Recent Developments in General Practice: Autumn 2016

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 23rd 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Fund were released, and were generally less than expected and given a national prioritisation that differed from (and superseded) those made locally.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!

Welcome to the club – the rise of Leg Clubs

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

Where to start with CCG GPFV plans

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.

What the Changes to General Practice Mean for Primary Care Premises

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.

The one new role every single GP practice should adopt

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!

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