15
dec
0

2021: The Most Challenging Year Ever?

Posted by Blogs, The General Practice BlogNo Comments

2021 has been quite a year.  What can we takeaway from everything that has happened, and where are we now as move towards 2022?

The year started with the vaccination programme (in a way hugely reminiscent of everything that is happening right now).  When things were critical, and a fast response was needed, it was general practice that the NHS (and the government) turned to.

For the first months of this year, the vaccination programme was exhausting.  There were real concerns that the programme would prove to be too much for general practice.  One GP predicted at the time, “Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (here).

While we didn’t end up with mass resignations, there was certainly a withdrawal from the programme by many because the constant demands were proving simply too much.  And when the delivery demands of general practice as a whole were increased in April, despite the ongoing demands of the vaccination programme, it did raise the question of who is looking after general practice?

No one, it transpired.  As complaints from the worried well emerged via sections of the press, rather than defend the over and above contribution already made by the service NHS England responded with a letter in May mandating practices to offer face to face appointments.  Understandably, this did not go down well.

Despite some huffing and puffing, at the time no real response was made by the service, much to the consternation of many.  But a few months later NHS England’s publication on improving access and “support” for general practice (essentially how they were going to performance manage practices into offering more face to face appointments) proved to be the straw that broke the camel’s back.

By this point the demand on the service had become so great that the model of access to general practice now required a virtual or telephone triage to protect the face to face appointments for those who really needed them.  Instead of supporting the use of this model, and helping to explain it to the wider population, ministers and NHS England spent time on national TV promising anyone who wanted a face to face appointment with their GP that they could have one.  Nothing could have been either less helpful or more incendiary.

As a result the BMA balloted on industrial action, and supported by the service it now has a mandate to take into next year.

The other big development in 2021 was the shift of the whole systems towards integrated care, as a replacement for the historic commissioner provider split.  The White Paper was published in February, and while it is still making its way through parliament the NHS has been moving at pace to be ready for its approval and it becoming legislation.

It has been a challenge trying to work out what the new system means for general practice.  Design guidance followed for the service in June, and we started to understand the importance of local place based arrangements for general practice, as well as the role of PCNs in representing practices in these models.

The big concern is that there will be a loss of influence for general practice.  While CCGs are (supposed to be) GP led, there is no such requirement of integrated care systems.  Indeed the formal role of GPs in the new arrangements is relatively limited, and leadership of the new system by general practice feels unlikely.  But, as ever, general practice has worked its way through the issues, and areas have worked out that by PCNs, federations and LMCs coming together general practice can have the strongest voice in the new system.  The overall strategy needed is one of pushing decision making to the most local level possible, working together to create a single local voice for general practice, and then using this voice to influence decision making locally.

Here we are at the end of the year, with the service feeling very much on the precipice.  Integrated care systems are due to go live during 2022 (dependent on when the legislation finally gets approved), industrial action looms (one assumes depending on the outcomes of contract negotiations early in the new year), and covid is fighting back to add yet more pressure on to the service.

We have now come full circle with a new call to arms for general practice to once again lead the vaccination charge for the country.  Let’s hope next year there is both more appreciation for the critical role general practice plays, and more support for the service to recover from what has undoubtedly been one of its most challenging years ever.

8
dec
0

GP Partner Training – the Learning So Far

Posted by Blogs, The General Practice BlogNo Comments

Earlier this year myself and a group of colleagues decided that we should put in place the training for new GP partners that we had been talking about for such a long time.  The course finally started in September of this year, and we have already learnt some interesting lessons along the way.

I teamed up with Tara Humphrey, PCN management expert, Director of THC Consulting and presenter of the Business of Healthcare podcast; Robert McCartney, general practice governance expert and Director of McCartney Healthcare Associates; Dr Naj Seedat, GP, trainer, partner in a large North East London practice and LMC Chair; and Dr Farzana Hussain, GP, GP appraiser, mentor, trainer and lecturer.  Together we formed a really strong team, designed to be able to meet all the development needs of new and aspiring GP partners.

