The Two Icebergs Facing General Practice

Guest Blog by John Tacchi, CEO, BIG Practice Ltd

If General Practice was a ship, it would be the Titanic, thundering through the night and on course for disaster. Beyond the well-rehearsed problems, I see two further “icebergs” facing General Practice hidden beneath the surface which could easily lead to catastrophe.

The first of these icebergs is premises and property. I recently had a conversation with a GP that I shall call Dr Average; a GP with an average sized practice (around 4,000 patients) and an average set up. He was very concerned because his latest invoice from the property landlord showed an increase in non-refundable costs from £1,000 to £42,000.

I took a deep breath, and asked Dr Average for his lease. He said he didn’t have one, and indeed there had never been one. As an ex-lawyer I found this staggering. As I told Dr Average, you occupy this building under a bare licence. That is a ‘good news/bad news’ position; good because you could leave tomorrow without the landlord having any recourse, but bad because the reverse applies too.

I suspect that this situation is being repeated across the country. Landlords are trying to achieve the correct market value for their properties, and GPs are facing a big increase in costs not covered by the reimbursement arrangements with NHS England.

Many GPs are in former residential premises that are not fit for purpose. But those that have moved to new purpose-built premises are also facing problems, as the reimbursement monies for premises dries up. According to the GP Forward View £900M is available for new GP premises, but without, it seems, the revenue funding to support this expenditure.

The second iceberg I believe we are facing is the resilience of GP practices as independent businesses. Let’s go back to Dr Average. He was concerned because the balance on the practice account had been declining over the last 15 months and was now a negative number. I looked into his accounts and they showed a relatively profitable business. However, I explained the P&L statement is a backward looking view and that we should examine the notes to the accounts. Dr Average was genuinely surprised; he didn’t know there were any notes to the accounts. I asked him for his cash flow forecast and he clearly didn’t know what I meant.

GPs run a unique type of business which ‘guarantees’ various elements of the income side of the equation, while at the same time provides a simple reimbursement for much of the cost side. In the past, running the business has often been a relatively simple exercise in cash management. But the current challenges facing General Practice require a more sophisticated business and financial skill set that many GPs and GP practices simply do not have.

I was recently involved in an exercise in the West Midlands led by Sandwell and West Birmingham CCG to gather detailed workforce data, and was staggered to discover that 40% of all GPs in the patch intend to retire in the next 5 years. The data also demonstrated that there are not enough ‘young’ GPs to replace this potential outflow. Many of the younger ones simply have no desire to become partners and take on the reality of sinking capital into a business that offers little guarantee of a return on their investment.

These two icebergs; the premises problem and the business problem are looming ever larger as the NHS changes and financial constraints continue. If the good ship “General Practice” is to survive in any meaningful form and avoid these icebergs then General Practice has to do what lawyers and accountants started to do 30 years ago, i.e. re-invent their ‘corporate’ structure and strengthen their business function and capability.  If it does not, HMS General Practice could well go the same way as the Titanic.

If you would help with any of these issues or would to contact John his e-mail address is john@bigpractice.co.uk

Five ways CCGs should be supporting General Practice

How can CCGs provide the kind of support that General Practices need to manage the problems they face now and in the future? In this blog, Ben Gowland suggests five key actions they can take.

There is tremendous variation across the country in the levels of support different CCGs are providing for General Practice. Here are the five most impactful actions CCGs can take to support General Practice locally.

One – Introduce a Single Contract to Uplift funding for General Practice

Bolton CCG has invested an additional £3m into General Practice and provided a guaranteed minimum income per practice. By both bringing together the different funding streams for General Practice and investing additional resources CCGs can create an uplift of core funding that will make a real difference to the problems GP practices are experiencing. Listen here to hear how Bolton CCG made this happen locally.

Two – Support the introduction of new roles into General Practice

As recruitment of GPs into practices becomes increasingly difficult, GP practices are being forced to look at the introduction of new roles into practice, such as advanced nurse practitioners, paramedics, pharmacists, physiotherapists, mental health workers and physicians associates. CCGs can support and accelerate the successful introduction of these roles by:

  • Establishing the local availability of each type of role
  • Bringing together into one place the additional funding available to support practices with these different roles
  • Providing information about the availability of local training, e.g. prescribing courses for pharmacists, and information on implementation issues such as indemnity
  • Creating local groups whereby clinical staff taking on these new roles can gain support from each other, and share best practice

Three – Support the establishment of a local Locum GP Chambers

GP locums make up nearly a quarter of the GP workforce, according to the National Association of Sessional GPs (NASGP). GP practices spend inordinate amounts of time finding GP locums, and often have to pay exorbitant rates. Encouraging the local locum GPs to establish a chambers will improve the availability of locum GPs, improve the quality, and reduce the cost. While CCGs cannot set them up directly, they can facilitate their development locally, for example by identifying and working with potential leads for the chambers, and establishing the demand from practices to support the business case for their establishment.

