On the Day Demand

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

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

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

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

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

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

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

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

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

Recent Developments in General Practice

There has been something of a frenzy of activity over the summer, following the publication of the General Practice Forward View (GPFV) earlier in the year, and if you have been away it is easy to have missed what has been going on!

Arguably the biggest development was the publication of the new MCP (multispecialty community provider) contract framework.  This, potentially, represents the end of the independent contractor model for General Practice.  Our 15-minute guide tells you all you need to know, but essentially it is about creating new organisations that general practice are part of, as opposed to new general practice organisations.

They are entirely voluntary, which begs the question why would GP practices choose to join.  I spoke to Tracey Vell, the LMC GP lead for the implementation of the new contract in Manchester, and she told me practices are falling over themselves to join for three main reasons: a way out of the current pressures; because they will be bought out of their building; and because the new organisation will pick up indemnity.

The publication of the MCP contract guidance, which outlines the new contract length will be 10-15 years, coincided with a resurgence in APMS contracts.  North Derbyshire, Blackpool and elsewhere are now introducing these not as a tool for competition to “market test” general practice, but as an enabler of integration between GP practices and other providers.

For some, the MCP is seen as the lesser of two evils because the alternative new model of care, the Primary and Acute Care System (PACS), is regarded as the takeover of general practice by the local hospital.  However, Dr Berge Balian, the GP lead at Yeovil Hospital for the local PACS, contends instead it provides an opportunity for general practice to be paid for work transferred from the hospital.  As a result, practices in Yeovil are choosing to give up their contracts to join Symphony Healthcare Services, an organisation wholly owned by the hospital.

The big question following the publication of the GPFV is where is the money?  This was brought into even sharper focus following the revelation much of the GPFV money would be allocated via the STP areas (cue the introduction of RCGP ambassadors to each STP area).   I spoke to Maureen Baker about the GPFV money to get her take on where it is and what it will really amount to, and for those still in the dark we have produced our own guide on how to find it.

“Primary care access centres” were trailed in the GPFV as a mechanism for extending GP access.  The BMA has since produced its own document, “Safe Working in General Practice”, renaming them “locality hubs” and describing them as overflow facilities for “full” general practice.  Either way, they amount to the same thing and require practices to work together to create them.  Handily, the Nuffield Trust published “Is Bigger Better? Lessons for Large Scale General Practice”.  They found evidence of improvements in quality lacking, but author Rebecca Rosen did conclude bigger is indeed better as a mechanism for enabling general practices to cope with the current challenges.  For those wanting to up their scale, Jenny Stone gave us a guide to practice mergers, and Nigel Grinstead shared the lessons he has learnt supporting federations and super practices to develop.

Meanwhile, the challenges of recruitment in general practice have not gone away.  We looked at the transformational impact paramedic practitioners have had on one practice, and asked the question more broadly as to whether social workers could form part of the practice team.  However, the action that can make the biggest impact locally in our view is the introduction of a local locum GP chambers.  Chair of NASGP Richard Fieldhouse explains what they are, and we heard from an ex-GP partner, a newly qualified GP, and a GP seeking a portfolio career about the impact chambers had on them.  We explained why you need one, how a CCG can support their development locally  , how a CCG can make the most of one they have, and we tackled the difficult questions and dispelled some of the myths about locums.

Finally, the Kings Fund produced a new report, “Clinical Commissioning: GPs in Charge”.  Author Ruth Robertson revealed they had discovered a frequently fragile relationship between CCGs and local practices, and predicted fewer, larger CCGs in future.  Less clear was whether GP leaders would remain in these bigger CCGs or take up residence in the new models of care.

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Locality Hubs: The Perfect Opportunity?

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

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

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

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

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

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

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

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

GP Locums – dispelling the myths

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

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

Is the use of NHS monies on GP locums a waste of scarce resources? Or is it a valid expenditure, pivotal to enabling a fragile system to continue to operate? I recently debated this with Dr Richard Fieldhouse, Chair of the National Association of Sessional GPs (NASGP). He took the opportunity to dispel a few myths.

Myth 1: GP locums are destroying continuity of care. The reality is very few us will see the same GP each time we visit our local practice. For at least half of us, it doesn’t matter which GP we see. For those where it does, practices are rarely organised to enable this. When a practice employs a locum GP, they are just as likely to be asked to see patients where continuity of care would have made a difference to those where it would not. You can’t blame locum GPs for how practices organise care.

Myth 2: GP locums deliver lower quality care. For a GP to be effective they need to be able to access a range of information, including patient histories, test results and local patient pathways. Practices rarely provide locum GPs with the information they need. It is not that locums deliver lower quality care, it is that practices prevent locums from performing and often make it impossible for them to function effectively.

