10 Surprising Lessons from over 50 Podcast Guests

I had just finished an hour long interview (by Skype) for the podcast. The conversation had gone well, and I was excited by the quality of the content. As usual, I started to upload the recording for editing. Only nothing was happening. Panic started to well in the pit of my stomach, as I pressed buttons and searched for the audio file. But the file wasn’t there. The conversation hadn’t recorded.

I am not a technical person. I don’t have a background in radio or recording. I started the podcast as a platform for great practice, new ways of working and innovation in general practice to be shared. Learning how to use the kit has probably been my steepest curve, but I have learned other things (about GPs, about general practice, about podcasts as a platform for sharing) from the many guests I have had the privilege of interviewing. Here are the 10 most surprising:

  1. Very few GPs use Skype. With all the chat about Skype GP consultations this wasn’t a problem I predicted, but I would say over half of the GPs I have spoken to had to set up an account (or ask their teenage children to set up an account for them).
  2.  Academics are rarely given a platform to discuss the implications of their research. When academics produce research they become very clear about what it does and doesn’t prove or say. However, here in the real world we are interested about the application of their research to our daily lives. Some academics have loved the opportunity to explore this, but most feel well outside of their comfort zone!
  3.  The non-GP general practice workforce doesn’t feel heard. When we talk about general practice most of us immediately think GPs. But there is a whole other “hidden” workforce out there of nurses and other clinical staff, as well as the practice managers and administration teams. These groups do not feel well represented, and the podcasts involving these groups have had tremendous support from their peers.
  4. Physician associates can add real value. A year ago when I discussed new clinical roles in general practice with GPs many were quite open to the idea, except for physician associates; the mere mention of whom usually provoked a withering look. However, our occasional podcast series exploring their impact has shown they can add tremendous value to practices.
  5. Locums are not all bad. An even less popular group than physician associates are GP locums. Last year we explored why GPs become locums, and the concept of GP locum chambers, and learned in a world where there are not enough GPs we need to find ways to make the most of this critical resource.
  6. It is not just GP practices that are independent, it is also those providing support to GP practices. We all know there are c7800 GP practices who contract independently with the NHS. Less well known is that what this in turn leads to is a sporadic and independent group of individuals and small companies that provide support to general practice. You won’t find many commissions for the big four consultancy firms from individual practices!
  7. The changes with the biggest impact are not necessarily the most complex. The change that I have seen with the biggest impact is “workflow optimisation” or, alternatively, “keeping the post away from the GPs”. It can save up to an hour of GP time per day.
  8. Great editing can perform miracles. Not everyone who comes onto the podcast is a fluent orator. But listening to the podcast you wouldn’t necessarily know it. On the other hand I have finished recording interviews and wondered whether there will be any tape left that we can actually use, once the stumbling and disjointed sentences have been removed. But out of the editing suite come these coherent, intelligible productions that make both me and the guest sound great.
  9. Being on the podcast creates opportunities for guests. I am not sure I anticipated how positive an experience being on the podcast could be for those being interviewed. For example, I recently received a note from previous guest Mia Skelly who said, “People’s general feedback has been very complimentary and it’s given me some wonderful opportunities to continue to promote general practice nursing”.
  10. The Ben Gowland podcast is not the best name for a general practice podcast. When I came up with the title I thought it sounded good(!), and I have been surprised to learn that 1) the title in no way explains what the podcast is about, and 2) people not knowing what it is about can make it harder to access. As a result, we are going to go for the slightly clearer but less narcissistic title “The General Practice Podcast” from April.

Maybe only some or even none of these things surprise you. But they all surprised me, and I am looking forward to continue being surprised by the second year of the show. Thank you for all your support over the last year, and if there any changes (other than the title!) you think we should be making, please do get in touch.

Why making change in general practice is difficult

I wanted to leave my job as a CCG Chief Executive for a long time. But it took many months until I finally handed in my notice. I was nostalgic about the past, and clung to memories of a time when I had loved the job. My attachment made leaving difficult. Despite the relentless, day to day pressure there was always this nagging concern; if I left I would no longer be needed in the same way. And I was not 100% clear what my new future would look like. In many ways a bleak certainty was easier to cope with than the uncertainty of the unknown.

I don’t think I am alone. Letting go (of control, of certainty, of routine) is difficult for all of us. Unfortunately, nearly all of the things that can make a difference for general practice seem to involve GPs “letting go” in some guise or other. So, for example:

  • Practice mergers. These involve GPs “letting go” of the control of their (smaller) practice for a lower amount of control in a bigger practice.
  • Introducing new roles. Bringing in clinical pharmacists, paramedics, physician associates and the like involves GPs “letting go” of some of their workload so others can take this on.
  • Workflow redirection. If you have not come across this yet you should (listen to this), but effectively it involves GPs “letting go” of their post, and trusting much of it to be handled by others.
  • New models of care. Okay, not yet a common solution but a designated national direction of travel, and it involves GP partners “letting go” of their independence and becoming salaried employees or, at best, board members in an NHS organisation.

