What the Changes to General Practice Mean for Primary Care Premises

The secret to what will happen in the future to primary care premises lies in the past. Understanding the current crisis in general practice provides vital clues as to the impact the new models of care and the like will have on estates.

The growth in demand on general practice (the number of consultations per head of population has more than doubled in recent years, in addition to the overall population growth) has not been matched by a similar growth in resources. The general practice estate is no longer big enough. Worse, the growth in regulation and the shift to NHS Property Services means the existing estate is becoming more and more of a cost pressure. Even though new, bigger premises are desirable, they are not necessarily affordable.

There are also less and less GP partners. In the last 10 years the number of GP partners has dropped by 9% while the number of salaried GPs has increased by 260%. As GP partners have become harder to recruit, many places have had to look at how to drop the requirement to buy into the property in order to attract new partners. As a result, GPs and GP practices are increasingly looking to “cash in” their property.

To cope with the pressures, general practice is making changes to the way it operates. New roles, such as pharmacists, physiotherapists and paramedics are being introduced to the practice; but only, of course, where they have the space. Less commonly, but increasingly representing the overall direction of travel, a number of places such as St Austell, Plymouth and Hampshire, are operating an urgent care “hub” – a single site where all of the on the day demand is seen by a multidisciplinary team, freeing up space on the other sites for longer planned and follow up appointments. And bigger practices are considering whether consolidation onto a smaller number of sites is possible in future.

But surely the Estates and Technology Fund has been put in place to address the estates problems in general practice? While the reduction in the match funding requirement is welcome (down from 33% to 0%), few practices so far have been able to benefit from the fund, especially compared to the number who spent hours completing the paperwork to bid for it in the first place.   Revenue consequences of new builds remain a problem for practices and CCGs alike, and the old notion that these simply have to be “absorbed” no longer washes.

The challenges general practice is experiencing mean some are looking to partner with other organisations to more effectively manage the demand. We are seeing more examples of practices joining up with volunteers and voluntary groups to offer more holistic care, and of practices trying to build links with community services. But space is a real barrier for many. Partnership working inevitably means some degree of co-location, and practices are not sat on empty rooms, waiting to be filled.

It may be that as a result of the new Sustainability and Transformation Plans (STPs) we have a reversion to some sensible join up of strategic estates planning, which will incorporate primary care premises. But it will need to happen quickly. In the meantime, the reality is that the new multispecialty community provider (MCP) and Primary and Acute Care Services (PACS) models offer a way out for general practice. When we dig underneath why GP practices are signing up to these new models, it is largely because these new contracts are offering to buy them out of their premises. Without this incentive, it is hard to see much movement towards them.

The pressure on general practice is such at present that if an attractive way out is presented, many are likely to take it. In the future, the trend will be to an increasing split of “hot” and “cold” GP sites, accelerated by the funding on its way for additional GP access. The move to operating at scale will ultimately lead to a reduction rather than an increase in the number of GP practice sites. And the development of MCPs and PACS models will see the estates increasingly owned by the community and acute trusts, within these new organisational forms.

The one new role every single GP practice should adopt

In all the work I have done on new roles in general practice, the role I have probably paid least attention to is that of “medical assistant”. They are tucked away within the Releasing Capacity in General Practice programme, under high impact change number 4, “Develop the team”, bullet point 5. It is small wonder they get overlooked!

Plus they are not really new roles. It is actually training for existing administration staff, specifically those who code, to be able to read, code and action incoming clinical correspondence according to agreed protocols, as opposed to passing everything on to the GPs.

But the impact is huge. I visited a practice recently who had implemented this system, and they were evangelical about the benefits! According to them the new system was saving each GP up to an hour a day. When the biggest pressure on GPs is workload it is not hard to understand why a change that can make a difference like this is so popular.

Not only is the GP time saved, but coding actually improves, and the administration staff undertaking the new way of working enjoy it and feel like they are contributing more to the practice.

Here is how it works. A lead GP from the practice is put in charge of working out how the different mail coming into the practice can be processed. The starting point is a set of protocols, worked out from practices where this has already been introduced. They really just require tweaking to reflect the specific needs of each individual practice, and then reviewing over time to continually refine them. The aim is to reduce the number of letters that need to be processed by a GP.