Four – Help local GP practices explore the opportunities of working at scale

Our Health Partnership is the largest ‘super-practice’ in the country. 32 practices in Birmingham came together to establish a single partnership, covering a population of 280,000. The origins of this came from the CCG providing some facilitation support and opportunities for local GPs to come together to explore what working together at scale might mean for them. Hear more about the origins of Our Health Partnership here and here.

Five – Facilitate the development of partnerships between GP practices and other local providers

Joint working between GP practices and other health providers, such as community trusts, acute trusts and local councils have enabled some GP practices to develop new staffing models, introduce new systems for managing on-the-day demand, and create an innovative approach to managing estates. The joint work between Southern Health and the practices in South Hampshire is a good example (find out more here). What GP practices lack is an understanding of the enthusiasm of different local organisations for this work, what type of joint work they are prepared/keen to consider, and who the best contact point within each organisation for practices is. CCGs can establish this information and make it easily accessible to practices, and then actively support joint initiatives as they develop.

General Practice Needs a Route Map

We know General Practice is in crisis. We know NHS England has published the GP Forward View. We know more money is on its way (despite arguments about how much!). But the curious thing is there is no clear direction for GP practices to follow.

I spoke recently to Dr Maureen Baker, Chair of the RCGP, (you can listen here) and asked her whether GP practices should now be looking to operate at scale. Her response? “I don’t think all practices will have to get bigger”. But some, presumably, will. It depends.

I asked her whether GP practices should be looking to take an active role leading the integration agenda or simply participating as others (such as the local community or acute trust) take a lead. Her response? “I don’t think it matters too much whether GPs are doing it or whether GPs are coming on board… It doesn’t have to be GPs that design it, lead it, run it.” Again, it depends.

Indeed, Dr Baker’s own summary for GP practices was they must look first to their own survival, but then consider that, ‘There is a range of ways of doing things… there is not a best way to do it”.

The GP Forward View (GPFV) in many ways reflects this. There is a huge reluctance to impose change upon General Practice, but at the same time a recognition that change is necessary. From an individual GP practice perspective, it has ended up almost as a smorgasbord of ideas and opportunities that can feel both overwhelming and lack the collective coherence necessary to create a clear plan for the practice.

GP practices have to sit, poised, ready to respond to expected announcements about deadlines for estates proposals, about funding for pharmacists and mental health workers, about the programme for online consultation systems, and about any local investments in extra capacity. Information drips through about each individually, as local commissioners await guidance from on high.

Without doubt, the GPFV brings opportunities for GP practices. But these opportunities do not sit together in a coherent narrative. There is no clear direction, no route map for practices to follow. It just depends.

I was working through with the GP partners of a practice recently to understand how they could tackle the challenges they faced, and what their plan should be. It was hard.   The problems facing General Practice have not gone away, and continue to worsen. Next year looks more challenging than this year for the practice. Opportunities exist, but they feel intangible, opaque, and like they are within the control of someone else and outside the control of the practice.

The partners reflected in the past making these decisions had been easier. There had been clarity from the PCT, or the Health Authority, or whoever the commissioner of the day was, as to the proposed direction for General Practice and what they wanted each practice to do. This does not exist today. Even within the same geographical area GP practices face challenges to lesser or greater extents, and the required response varies. It depends.

But no-one is helping practices work out what their individual response should be.

You could argue the lack of a clear direction is a good thing, as it provides choice and freedom for practices, and empowers practices to be masters of their own destiny. I wonder, however, whether we have taken this too far, and as a result have created an almost impossible task for practices who lack the headroom and time to navigate through such difficult terrain. My sense is many GP practices want and need leadership – someone to say this is the route you have to follow, and if you do this it will be ok. General Practice needs a route map.

Will GP leaders let go of their CCG babies

The time has come, suggests Ben Gowland, for GP leaders in CCGs to consider moving from their role in the CCG to a leadership role in the development of core general practice. 

I have suggested this before.  The reaction seems to be determined by where the individual is sitting: if they are in General Practice without involvement in the CCG they are generally in favour.  However, if they are in a CCG they are generally against.

Initially I thought this was because of the money.  GP sessions are rewarded (often handsomely) by CCGs, to the point where some GP leaders can no longer afford to give up their CCG role.  Indeed, whoever the GP, if their time is no longer funded, it is lost, as it will be swept up in the tides of unrelenting demand on their practice.  I suggested that CCGs continue to fund their time, as part of its work to support the transformation of General Practice, by seconding them back to General Practice.

This would work.  But the objection is not primarily about the funding.  The main objection is the need of the CCGs for GP leaders.  How could there be clinically led commissioning if the GPs are leading the development of core General Practice instead?