This is why making change in general practice is difficult. It is why practices don’t merge, don’t introduce new roles, don’t make changes to how they operate, and don’t jump into bed with the local hospital just because they are under pressure. The changes may be logically sensible to an outsider, but if they are not underpinned by a strong desire to take whatever action is needed they won’t be implemented.

The big mistake made by those trying to lead change in general practice is starting with the solution, with a description of the change that is to be implemented. Taking the desire to actually make the change for granted, on the basis of the parlous state of general practice, is a fast track to failure.

Professor John Kotter, regarded by many as the leading contemporary expert on change, believes[1] assuming people know they are in trouble and need to change, and focussing instead on strategy and solutions, is what kills most change efforts. He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change.

Ultimately I made my decision to leave based on a strong desire to create a new future for myself. After many months of anxiety, frustration, and (frankly) inaction, I reached a point of determination to make a change, however hard it would be. It was only then I was able to actually resign. To be successful, those leading change in general practice must first focus on establishing a sense of urgency for change, before ploughing into the details of the uncertain future they want to create for their GP colleagues.

[1] A Sense of Urgency, Kotter J.P. Harvard Business Review Press, 2008

Why the new GP contract is disappointing

There has been a cautiously positive reaction to the GP contract. But for at least one enthusiast for general practice, it doesn’t live up to its promise. Here, Ben Gowland explains his huge disappointment…

The GP Forward View was published in April last year. It promised an additional recurrent investment of £2.4bn into general practice. But for all its rhetoric, the finances have been hard to pin down. After a raft of national pots of money that have all translated into very little at local level, all hopes were pinned on additional money arriving in the core contract.

And has it? Well in 2015/16 the contract was uplifted by £220m, the equivalent of 3.2%. That was pre-GPFV. So what was the outcome of the 2016/17 contract, the first one after the publication of the GPFV? An uplift of £239m, or 3.3%. An almost identical award.

What does it mean for the promised additional £2.4bn? Well at the current rate of uplift, which does not like it will change, an additional £1.3bn will have been added by 2020/21. The global numbers sound a lot, but the reality is last year’s contract award did little to assuage the problems faced by general practice, and there is no reason to believe that similar uplifts next year and for three years afterwards will have a greater impact. The rises continue to be offset by a parallel growth in costs.

The tinkering with the elements of the contract, and moving money from one part of the contract to another, really only acts as a smokescreen for the overall failure to invest. It creates opportunities for people who don’t understand general practice to complain about specific elements (e.g. funding the cost of CQC registration), and leads to odd behaviours (e.g. locums increasing their fees by 2% because of the indemnity reimbursement).

The only significant recurrent additional funding in the GPFV, on top of the contract awards, is the funding for additional access. This is £500m, and we know it translates into £6 per head of population. But it is not funding for individual practices. The sites involved in the prime minister’s challenge fund, which receive the money recurrently from April onwards, have to bid for a large single contract. So it is only really available to large organisations. Plus, individual practices just don’t want to do it. As one GP explained to me, if a practice receives what amounts to £115 per patient for 8 – 6.30 Monday to Friday, why would they extend that to 8 to 8 7 days a week for an additional £6 per patient?

So where is the rest of the GPFV money? £2.4bn has been promised. £1.3bn will be in the core contract. £500m is for extended access. Where is the other £600m? I have not yet met anyone who can answer this. It begs the question as to whether it will ever arrive.

Worse, NHS England are predicting a £70m underspend on primary care and public health budgets this year. An underspend that will offset an overspend in the acute sector. Changes to the tariff have pushed many CCGs into financial difficulties, and it seems unlikely all will be able to meet the requirement to provide £3 a head to general practice in the next 2 years. And it is not official, but I am yet to meet someone who does not believe the promised £900m capital fund (the Estate and Technology Transformation Fund, or ETTF) has been cut.

The GPFV made specific promises about putting funding into general practice. This year’s contract award was the last chance for NHS England to demonstrate it was going to meet these promises. But the contract disappoints, and instead reinforces a growing belief these promises are never going to be met.

GP Mergers – A Blessed Union?

In the first of a short series of guest blogs, Robert McCartney warns that the marriage of two practices will only be a success when there is a healthy pre-nuptial agreement between both parties.

Mergers are the ultimate form of marriage between GP practices. When they include the consolidation of the contract into a single patient list it becomes incredibly difficult, maybe impossible, to separate them again. As a consequence, the parties must understand the commitment they are entering into as there is no easy divorce.

During my recent podcast with Ben Gowland at Ockham Healthcare I stated that spending the time understanding and sharing a common vision of the future is essential. This applies to the relationship analogy. The most successful marriages are built upon a shared vision for their future, an understanding that there may be challenges but they will be overcome together and a trust that your partner will support you despite the occasional disagreements.