We designed the course into 20 sessions, broken down across three broad areas: understanding the business (i.e. what goes on within the practice); understanding the environment (i.e. what is happening around the practice that affects it); and understanding the risks (i.e. how do you build a strategic plan for the future).  Naturally the weighting of the first area is greater than the other two, as there is so much within the business of a practice for any new partner to get their head around!

We wanted the course to not be too demanding on GP time, which is why we went for the model of an hour a fortnight over a period of 9 months.  This has worked to the extent that it has made the course manageable in terms of time for participants.  The challenge, however, has been how to cover such huge topics as managing people or understanding premises in just an hour.

We have been working hard to do this well, but for some topics we just had to extend the sessions.  For example, when accountant James Gransby ran the session on understanding the practice finances we had to make the session an hour and a half.  Even then it was hard to cover everything for such a complex topic!

The other challenge we have experienced is how to make the sessions interactive when there is so much content to work through.  In an hour the scope for really interactive sessions is limited, but at the same time the more interactive the sessions are the more valuable they can end up being for participants.

Another lesson we have learned is that one of the biggest challenges new partners experience is taking on the role as a business owner and what this means in terms of how they lead and manage staff.  This is a really critical area for GP partners, as their leadership style really affects the culture of the whole practice.

As a result of all this we have made some changes to the programme, for the next cohort of new or aspirant GP partners who will be joining.  In the new format content will be delivered over six monthly half day sessions.  This will allow us to create longer, more interactive sessions where we can tailor the content to the specific needs of those on the programme.

We have also included core strengths training as standard, as it really helps new partners understand and develop their leadership style, and given over a whole half day session to leading and managing people.

We always knew developing this training would be a journey, and that we would be learning as we went along.  We are delighted with how the programme is going so far, and excited to make the changes to make it even better going forward.

The programme for our next cohort commences on the 1st February 2022.  We still have some places remaining, so if you or someone in your practice is interested you can find all the details here.  Alternatively get in touch and I am happy to talk through individually what we are doing so that you can work out whether it is right for you – I’m ben@ockham.healthcare.

1
dec
0

50 to 1

Posted by Blogs, The General Practice BlogNo Comments

I am spending some time working with a number of areas thinking through how to create and develop a strong, unified voice for general practice, that can be effective and influential within the new integrated care landscape.  It is a challenge that is harder than it sounds.

The problem comes because “general practice” in any given area generally consists of about 50 different, independent, autonomous organisations.  There are the 40 or so individual practices, 5 to 10 PCNs, maybe a federation, and the LMC.  How do you get 50 organisations to speak and act with one voice?

There is a framework that is quite helpful to consider in this context, called the Cynefin Framework.  Essentially it breaks problems down into different categories.  For our purposes what is helpful to understand is that there is a difference between simple, complicated and complex problems.

Simple is a problem that has a relatively straightforward solution, such as how do I lower my car window.  There is a specific, straightforward answer (press the right button).

Complicated is a problem that does have at least one solution, but which can be difficult to deliver.  An example that is commonly used is sending a rocket to the moon.  It is not a simple thing to do, and may well require multiple teams and specialised expertise.  But by really effective project planning, and using the experience of those who have done it before, it is possible to create a path to making it happen.

Complex problems are ones that are impervious to a reductionist approach that strips the problem (however complicated) down to its core components to work out the solution.  The example commonly used is raising a child.  There is no handbook because each child is unique.

For a complicated problem you can use a project planning Lewinian style approach to solving it.  But for a complex problem the approach needed is an emergent one, using trial and review (like PDSA cycles for you NHS improvement fans, or probe, sense and respond which Snowden, who introduced the Cynefin framework, uses).

This distinction is useful because in healthcare we commonly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches.  We look for business cases with defined outcomes as a default mechanism for moving forward, when this approach can only work for something that is simple or complicated, not for something complex.

Back to our problem.  How do we get 50 general practices organisations to operate as 1?  It is a complex problem.  There is no handbook, because everywhere is different.

That is not to say it is impossible.  What we can do, even operating in the domain of emergence, is understand what factors we need to build in order to give ourselves the best chance of success.  Two stand out.