Here we get into a debate about priorities.  We have to weigh up two different things.  On the one hand we should consider the influence of commissioning on the system.  If valuable GP leadership time is to be spent in CCGs, it has to be worthwhile.  On the other hand, we should consider the needs of General Practice, and the impact that GP leadership time could have there, and the impact this would have on the system.

Recently Simon Stevens, the Chief Executive of NHS England, has suggested ‘combined authorities’ for the NHS.  He wants to bring together commissioners and providers in order to simplify decision making and service change, based on the 44 STP (system and transformation plan) areas.  What this means is an end to any notion of a ‘commissioner-led’ NHS.  The reality is the NHS is currently regulator-led, and the role of commissioners is becoming increasingly unclear.

General Practice, on the other hand, is deep into a crisis of its own.  In short, demand is up and GP capacity to cope with the demand is down, and costs continue to rise while income has fallen to a smaller and smaller share of total NHS income.  At the same time, General Practice is purported to be at the centre of the new models of care at the heart of the five year forward view for the NHS.

In simple terms, the influence of GPs going forward is likely to be much greater as providers within any new models of care than through any commissioning organisation.  For this influence to become a reality GPs need to be organising a voice around the table, and developing an ability to take on the system integration role envisaged for it.  This requires transformation, and transformation requires GP leadership.

The emotional attachment GP leaders have to the CCGs many of them created is understandable.  But the world has changed significantly in the last few years.  It is time to re-evaluate. It is hard to put CCGs higher up the priority list than the development and transformation of General Practice.  CCGs have developed and are old enough now to cope without the intense parenting they have had so far from their GP leaders.  Now it really is time for these GPs to let go of CCGs and focus their efforts where they are needed most – back home.

Integration and Little Green Fairies

Ben Gowland muses on the potential roles for GPs in the integration agenda and finds himself away with the fairies.

I recently asked a GP whether she felt that GPs should play a leading role in integration across the system. She peered at me through her half-rimmed spectacles, and said, “I don’t even have time to go to the loo let alone get involved in Integration. It sounds great in theory but there is more chance of little green fairies doing a magic dance at the bottom of my garden than there is of me taking on any more work.”

So that was me told. The RCGP have produced a new report entitled, ‘The Future of GP Collaborative Working’. You can find it here. The report, as far as I can tell, has two key messages. One is that GPs, as the expert medical generalists, have a key role to play in the integration of services around patients with increasingly complex needs. The second message is that this central role of GPs is often not recognised and that any additional funding generally either falls short of what is needed, or is not maintained over the longer term.

So we are left with something of a conundrum. This is the ‘little green fairy’ problem; GPs now exist under such extremely severe time constraints that the prospect of them taking on more and more system responsibility seems, to many, simply preposterous. There are not enough GPs and no prospect of there being enough any time soon. But, at the same time, the system requires GPs to play a greater role in bringing services together around the needs of patients.

The RCGP Report contains a number of really interesting examples of how GPs have taken a leading role in integration. They are worth a closer look. They fall into three groups. There is one whereby a new service has been created that employs GPs directly into a new service, for example the @home scheme in London and the Memory Assessment Service in Brighton. There is a second whereby a small number of GPs are upskilled in a specific specialty and then work in partnership with a specialist centre to improve the General Practice offering, e.g. the child health hubs/clinics in London and in Lerwick in the Shetland Isles. The third is one whereby the GP practice team is expanded, for example the addition of a prescribing pharmacist as a partner, or employing a mental health therapist.

The analysis required is of the impact of these developments upon General Practice overall. Integration does not replace the need for core General Practice. Rather, it aims to fill the hole that often exists between core General Practice and secondary care, and indeed other services. But filling that hole at the expense of the core General Practice service would clearly be a mistake (a point, I fear, that is missed by some new-models-of-care enthusiasts).

This isn’t wholly scientific, but here is the little green fairy analysis of these three groups of examples:

Group One could either attract new GPs into the profession by creating a new range of options for newly qualified GPs to choose from, or it could pull from an already too small pool and make it smaller. Little green fairy verdict: I’m dancing.

Group Two can enable a small number of GPs to develop an interest, receive proper support, and enable that to be monetised by the practices of those GPs to recruit replacement capacity. At best the impact on GP practices is likely to be neutral. Little green fairy verdict: now you see me, now you don’t.

Group Three involves reshaping core General Practice by incorporating new roles and responsibilities as a driver for integration. This enables core General Practice to develop alongside integration initiatives. Little green fairy verdict: I’m toast.

We need integration; not as a replacement for General Practice but as well as General Practice. GPs have a key role to play. The only way this is going to be realistic at any sort of scale is if the integration work helps, rather than adds to, the delivery of core General Practice by GPs. If it doesn’t, then we would be better off looking at the end of our gardens for the elusive magic dance of the little green fairy.

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