If the ‘soft’ merger elements linked to developing the relationships, like creating a shared vision and building a framework for the future of the partnership are rushed, the ‘hard’ formal merger steps may still happen but it increases the likelihood that the merger will fail.

Practices are currently under immense pressure and time is not a luxury many GPs have. Whereas a corporate merger may take months or even years to achieve, GP practices are looking to complete the process within a few months.

Fortunately, unlike a marriage there are some firm, definable objectives that all practices will be working towards. By ensuring that the parties focus on these at the earliest possible opportunity the ‘dating’ process can be accelerated with a reduced degree of risk.

The parties need to be willing to be forthcoming and ‘lay their cards on the table’ at an earlier stage than they may otherwise want to do. This openness is essential. In the past year, I have seen proposed mergers fall apart for a range of reasons based on people not being open until far too late in the process. This includes; forgetting significant funding repayment plans on properties; an unrealistic expectation as to equivalent sessional pay; and, despite comments to the contrary in the initial discussions, a complete refusal to consider using allied health professionals.

I have found that practices considering mergers have benefitted from having an independent third party facilitate and structure these discussions. This is especially important where time is of the essence. They are the pre-marriage counsellors focused on ensuring the merged practice is built on firm foundations.

For more information or if you would like support in any merger process you are considering or undertaking please do not hesitate to contact me.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the first of a short series of blogs he will be writing 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.

 

The Future of GP Visiting

In his latest blog Ben reflects on attempts to set up an outsourced GP visiting service and what it taught him about the way GP practices innovate.

A few years ago, when I was working in a GP federation, we set up a GP visiting service. The basic premise of the service was that, because GPs were so busy, they were not able to meet all the patient requests for visits. As a result, we hypothesised, patients were being admitted to hospital when an admission could potentially have been avoided if a visit had taken place. So we funded a pilot in which the out-of-hours service provided a GP to carry out visits during the day that they would not otherwise have been able to carry out.

Do you think it worked? It didn’t. The service was not fully utilised (despite only one GP being available for 30 practices). Uptake was limited to a relatively small number of practices, with many of the practices rarely, if ever, using the service. It was not possible to produce any correlation between the service itself and emergency admission rates (which instead stubbornly continued to rise), and, unsurprisingly, the pilot was stopped.

Contrast this with a practice I visited recently. There they have paramedics for 6 sessions a week, who carry out 5 or 6 visits a day, for a practice that in total undertakes between 7 and 10 visits a day. There are clear parameters in place for visits the paramedic will undertake and those that are best carried out by a GP, e.g. palliative care visits. The practice is extremely happy with the service and is soon to increase the number of paramedic sessions from 6 to 8.

In Shropshire the local out-of-hours provider Shropdoc has developed an Urgent Care Practitioner role in which staff with a paramedic, nursing or physician associate background are trained to be able to offer (amongst other things) home visits for GP practices. The role is proving extremely popular both with staff and practices alike. You can see a video of the service here.

A visit for a GP, with all of the travel involved, is a time consuming activity. While average consultation times may average 8-10 minutes, the total time required for a visit is at least double that, and often much more. Practices vary considerably in the number of visits they undertake. A recent comparison across five practices working in the same town revealed a fivefold difference in visit rates – varying from an average of 0.2 visits per 1000 patient population per day, to 1 visit per 1000 patient population per day.

So where did I go wrong with the GP visiting service we instituted, and what are others now doing right? I think I failed to fully understand visits are an integral part of the service a GP practice offers. Any attempts to change the way they are carried out must be fully owned and bought into by the GPs in the practice. Trying to “outsource” visits to a separate agency that does not know the patients is unlikely to work. A more successful approach is to use other roles, as long as they operate under the guidance of the GPs and not separate from them.

Equally, success in the redesign of GP visits cannot in isolation be measured by the number of emergency admissions. It is the continuity of care GP practices offer that will ultimately support patients to manage their conditions effectively. Freeing up scarce GP time to be deployed where it is needed most (which, paradoxically, will sometimes be in a patient’s home) is now a critical factor in enabling this, and would have been a much better measure of success.

It is hard to replace the long hours GPs work (at no extra cost) with a paramedic or nurse practitioner in a small, cash-strapped practice. As practices become bigger they have more freedom and more flexibility to experiment with different systems for triaging requests for visits, with the introduction of new roles, and with new ways of working for visits.

In my attempts to set up a visiting service I should have remembered that most successful change in general practice is generated within the practice itself, not imposed from outside. Changing the system for practice visits proved to be no exception. In future, as practices become larger they will have more capacity to test different ways of working and that is one of the reasons I established Ockham Healthcare; to support and promote the many innovations that will inevitably result.

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