2
feb
0

Why Would Sajid Javid Claim to Want to Nationalise General Practice?

Posted by Blogs, The General Practice BlogNo Comments

On Saturday the Times reported a plan by Sajid Javid to ‘nationalise’ general practice.  It seems (once again) general practice has become something of a political football.  What are we to make of this latest report?

We need to put this latest development within the context of everything that has happened in recent months.  In October last year the government, clearly frustrated by complaints in the Mail and other elements of the press about challenges with access to a face to face appointment for a GP, pushed NHS England into the production of their document “Our plan for improving access for patients and supporting general practice”.

As a result the profession, already incensed by the lack of support from NHS England earlier in the year over the same issue, voted in support of a mandate for strike action.  Not, one would think, the response the government was looking for.

At this point (in November last year) the Health and Social Care Committee, now led by a transformed Jeremy Hunt seeking to use his position chairing this committee to undermine the government at any point, launched an Inquiry into the Future of General Practice.  Evidence for this inquiry can be submitted until this Friday, 4th February.

The Times article indicated that a review of General Practice is “planned” by Javid, so we can assume this is not the same as the Health and Social Care Committee Inquiry.  There are undoubtedly politics that we are not aware of between Hunt and Javid also at play, but what the Secretary of State certainly won’t want is Hunt’s Committee telling him what he should be doing with general practice.

The other important piece of context for this article is the wider shift to integrated care, and what this means for general practice.  As I discussed a couple of weeks’ ago, the Planning Guidance for the NHS seems very geared towards the role general practice can play in support of acute trusts, in particular in relation to the rollout of thousands of virtual wards.

A review of PCNs was also announced in November last year, and interestingly this review is now framing itself in terms of what “integrated primary care” looks like.  In this video the leader of the review Clare Fuller does not reference PCNs once.  This review is due to report next month, so it is not beyond the realms of imagination to think that this is the review that Javid is referencing in the Times article.

This would also explain the timing of the article, although of course all this is being carried out at exactly the time that the newly elected GPC committee, armed with their strike mandate, are negotiating the first contract.  This government, for longer than most of us can remember, wants better access to a GP above all and everything else, and if negotiations are not going well this might be the perfect time to threaten nationalisation to move things along.

The argument for organising health services around the needs of hospitals (as opposed to the health needs of the population) is so antiquated that it is hard to believe that it is being taken seriously.  That said, with this government anything is possible, and there are disturbing trends within Integrated Care Systems and the guidance around them towards creating primacy for the needs of hospitals.

But overall my sense is that general practice has very much become a political football, and that most of this is political game playing.  I don’t really think Sajid Javid wants to nationalise general practice, and to end up in a full on dispute with the profession, but I think there are things that he does want and reports like this are simply a means to help him get them.

26
jan
0

5 Things to Watch Out For in 2022

Posted by Blogs, The General Practice BlogNo Comments

What is on the horizon for general practice in 2022?  Here are 5 things to watch out for in the year ahead.

February: Contract Negotiations.  We are three years in to the 5 year deal agreed in 2019, so you would think that contract negotiations this year would be relatively straightforward.  However, once you throw in Covid, the government’s concern with GP access, a new GPC leadership team, and the vote in support of industrial action made by the profession at the end of last year, the negotiations this year could well be a spikier than normal affair.  Despite the profession’s reaction there has been no softening of the national stance on GP access, and so it will be very interesting indeed to see what comes out of this particular set of negotiations.

March: PCN Review Report.  In November last year a review of PCNs was announced, and how “they will be working with partners across newly formed integrated care systems”.  Potential concerns were highlighted at the time, namely that it implied a need for more national control over PCNs, that it could signal a shift of ownership of PCNs away from practices, and that it may very well further distance PCNs from the pressing issue of general practice sustainability.  This report is due in March, most likely coinciding with whatever comes out of the contract negotiations, and there is a good chance it will have big implications for general practice.

June: 3 years of PCNs.  It may only feel like yesterday but in June it will be three years since PCNs were first established.  PCNs now, with their large team of additional role staff and increasing set of delivery responsibilities, are significantly different from what they were back in 2019.  However, three years may also mark the end of the tenure of many of the initial PCN clinical directors.  While we have experienced some turnover of CDs already, this year could well see a much a greater turnover with many coming to the end of the term they initially agreed, and taking on the role may prove a tough challenge for those coming new into the role this year.  How this affects PCNs as a whole is something only time will tell, but unless more support is put in place it is unlikely to be positive.

