Ockham Healthcare: Supporting innovation in General Practice

General Practice in 10 Years’ Time – Part 1

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.

The Future of General Practice – Have Your Say

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!

What is the Future of General Practice?

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.

What the new ACO contract means for general practice

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.

Navigating the podcast: Introducing new roles

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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