discharged or there being clear rationing or higher bars on referring patients.  The Plan risks getting this wrong.  Patients don’t just go away because they can’t get a referral to hospital.

A major focus is placed on moving all of England to the ICS model by 2021. This is too aggressive as some areas just will not be ready in time.  Areas with large system-wide deficits or strict system controls are most likely to have difficulties in setting up effective ICS because it’s just not a priority compared to that big financial black hole

Another aspect of ICS is the move to Integrated Care Provider contracts. This will require legislative change to enable, but will effectively shortcut alliances of NHS public providers into formal status while also allowing a complete removal of the necessity for procurement for work in the area. A concern is the Plan suggests only allowing this for statutory bodies.  While this will exclude the big private providers, such as Virgin, it will also exclude GP Federations.  Much is required to make this work, and the elephant in the room of Brexit makes legislative changes unlikely for quite a while.

CHAPTER 2 – PREVENTION AND HEALTH INEQUALITIES

This chapter concerns itself with the prevention agenda and addressing health inequalities.  It does it very well and makes a strong case for addressing deprivation related health inequalities.  For this alone, this Plan succeeds and deserves support.

The Plan is clear that more funds will be targeted at areas with high deprivation and high health inequalities.  The concern for many areas with high deprivation is that they’re often grouped with areas of middling or low deprivation and any aggregation of their “scores” would see a loss of any such deprivation premium.

I would like to see a central strategy of highlighting discrete areas of high deprivation and high health inequalities and mandating special funding for them.  A secondary, but just as important, strategy is that this extra money must not be allowed to be diluted across an ICS/system; it must be provided to help health inequalities among the most deprived patients in England, not to give extra to areas that don’t need as much help.

CHAPTER 3 – CARE QUALITY AND OUTCOMES

This chapter is a mixed bag of strong content matching chapter 2 and defensiveness over the consequences of previous decisions.

The cancer prevention and early diagnosis parts of this Plan fall heavily on primary care with extra resources being made available for urgent referrals and diagnostic tests.  It will put pressure on GPs to deal with the turnaround and meet targets but it is achievable and will help patients.  A critical component is the funding though and ensuring it comes before the targets.

There’s a strong focus on mental health with distinctions between CYP and adult MH, as well as plans for addressing the current service gap of 18-25-year-old patients moved from CAMHS to adult MH services. Much of the load from this will land on primary care through IAPT extensions, and it’s worth dedicating time to what this will mean for both individual practices and at-scale General Practice. I’d recommend that GP Federations make this a core part of any clinical strategy they’re developing.

One thing that will benefit patients is the commitment to get 70% of acute hospitals to the Core 24 standard on emergency MH support by 2023/4 and then to 100%. This will give GPs a much needed emergency referral source that is missing at present across the greatest part of England.

The less good side is learning development and autism where the plan seems disjointed and is proud of the fact that inpatient provision will be halved by 2023/4 considering that it was already effectively cut in half from its 2010 numbers by 2015.  As always, the load from these patients moved back to the community risks landing on primary care and often take GP time.  Again, we need a GP at-scale strategy for these patients to treat them with the dignity and care they deserve while also not impacting overall workloads.  The relatively low numbers would suggest this may be best dealt with in practices with at-scale support.

Interestingly, there are some changes to the planned vs urgent care model that will help primary care. There are plans to provide funding for increased planned care capacity, but not necessarily in acute hospitals.  This is a welcome change from the now habitual “cut referrals” strategy to reduce waiting lists.  Also, there are plans to force physical separation between urgent/emergency care and planned care so that disruptions such as winter pressures will have fewer major impacts on planned care.  This would be a major expense though, and I doubt the government will provide the capital needed for the physical building separations.

CHAPTER 4 – NHS STAFF

Of greatest importance to GPs in this section is the confirmation that GP indemnity will be cost neutral.  This means it will be paid for but then clawed back through other parts of GP funding, most likely GMS/PMS contracts.

