Ockham Healthcare: Supporting innovation in General Practice

Kaizen vs Kaikaku: Does general practice need big bang or incremental change?

Before I moved into the world of general practice, I used to live in the world of service improvement. It was a strange world, with its own language, traditions and practices. I kind of liked it, and look back on it fondly sometimes as you would when you remember a great place you once visited, like that trip to Sydney in 2003 when England won the rugby world cup, where they put beetroot on their burgers and thought calling me “blue” was hilarious on account of my red hair.

Anyway, in the service improvement world there is an ongoing debate about which type of change is best: should you go for small-scale continuous improvements, or a big bang change? In the world of general practice we are now facing the same question: can we adapt the existing model of general practice through incremental improvements into something different, or is a more radical approach required? Evolution versus revolution.

In the improvement world they use the terms “kaizen” (for evolutionary incremental improvement) and “kaikaku” (for revolutionary radical improvement). In the GPFV, high impact action number 10 is; “Develop quality improvement expertise”. Some believe this is the most important of all the actions because it gives practices a mechanism for making the other changes successfully. It includes techniques such as “plan, do, study act cycles” (or “PDSA cycles”) which encourage rapid cycles of testing of changes to enable successful adoption. This, and the techniques like it, are based firmly in the kaizen school of incremental improvement.

I have recently questioned whether the GPFV is failing to have the desired impact because it is trying to tackle each of the problems individually, rather than creating a clear vision for the future. A number of responses have challenged this, suggesting in particular that if all of the 10 high impact actions were implemented in a single practice that in itself would constitute our required vision.

But would it? If every practice implemented each of the 10 high impact actions, in a structured, incremental way, would the current problems of general practice be over? Certainly life would be better, but would it be enough?

Where they got to in the improvement world is that it is not an either/or. Big bang change is needed to break paradigms and elevate the awareness of people to a higher level of understanding. It is needed in addition to continuous improvement, not instead of it. While some problems can be solved by incremental improvement, others do require radical improvement to start with.

The challenge facing general practice is such that I don’t believe incremental improvement on its own will be sufficient. It needs kaikaku as well as kaizen. While the 10 high impact actions are an important part of the transformation needed in general practice, they are not the totality of it. I understand the GPFV is more than the 10 high impact actions, but if they are the element that provide the vision of the future, my contention remains they are not enough and a more radical transformation is needed.

Is the Primary Care Home the “answer” for general practice?

Recently I have been wondering if we have been going about tackling the challenges in general practice all wrong.

We have been focussing on the problems practices are experiencing now, and trying to systematically tackle them one by one. Logical. But it assumes the cuts are only superficial, and once they are patched up individually general practice will be well.

The General Practice Forward View (GPFV) approach is to identify each of the issues general practice is facing, and to come up with “answers” for all of them. So for example workforce is the issue and 5000 more GPs is the answer. Or infrastructure is the issue and the ETTF (estates and technology transformation fund) is the answer. Or workload is the issue and contract changes to stop secondary care increasing general practice workload is the answer.

You could argue the real issue is underfunding, and that more money is the answer. But despite the rhetoric, there never was an extra £2.4bn for general practice (see here for more detail). In 2016/17 not only was funding flat (taking into account inflation), growth was half that received by acute trusts. We operate in the system we operate in.

But whether or not the “answers” are working individually, they certainly are not working collectively. I don’t think it is a failure of implementation. Rather, the approach was wrong in the first place. Wrong because it started with the problems, not the strengths of general practice. It started with individual challenges, rather than a compelling vision of the future. And it started with the premise of offering more within a system that cannot offer any more.

Compare this with the NAPC’s primary care home initiative. I knew quite a lot about it, but what I couldn’t quite comprehend was how it helps general practice meet its current challenges. I spoke recently to Dr Nav Chana, Chair of NAPC, and asked him about this. What I learnt from that conversation was the starting point of the primary care home is not so much the sustainability of the current organisational infrastructure of general practice, but a desire to improve the health of local populations, to bring increasingly fragmented workforces together, and to put the control of resources for that population into one place.

What that then means for GP practices as organisations they don’t know yet. What they do know is they are building on the strengths general practice currently has, they are making the service attractive to those who work there again, and that by focussing on meeting the needs of the local population the most appropriate future form of general practice will emerge.

It makes sense. A model that meets the needs of a defined local population will solve recruitment problems because it will attract staff to work there, will solve financial challenges because it will attract investment and funding, and will solve workload issues by different staff groups all working effectively as an integrated team.

Of course it will need help to get there. But by using a future focussed and population centred approach, the primary care home initiative has much more chance of providing general practice with a realistic route out of its current malaise than the backward looking, issue based approach of the GPFV.


What GPs should consider if they are thinking about partnership

If you are a GP who is thinking about becoming a partner, what questions should you ask to be sure you are making the right decision? In this guest blog (his third for Ockham) mergers expert Robert McCartney introduces a checklist of things you should consider to help you make the right choice. You can download and print off the checklist following the link beneath the blog.