The first is the need to build some capacity and capability at the collective general practice level.  If general practice is trying to operate as one then whatever forum or entity is trying to bring it all together needs to develop the ability to do a number of things.  It needs to be able to communicate with its 50 organisations.  It needs to be able to coordinate activities across those organisations.  It needs to be able to interact effectively with partner organisations.  These things don’t happen because the different parts of general practice simply meet together.  They need to put in place.

The second is the need to build trust.  Trust is the key ingredient.  If the 50 organisations don’t trust the 1, all is lost.  Here we get into the area of the prisoner’s dilemma, which explains why rational actors won’t cooperate even when it is in their best interest to do so.  Just because it makes sense for general practice to create a single unified voice it doesn’t mean they will do, and in fact without trust it is much more likely that they will not.

It is particularly challenging in general practice because we are all so instinctively independent.  That is why we have 50 different organisations in the first place.  We hate our independence and ability to act autonomously being in any way compromised.  We find working in PCNs difficult enough.  We instinctively pull away from any notion that we might get into scenarios where our practice or PCN has to act for the greater good rather than simply what is best for our practice or PCN.

As we move forward with the 50 to 1 challenge, our approach then needs to be an emergent one, i.e. one where we try things, see how they work, and then adjust accordingly.  We need to keep our eyes on the outcome (why are we doing this), and work hard to build trust and create some capacity and capability along the way.  It might make plan writers uncomfortable, but it is the way forward that will give us our best chance of success.

24
nov
0

The Inquiry into the Future of General Practice

Posted by Blogs, The General Practice BlogNo Comments

The Commons Health and Social Care Committee has announced a review into the future of general practice.  What does this mean, why would they do this, and what are the implications for the service?

The Health and Social Care Committee is a cross party committee charged with overseeing the operations of the Department of Health and Social Care and its associated agencies and public bodies (including NHS England).  It essentially has a scrutiny role.

The Committee chooses its own subjects of inquiry, which it then undertakes by reviewing written and oral evidence.  Once complete, the findings of the inquiry are reported by the Committee to the House of Commons.  The government then has 60 days to reply to the Committee’s recommendations.  The government does not have to accept them, e.g. the Environmental Audit Committee inquiry into disposable packaging recommended a 25p “latte levy” on disposable coffee cups; but the government rejected it, preferring for coffee shops to incentivise customers by offering discounts for the use of reusable cups.  However the cross party nature of the Committee, designed to build consensus across parliament, means its recommendations do still exert considerable influence.

This committee on the 16th November launched an inquiry into the future of general practice.  Its headline focus is to examine both the challenges facing general practice over the next 5 years, and the biggest and current barriers to access to general practice.  The committee is actively seeking evidence from anyone with expertise in the area (i.e. you, if you are reading this).  The deadline for submissions, which must be no longer than 3,000 words, is Tuesday 14th December.

It is one of 9 current inquiries the Health and Social Care Committee either has underway or that are complete and are awaiting a government response.  The others are workforce burnout, lessons learnt from coronavirus, children and young people’s mental health, treatment of autistic people and individuals with learning disabilities, supporting those with dementia and their carers, cancer services, clearing the backlog from the pandemic, and NHS litigation reform.

The inquiry into general practice will cover a range of issues (you can find the full terms of reference here), but it includes regional variation in general practice, general practice workload, and the partnership model of general practice.  The specific question in relation to the latter of these points is, “Is the traditional model of general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?”.   There is also a question about PCNs, “Has the development of PCNs improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?”.

What can we make of the announcement of the inquiry into the future of general practice?

The first point to note is the timing of the announcement.  It has come at a point where there has been considerable media and public attention to the challenges around access to general practice, and is also hot on the heels of the announcement of a ballot for industrial action of GPs by the BMA in response to NHS England’s recent publication on improving access and support for general practice.  It does not seem unreasonable for this to have been picked up as a point of concern by the Committee at this point in time.