The remainder of chapter 4 shows this is the weakness of the whole Plan. It needs a robust workforce strategy and struggles without it.  Treat this chapter as a placeholder for the proper strategy later.

There is too much concentration on the centralised functions writing the plans and far too little recognition that it’s locally that workforce fails when grand strategies are applied.

It also shies away from changing previous poor decisions, such as materially defunding the NHS Leadership Academy, but talks about improving training & CPD coverage.

CHAPTER 5 – DIGITALLY-ENABLED CARE

There’s some blank cheques written in this section that recognise the aims of the Health Secretary, but these haven’t yet been fleshed out beyond bare skeletons.

A key example is the paragraph about improving IT to make work more satisfying (“faster, better and more reliable”).  Yet with no ideas on how they’ll do that when programme after programme has failed to touch the subject.

It also fails to deal with the massive infrastructure upgrade of resilience that is essential if the NHS is moving away from on-site presence to off-site coverage.  If a system goes down or is slow when the patient and clinician are face-to-face then it’s often simple to work around; if a system goes down when it’s a virtual consultation then it usually stops. This is a massive expense, based on my own experience of grand-scale upgrades, doubling the capital IT budget for a few years MIGHT just achieve this.  There’s no getting away from this, to make it “faster, better and more reliable” will require huge and probably politically unbearable capital investment with revenue uplifts.

CHAPTER 6 – TAXPAYERS’ INVESTMENT

The Plan bakes in a 1.1% annual “productivity growth” dividend.  This is unlikely as there’s very little “fat” left in the system.  The NHS as it stands is far more efficient than the vast majority of even the best private sector organisations.  Any more cuts will be right into muscle.

It does make an interesting comment that community care clinical staff spend more time doing admin and non-patient facing work than patient-facing work. I would put that this is a recognition that admin cuts have gone too far and investment in specialist admin staff and tools would more than repay themselves in freed time to deal with patients.

Finally, it makes the point that the central admin budgets of the NHS, including provider Trusts, will be expected to be cut by £700m/year.  Again, from where?

CHAPTER 7 – NEXT STEPS

An interesting point here is the Plan’s aim to provide five-year indicative budgets.  My hope is that this will remove the year-by-year short-termism of the NHS and allow long-term efficient and multi-year budgets. This is an area where Federations and private providers can outperform the NHS at present as we’re not bound by in-year spending of funds.  It will only be good for the rest of the NHS to catch up.

The legislative changes required to make this plan work are also interesting.  The bits that impact at-scale General Practice are around the ICS/ICP and integrated care Trusts and the removal of procurement mandates.  The latter would allow CCGs to make direct contracting between NHS organisations easier and remove the significant wasted costs we see in NHS procurements of very low-level services.  Both are items that should gain strong support and advocacy from GP at-scale groups.

WHAT IT’S MISSING

I hope some readers are still here!  As a bonus to those of you who made it, I noted two major areas that this Plan misses that I’d hope would make it.

Point 1: National detailed minimum standards of care matched to local needs.  Targets are fine in their own way (same with CQC inspections) but they’re negative and, regardless of what they say, just are not patient focussed. I would like a grand programme that sets standards of care across all health issues and provokes discussion on prioritisation for care to help the NHS set its own localised plans.  For example, what’s unique about a deprived area’s health inequalities that explains WHY it has lower levels for patient care?  What does that mean and how does the area plan to meet, and exceed, national minimum standards of care?  Long-term local plans should then be externally funded for removing health inequalities matched with central funding for delivery that supplements local commissioning funding.

Point 2: Demand analysis.  The NHS is woefully unaware of its actual demand.  How many patients don’t bother when they can’t get a GP appointment?  How many GPs won’t refer clearly ill patients because they know they’d be rejected?  The NHS is terrified of these figures as they’d be spun out of all proportion by the media, but they’re needed to model demand properly.  The NHS needs an adult conversation on demand and how it should be met, including what we expect the public to do themselves.  It’s a weakness to continue scaling services by supply rather than demand.