July: Integrated Care Systems go live.  It feels like we have been living in the shadow of integrated care systems for some time now, but (according to the new planning guidance) they will finally go live in July this year.  This means CCGs will formally be abolished, and general practice will be left to fend for itself amongst the other providers as we all ‘work together’ to agree how care is organised and how resources are divided.  The extent to which general practice can influence and impact these new systems may well be very important in determining the level of local investment and support in the service going forward.

October: Shift of Extended Access to PCNs. Well, maybe.  This shift was supposed to happen in April last year, and then in April this year, and now in October this year, and the continual delays do raise the question as to whether this shift will ever really happen.  But if it does it may well spell the end of financial sustainability for the significant number of GP federations that rely on this funding, and this in turn could well create difficulties for both local practices and PCNs.  It is an issue that when the guidance (finally) comes out will need some working through to ensure we don’t end up with more problems than we have now.

19
jan
0

What this Year’s Planning Guidance Means for General Practice

Posted by Blogs, The General Practice BlogNo Comments

Each year the NHS publishes planning guidance.  This year is no different, and on Christmas Eve (happy Christmas everybody…) true to form the NHS published “2022/23 Priorities and Operational Planning Guidance”.   It outlines for the NHS what needs to be achieved in the year ahead.

While it is not a document specifically aimed at general practice (rather it is aimed at the NHS as a whole), it provides an interesting perspective on how general practice is viewed within the system, what the priorities for general practice are likely to be, and gives some indication as to what will feature in next year’s GP contract.

The document sets 10 priorities for the NHS.  General Practice explicitly features in one of them, namely to, “Improve timely access to primary care – maximising the impact of the investment and Primary Care Networks (PCNs) to expand capacity, increase the number of appointments available and drive integrated working at neighbourhood and place level” (p6).

So first off, in case anyone thought there might be some national backing off from the October guidance that generated such a backlash (including a mandate for national strike action for the GPC), there is a clear reinforcement of the need for the paper to be implemented (“In line with the principles outlined in the October 2021 plan, systems are asked to support the continued delivery of good quality access to general practice through increasing and optimising capacity, addressing variation and spreading good practice” p25).

More interesting is the newer theme that pervades the text around integration.  Integrated Care Systems go live next year, although this document confirms that this will now happen on July 1st not April 1st to allow time for the bill to pass through parliament.  Systems are exhorted to, “maximise the impact of their investment in primary medical care and PCNs with the aim of driving and supporting integrated working at neighbourhood and place level.  Systems are asked to look for opportunities to support integration between community services and PCNs” p24.  The review of PCNs will be reporting in March, and I wouldn’t be surprised if it marks a shift of PCNs away from ownership solely by practices.

Systems will also be judged by the extent to which their PCNs have made use of their ARRS allocation, and are also asked to support employment models across organisations, “Systems are expected to support their PCNs to have in place their share of the 20,500 FTE PCN roles by the end of 22/23 and to work to implement shared employment models” (p24).  It is interesting that underneath the opportunity for PCNs to use the ARRS funds there is a top down pressure on local systems for all the money to be spent.  Indeed, the rationale used is not to support general practice, but “to support the creation of multidisciplinary teams” (p9).

There is a further notable nuance that PCNs (not practices) are treated as the unit of general practice in the guidance.  It claims that there will be, “ a suite of national GP recruitment and retention initiatives to enable systems to support their PCNs (not practices) to expand their GP workforce and make full use of the digital locum pool” (p9).  We also won’t hold our breath in anticipation of all the same additional GPs we have been promised for the last 5 years…

There are two other major items of note for general practice in the guidance.  The first is the big push in the guidance on the roll out of virtual wards.  The ambition set is that by the end of 2023 there will be 40-50 virtual wards per 100,000 population.  These are to be based on a partnership between secondary, community, primary and mental health services, and they “should only be used for patients who would otherwise be admitted to an NHS acute hospital bed or facilitate early discharge” p21.  £200M in 22/23 and £250M in 23/24 is being made available to develop these wards, although given the numbers of wards expected how they will work is a mystery, as my back of the envelope calculation gives each ward less than £10,000 to operate.

The other item of note is a promised new IIF indicator for PCNs to incentivise contributions to a minimum of 2 million additional pharmacy consultation appointments in 2022/23.  According to the guidance (p25) this will move “more than 15 million appointments out of general practice”!

Overall, the main takeaway is the pressure that will come around ‘integration’ – PCNs and PCN staff to work across organisations, multidisciplinary teams, multi-organisational virtual wards, joint working with pharmacies, and (of course) new integrated care systems in charge of everything.  What could possibly go wrong?

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.

Page 33 of 89
1313233343589