Myth 3: GP locums earn more than most GP partners. GP partners, who sign the cheque for the invoice, see the gross amount the locum receives. They then compare this with the net amount they take home, and, inevitably, the gross amount is larger. This does not mean the take home pay of the locum is greater! And when a locum GP is employed through an agency, the cost includes a 20% or 30% agency mark up. Money to the agency is not money to the individual locum.

Myth 4: GP locums are a small, greedy minority of the profession. The number of locum GPs stands in the region of 17,000, and represents about a quarter of all GPs. It is not one or two GPs out to make a fast buck. It is an increasingly popular career choice, and, as our recent podcast series has shown, attracts a range of GPs with a range of different motivations. Characterising locum GPs as a drain on resources serves to disempower a substantial, and growing, portion of the total GP workforce.

In future, all GPs may be locums. If the profession does eventually follow through with its threat of mass resignation, local locum GP chambers represent one of the most likely future employment scenarios for GPs. Even if GPs resist the temptation to press that particular nuclear button, the growth of multispecialty community providers (MCPs) may also see a rapid growth in local locum GP chambers, as the historically independent-minded profession seeks to resist a salaried fate.

The time has come for the debate to move on. The focus should no longer be on the validity of locum GPs, but rather on how the system makes best use of what Richard describes as “the rich pool of agile talent” it has at its disposal.

 

A new lease of life for APMS Contracts

General Practice has never really liked Alternative Provider Medical Services (APMS) contracts. This is because they are the only GP contracts that can be negotiated with those who are not NHS GPs, such as foundation trusts and commercial organisations. But, writes Ben Gowland, they may be about to experience a resurgence…

APMS contracts were introduced really as a mechanism to enable NHS commissioners to market test General Practice against the private sector. But fears the APMS contract was going to lead to the privatisation of General Practice proved unfounded. Research by The King’s Fund[1] found use of APMS contracts by PCTs was limited and very few APMS contracts had been awarded to independent providers.

There is no specified maximum contract length for an APMS contract, but they were typically awarded for a five-year period. This is in stark contrast to the unlimited contract length of the main GMS and PMS contracts. This drew criticism from the profession as providers would not make long term investments, or tackle long-standing problems such as premises leases. A 2015 study published in the Journal of the Royal Society of Medicine found APMS practices provided worse quality care than practices on GMS or PMS contracts, even when demographic differences such as age and deprivation were taken into account.

But change is afoot. A hospital foundation trust in Chesterfield has been awarded a 15-year APMS contract to run three GP practices serving more than 20,000 patients in Derbyshire. 15 years, and with an option to extend for a further 3 years! The APMS directions do not specify a maximum contract length and a contract exceeding 5 years can be agreed locally, but even a few years ago this would have been unheard of.

Now, as with all aspects of integration, using the APMS contract in this way creates issues for commissioners. The 2013 APMS directions[2] state the APMS contractor is required to be a member of the CCG. So by deduction Chesterfield Royal Hospital must now be a member of the local CCG. Equally, when the APMS contractor makes a decision to refer a patient it must ‘do so without regard to its own financial interests’. Choice and integration are not easy bedfellows.

But North Derbyshire CCG are not alone. Other CCGs, e.g. Blackpool CCG[3], have also been considering APMS contracts of 10-15 years (interestingly the same length as the new multispecialty provider, or MCP, contract). Clearly, something has changed.

The world has shifted since 2004, when APMS contracts were first introduced. Then the focus was on competition and market testing. In our post-Five-Year-Forward-View-world there is a new game in town: integration. APMS contracts are changing from a tool to enable competition to a tool to enable integration. Hence the sudden shift from short to much longer term contract durations. Blackpool CCG explicitly stated that ‘longer term contracts offer stability and an incentive for providers to participate/engage in CCG strategy, new models of working and integration in neighbourhoods’.

Suddenly APMS contracts have a new lease of life, as an enabler to integration. The 15 year APMS contract award in Chesterfield was met with local LMC approval. General Practice antibodies to the APMS contract appear to be dissipating (although lingering concerns over the contract value relative to GMS/PMS inevitably remain). Extending the term of the APMS contract, keeping it within the NHS ‘family’, and using it as a building block for the new models of care, mean it may be about to become much more prevalent than ever before.

[1] Walsh N, Maybin J, Lewis R (2007). ‘So where are the alternative providers in primary care?’ British Journal of Healthcare Management, vol 13, no 2, pp 43–36.

[2]https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183370/apms_directions_2013_acc.pdf

[3] http://blackpoolccg.nhs.uk/wp-content/uploads/2015/10/Item-6-APMS-Paper-Oct-PCCC.pdf

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