As mentioned, this is my interpretation with my tinted glasses on of at-scale General Practice. I instinctively wanted to dislike this Plan before I read it but I actually do like it.  It’s honest and doesn’t pretend to be complete, it also is a vision statement where you can forgive the lack of detail as long as there’s a genuine aim to produce proper plans in a relatively short time.  With that in mind, give it your own read with that in mind rather than “that won’t work”. https://www.longtermplan.nhs.uk/

My Top 3 General Practice Podcast Episodes of 2018

We have had quite a year on the General Practice podcast.  We kicked off in January with episode 93, with Martin Ramsay explaining the technicalities of setting up a super-partnership, right through to December when ex-RCGP president Terry Kemple introduced the Green Impact for Health toolkit that practices can use to play their part in making the planet sustainable.

Our most popular guest without question was Dr Rachel Morris.  In April she talked to me about the Red Whale Lead, Manage. Thrive! Course and their new working at scale course – an episode downloaded over 1750 times, making it the most listened to episode of the show.  She followed this up with the second most popular episode in November, when she shared her insights into GP burn-out, stress and resilience.

We tried out panel discussions on the show for the first time.  We brought some of the leading thinkers and practitioners together to discuss how technology will shape the future of general practice (here and here), what the infrastructure of general practice will look like in the future – including whether the partnership model will survive (here and here), how much impact the new models of care, including developments such as the primary care home, will have on general practice (here and here), and how much millennials, both as GPs and patients, will change the way general practice operates (here and here).  It all made for fascinating listening, and has certainly changed the way I think about how general practice will develop into the future.

But none of these made my own personal top 3.  Our own efforts to think about the future of general practice were somewhat put to shame by the work of Andy Wilkins and the authors of a report entitled “Beyond the Fog”.  They took all the current trends, such as technology, personalised medicine and systems biology, and worked out what they all might mean for the future delivery of healthcare.  The results are fascinating.  Over the course of two episodes (here and here), Andy describes ideas such as “always on” healthcare (24/7 digital monitoring of our health) and a “digital health coach” (think Alexa offering you personalised health advice), and gives his own insights into the implications for general practice.

What we most love featuring on the podcast are practical examples of innovations that have made a real difference to practices and to their patients.  For me this was exemplified in episode 132 by Alison Halliwell.  She told me the story of how she had set up a mental health service within a GP practice in Fleetwood.  When she started (back in 2004) 42% of patients were presenting with a mental health component to their illness.  Since then, down to the hard work and persistence of Alison and her team, only 8% of GP time is spent dealing with mental health issues.  Real innovation, delivering real benefits for GPs and their patients alike.

The final episode in my top 3 is another example of inspiring local innovation.  It came in June, when I was invited to Peterborough to visit Dr Neil Modha at Thistlemoor Medical Centre.  I am fortunate in my work to visit lots of different GP practices, but I can honestly say I had never been anywhere quite like this before.  They have adapted their model to meet the demands of a large non-English speaking population and a local shortage of GPs by training members of the local community to be healthcare assistants who take histories, translate, and present patients to the GPs.  On top of that, the practice sees more patients per day than many A&E departments!

These were my top 3, but I would love to know yours!  Get in touch and let me know. Finally, a big personal thank you from me to all of our guests, for the generosity of their time and the inspiration they have provided, and to all of our listeners for all your support and encouragement.  I can’t wait to see what 2019 brings!

What is a Primary Care Network for?

One of the best things about my job is I have the opportunity to speak to some of the leading practitioners and thinkers in general practice.  This week was no exception as I was lucky enough to interview Dr Robin Miller, the Deputy Director at the Health Services Management Centre at the University of Birmingham.  Robin has published two really important papers on transformation in general practice recently (you can access both of them for free here and here), and we discussed them for a forthcoming episode of the podcast.