We undertake a lot of work assisting practices in developing plans for the future and redesigning systems which strengthen general practice. However, much of this work is undermined by the simple fact that there are insufficient numbers of GPs willing to be partners.

Exploring this with a range of junior, salaried and locum GPs it has become evident that the biggest issue is a lack of understanding about the potential benefits and opportunities partnership still offers.

Work must continue to tackle the issues facing general practice but, at the same time, we need to highlight the positive side and help develop the vision of what general practice could look like if the independent contractor status is secured for future generations.

Feedback highlights that potential GP partners do not know what questions to ask to make an informed choice about the opportunities within practices. The checklist, which we have made available below, has been produced to help those GPs considering partnership for the first time. It is not a complete list but should help structure your thoughts around the type of information you need to know before agreeing to invest in the practice.

As a general point it is recommended that you obtain support and advice throughout the process. The local LMC and trusted GP partners will be able to assist you in identifying when an opportunity is suitable for you.

Entering partnership includes accepting a degree of responsibility for the management and running of the business and you should therefore invest in gaining some simple business skills. It is not necessary to enter onto a MBA course but finding suitable sessions on understanding accounts, HR responsibilities and the principles of leadership will all help you once you enter partnership.

When you are considering the list remember that the final decision will also come down to whether you feel the ‘fit is right’. The culture, relationships and general environment of the practice must suit you or have the ability to develop with you over time. The empirical data collated will give you confidence that you understand the practice but only through spending time and talking with all members of the practice will you be able to make an informed decision.

Download the checklist here.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the third in a short series of blogs he has written for Ockham Healthcare. If your practice needs a helping hand with its fledgling relationships, you can contact Robert via e-mail at rm@mccartneyhealth.co.uk or call 0203 287 9336.

Guest Blog – GP Partnership: A Salaried GP’s view

Last week Ockham Healthcare hosted an event in central London looking at the rise and fall of the GP partnership model with the aim of encouraging GPs and trainee GPs to consider becoming partners (more information here and a video of the event is available here). One of the attendees was salaried GP Camille Gajria from London who, in a guest blog for us this week, summarises the event and outlines the messages she will be taking away.

On the eve of the NHS’ 70th year, Ockham Healthcare held a live panel event for GPs considering partnership.

GPs chose to be independent contractors when the NHS started. This has often enabled innovation and healthcare tailored to the local population. Although there have been trends towards and away from partnership over the years, currently unprecedented numbers of practices are becoming unviable and closing. So why would anyone want to be a partner now?

Dr Mayur Vibhuti, a GP partner and GP trainer opened by explaining that his role allows him to make tangible improvements to the health of his community. It was interesting to hear how a 7000-patient practice is thriving given the political thrust to work at scale.

Robert McCartney, who runs a primary care mergers consultancy, described practices as community hubs which will always be needed, particularly for people with long-term conditions.

Ockham Healthcare Director, Ben Gowland laid bare the responsibility, risks, and rewards of running a business, including the fact that if the profession became entirely salaried there would be even less control over various aspects of work. He gave a frank explanation on premises and equity- the market shows that GP property is a valuable commodity due to notional rent not being dependent on outcomes, and should ideally be owned by the business. An Ockham podcast published on 10 July has more detail on this.

When choosing a practice, the panel emphasised the importance of finding one with values appropriate to one’s own, identifying risks the practice may be due to face, their plans for the next 5-10 years, and how well they understand their income and expenditure (e.g. do they know at what list size an extra clinical session becomes viable). One point I had previously not considered when looking for a partnership is to assess the relationship with the locality- if one practice is struggling, there would be effects on the others, such as a sudden, unsustainable increase in list size.

There was discussion about how to gain requisite skills for partnership, and where to source help.

The session was expertly chaired by Nish Manek, the National Medical Director’s Clinical Fellow and Teshseen Khan, a Population Health Fellow at NHS Lambeth CCG. They asked and fielded probing questions, both from live and virtual viewers. It was refreshing to have an open discussion about these topics in relation to the current state of general practice, with a diverse and knowledgeable panel and audience.

GPs as independent contractors have been the foundation of the NHS and led innovation throughout its history.  Rather than necessarily having to change models to make partnership more attractive, I left feeling GPs need to be conversant with politics, finance, and management, so that we make informed decisions about our roles and the services we run for patients.


Becoming a GP partner – your questions answered

This week’s “blog” is, in fact, a video of last night’s (4th July) live event where an expert panel answered questions on GP partnership. The panel consisted of Ockham Healthcare founder and Director, Ben Gowland, Dr Mayur Vibhuti a GP partner and GP trainer and GP practice mergers expert Robert McCartney. Taking questions from a live audience plus those tweeted in from across the country, the panel discusses the idea of GP partnerships in today’s highly challenged environment for general practice. Should GPs become partners? What makes a good partnership? Should partners own their own premises? What are the risks? How does a partner achieve change with a group of difficult partners? These questions and many more are addressed in this highly topical and unique event…

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