The second point to note is that the Chair of the Health and Social Care Committee is Jeremy Hunt.  Jeremy Hunt appears to be enjoying his role as a backbench GP, able to chair this committee from a position of considerable knowledge, particularly in terms of how he can make life as uncomfortable as possible for the government.  His own response to the NHS England document was that it “won’t turn the tide” for GPs, and this seems to be reflected in some of the wording of the terms of reference, e.g. “to what extent does the government’s and NHS England’s plan for improving access for patients and supporting general practice address these barriers” (to access to general practice) when it is already clear to everyone that it does not.

There will be the more cynical who assume this is a back door attempt to end the independence of general practice and shift practices into the main body of the NHS, or conversely to privatise things further by shifting all remote and telephone consultations to digital first providers to “reduce pressure” on practices.  And while it does seem odd to want to look at the partnership model of general practice only a few years after the 2019 review by Nigel Watson, the cross party nature of the committee, along with the methodology of collating evidence from as wide a group of experts as possible, does make this seem unlikely.

Whilst it is hard for anyone in general practice to trust anything led by Jeremy Hunt, my sense is the best course of action would be for as many of those working in general practice as possible to give evidence and provide their views on the questions asked and what is needed going forward.  It feels like a genuine chance to be heard, and is a welcome change from the recent policy directives received from NHS England which have had little or no consultation at all.

17
nov
0

3 Reasons to be Concerned about the Newly Announced Review of PCNs

Posted by Blogs, The General Practice BlogNo Comments

The NHS announced last week that  they would be undertaking a review of primary care networks and how they will “work with partners across newly formed integrated care systems to meet the health needs of people in their local areas”.  The review will report by March 2022, ahead of ICSs going live as statutory bodies.  Whilst it might all appear very anodyne on the surface, it does set alarm bells ringing.

There are three reasons for concern.

  1. The perceived need for greater national direction

What the announcement of the review signals is that NHS England, in what is now customary NHS England style, is seeking greater control over PCNs and how they operate.  The initial language used around PCNs was that they how they operated was for local determination by local practices to best meet the needs of local communities.

That, however, now appears to be going out of the window.  NHS England clearly wants to set more guidance and rules on PCNs and how they work.  The contractual constraints of PCNs are already suffocating for many, and so it is hard to see how extra national directions will be helpful.

What we have with this review is a signal that someone somewhere high up is not happy with how PCNs are progressing, and has put this review in place to change where they are headed.  This review has also been announced hot on the heels of the BMA motion for industrial action and mass resignations from PCNs.  This may be unrelated, but it does lead on to my second concern.

  1. It signals a shift in ownership of PCNs away from practices

If you read the announcement from NHS England you will notice it has a very clear focus on joint working.  It talks about how PCNs “will work with partners”, how they can “drive more integrated primary, community and social care services at a local level”, how they can “bring partners together at a local level” etc etc (it carries on like this throughout).

If you recall when PCNs were first announced there was quite a number of references made to how PCN Boards would be expanded over time to be more than simply the member practices.  Whilst some PCNs have widened their PCN Board membership, most have not.  Given the language in this announcement it would be astonishing if the recommendations made were not about a shift of PCN ownership away from practices and towards a much wider ownership.

How far-fetched is it to suggest that this report will end up “recommending” a place for councils, community trusts (and no doubt others) on PCN Boards? Maybe a direct accountability into place-based partnerships will be imposed on them.  Whatever comes, it is hard to envisage a positive outcome of this review for practices.

  1. It further widens the gap between PCNs and the sustainability of general practice

At a critical point in time, just over half way through the 5 year GP contract that introduced PCNs, when general practice has reached such a desperate place that it is prepared to consider strike action, this review is announced.  In the announcement general practice or GP practices receive only one mention, and that is about the need to improve partnership working between GP practices and other organisations.

This report will not be looking at how PCNs can better support the sustainability of GP practices, despite the majority of the additional funding for general practice coming via PCNs.  It is hard not to see the announcement of this report as part of NHS England’s response to the GPC’s threat of industrial action, and if it is it spells more bad news for general practice.

I am not generally a pessimist or a conspiracy theorist, but everything about this report sets alarm bells ringing.  Time will tell whether these are unfounded concerns, or whether it is the first signal of yet more challenges to come for general practice.

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