The conversation really challenged some of my thinking.  We all understand the idea of a primary care network being about practices working together around populations of 30-50,000.  Where I had got to previously was that there are almost two options around this.  The focus could be on those practices working together to support core general practice.  The crisis in general practice is, and remains, real, and these networks form an opportunity for practices to find a way through this by introducing new roles, developing shared systems for managing demand, creating back office efficiencies, and introducing new technology.  Granta Medical practice is a fantastic example of using this population size to deliver these benefits.

The second option has more of a focus on the local community formed by the 30-50,000 population, and on making changes to impact health outcomes.  It includes a much stronger focus on prevention, on the wider determinants of health, and on integrating services across health and social care to better meet the needs of the local population.  This approach is beautifully illustrated by Dr Steph Coughlin and her colleagues in City and Hackney.

The first option is more internally-focussed on the practices themselves, working together to support their long term viability.  The second is more externally-focussed on the local communities, and developing the role of general practice to support them.

Back to my conversation with Robin Miller.  He has published a number of lessons about primary care transformation, from research into national and international primary care transformation initiatives.  Two lessons particularly stood out for me.  The first is that “transformation” of general practice requires more than an incremental approach.  It requires a more fundamental redesign based on its purpose and contribution to society.  In the transformation programmes Robin looked at the GP leads had to change how they viewed their role in local health and care systems.  The practices had to move beyond their individual histories and interests and put the interest of people and communities at the centre of their work.

The second lesson is that when practices move beyond their traditional practice boundaries it changes the role of GPs.  The role changes from one defined by the trusted relationship between the GP and the patient to one defined by the GP as contributor to the wider primary care team.  Moving outside a domain where GPs can dictate what happens (as the owners of the business) to one where GPs need to influence each other and other clinicians, individuals and organisations, also requires GPs to find new ways to communicate and interact.  It requires a more facilitative approach.

Back, then, to the role of primary care networks.  It seems there is a more fundamental question than I had previously realised sitting behind them.  Are they a vehicle, an enabler, for primary care transformation?  Or are they this year’s initiative, to be tolerated until the next one comes along?

If it’s the latter then, fine, use them as a way of enabling practices to gain some incremental sustainability benefits by working together.  But if it’s the former (and, given the parlous state of general practice, it does feel like a tremendous opportunity) then it is not the either/or choice I had originally envisaged.  It is a platform to widen the primary care team, shift the role of general practice within the local community, yes make practices sustainable but at the same time make a more fundamental impact on local health outcomes.

As with everything in life, it is not black or white.  In any area there will be GPs wanting the latter, those wanting the former, and a majority in the middle not really engaging with the question.  The leadership challenge is to set a direction locally and to galvanise practices behind it.  This may require an initial focus on incremental benefits to practices to lead them to the wider transformation possibilities.  The journey will inevitably be difficult (change always is), but maybe, just maybe, a primary care network is a vehicle for real transformation of general practice.

What is your story?

Persuading GPs to work together at-scale, in whatever form we prefer, is a challenge. It is difficult because people (all people, not just GPs) don’t like change. We all remain anchored to our past and the certainty that provides. We all have an aversion to loss, and are more concerned with losing what we have than the prospect of gain. And we all have a strong desire to hang on to what we have, because simply owning something makes it seem more valuable to us.

Why would GPs give up the certainty and security of working as an individual, autonomous practice, and start to hand over some of that autonomy and freedom to an at-scale entity? Why would they change the model that has barely changed in 80 years because suddenly someone else thinks the model needs to be different?

The leadership task of the at-scale organisation is essentially one of persuasion, of winning hearts and minds so that GPs and practices will decide to make this change. This act of persuasion is not about analysis, or a simple presentation of the facts. It is about inspiring people to implement new ideas in the future. And not just grudgingly but enthusiastically, because they believe in it.

So how do we do this? How do we take our own hypothesis (that by working together we can make general practice a better place to work, able to deliver better care for patients, and have more influence on decision-makers) and persuade GPs and practices to give up some degree of local autonomy, and maybe some of their own money, to test it?

It is all about the story we tell. To win hearts and minds we need to tell a compelling story. Where management is concerned with how we deliver the goals we set for ourselves, leadership is concerned with establishing those goals in the first place. It is about creating a consensus about the goals to be pursued and how to achieve them. Storytelling is not a replacement for analytical thinking, but it enables us to imagine new perspectives and so is ideally suited to communicating change.

The best stories to spark action are what Stephen Denning[i] describes as “springboard stories”. These stories are based on actual events, where someone else (preferably a similar group of GPs or practices) has made a change that has been successfully implemented. It includes an implicit alternate ending of what would have happened had the change not been made. It is told in a way that allows the listener to create an analogous scenario for change in their own practice (“what if we did this here?”).

Sparking action is only the beginning. But thinking about how we inspire practices to work together and make the possibilities come alive through the stories we tell is an important starting point. Doing it because we feel we have to, or because everyone else is, or because the CCG/system wants us to means we can have the names and structures in place but lack the energy or commitment to make any real change happen. Sometimes we need to go back to the beginning to move forward.

What is your story?

 

[i] The Leader’s Guide to Storytelling, Stephen Denning, 2005

What does the cut in CCG running costs mean for general practice?

It was announced last week that CCG running costs are to be cut by 20%. CCGs are being asked to do this by “exploring mergers and joint ways of working”.

It all seems a long way from the days when CCGs were being set up. The argument then was about the “right” population size for a CCG. Small would allow a close relationship between the practices and enable clinically-led local change. Large would give CCGs a stronger voice, allow economies of scale, but risk creating distance to member practices.

While the backdrop to that particular discussion was a huge cut in management funds for CCGs (as compared to their predecessor PCTs), this latest cut ends any remnants of the historical debate. CCGs will no longer be vehicles for local clinically-led change, as they take a more strategic role across a wider area.

At the same time the system moves away from the commissioner provider split and towards integrated care systems. So whose responsibility is local clinically-led change in the emerging world? The size and role and funding of CCGs suggests it will no longer be their responsibility. In the realm of integrated care it is for local providers to work together to drive local change. Part of the drive for primary care networks is to have some form of infrastructure to enable this to happen at a local population level. Without them it is very hard to see anyone able to do this.

But what we haven’t seen happen is the corresponding shift of any resource to primary care networks for this redesign work. If the redesign responsibility is being taken away from CCGs and primary care networks are expected to pick this up, then resource surely needs to follow. Maybe it will in future, but nothing has been announced so far.

And in this in-between world where CCGs retain their statutory responsibilities but are increasingly starved of the resources to deliver them, then the change model seems to be shifting from one of co-design with local practices (that might actually work) to one of large scale schemes being universally implemented by CCGs across a large (and diverse) area, without any local tailoring. Not a recipe for success.

In future the new strategic commissioners will (hopefully) outline the outcomes they would like to local providers, who will then come up with ideas for how to make this happen, and schemes will be developed with local ownership that are likely to work. But what is missing at present (apart from any sense of a bottom-up mindset) is the shift of resource to the local areas to do their part of this work. And so instead we drift further and further into a world of top-down imposed models that has been proven many times over not to work in the NHS.

What are GPs to do? I would suggest three things. First, de-prioritise the investment of GP time into CCGs. If CCGs are no longer about clinically-led change for local areas, at a time when there is a real shortage of both GPs and GP leadership capacity, that time would be better focussed elsewhere. Second, resist calls to implement unachievable top down schemes, and argue for both the opportunity and the resource to develop locally-workable alternatives. Third, push for recurrent investment in primary care networks and at-scale general practice as an enabler of locally driven change for the system.

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