So for example if there is a letter informing the GP a patient has failed to attend a mental health appointment, the agreed action could be “book telephone appointment with the GP”. Instead of the letter going backwards and forwards between the clerical staff and the GPs, the action is implemented straight away. If the practice wants a different process to be followed for this particular pathway, it can set its own rules for the clerical staff to follow. Meanwhile letters that the GP absolutely needs to see, such as a safeguarding issue or a serious or complex diagnosis, are passed straight on to a doctor.

The other key difference is that instead of the letters going to the GP to outline what needs to be coded, and the letter then coming back to the coders, the clerical team will code directly from the letter. After the initial training, the lead GP audits and checks and feeds back very regularly at first, but then increasingly infrequently, as the clerical team develop the skill set. The wasted GP time is cut out of the loop.

The practice I visited, who had been refining the system in their practice over 3 or 4 months, estimated a reduction of 70 to 80% in the correspondence now going to GPs, compared to before the introduction of the scheme.

This new way of working, which I have seen termed “workflow redirection”, “workflow optimisation” and “document handling”, depends very much on the oversight, governance and audit within the practice from the GP lead for it, and the new skills and new way of working of the administration team, or “medical assistants”. The practice I visited did feel that it increased the administration burden on the clerical team, and they had to increase capacity to absorb the additional requirements. The team in Brighton who first developed the change suggest it requires an additional 3.5 admin hours per day per 5,000 patients. You can see the video they have produced about the change here.

Introducing medical assistants might not be the sexiest of changes developed to support the challenges facing general practice at present, but it may well prove to be one of the most useful. If you are struggling to make any change at all in your practice, I would highly recommend you start with this one. Start with just one GP’s letters. Measure the benefits. Others will soon become interested!

Who Can Represent General Practice Locally?

To ensure they are adequately heard in the development of STPs, GP practices need a strong and clear voice. But who will represent them? In his latest blog Ben argues that there are a number of options but ultimately local GPs must decide this for themselves.

There is not always strength in numbers. While there are 7875 GP practices, there are only 154 acute trusts, yet the influence of the latter appears far larger in the development of the 44 local Sustainability and Transformation Plans (STPs). Worse, the numbers work against practices: while it is possible for every acute trust to be represented on STPs (there are an average 3.5 acute trusts per STP), the same is not true for every GP practice (there are an average 179 GP practices per STP).

Does this matter? Is representation important? General practice has left many of these things alone in the past and in the main has avoided what would have been a colossal waste of their time. But the world is shifting. Alongside the ever growing pressure on resources, providers are being asked to come together and decide for themselves how what little money there is should be spent. Instead of a series of bilateral agreements between the different providers and a system arbiter, the STPs are looking for a single agreement across all parties.

In the past general practice could ignore local developments, protected by a single, nationally negotiated contract. But now the NHS is shifting to a series of bespoke, local agreements. Much of the promised additional £2.4bn for general practice is coming outside of the core contract. New, local, multispecialty community provider (MCP) contracts are emerging, with much more room for local negotiation than was ever possible with the national GP contract. It is a brave GP practice that will allow the other providers in the system to determine how much funding, and with what strings, they should receive.

So if we accept it is not possible for 179 practices to all represent themselves in local discussions, even if only for practical and logistical reasons, who should represent them? Insufficient thought and effort has so far been put into resolving this question, not only by local systems but also by practices themselves. In many cases the local system has decided how general practice is to be represented. But if I ran a practice, I would want to make that decision myself, along with my fellow practices.

There are a number of options available. First, the CCG could represent its practices. It is after all a membership organisation and each practice is a member of its local CCG. The problem comes because the remit of CCGs extends across all providers, and they continually have to go to extraordinary lengths to demonstrate they are not favouring their member practices. It is more or less impossible for CCGs to both carry out their role as CCGs and simultaneously represent general practice effectively.

Second, the RCGP could represent general practice. The RCGP has appointed RCGP ambassadors for each of the 44 STP areas, whose role (according to the RCGP website) is to “maximise investment in general practice at a local level, track developments, and make sure that GPs have a very strong voice in the GP Forward View across England”. The RCGP is supposed to focus on improving patient care, clinical standards and GP training, and while I am sure the RCGP ambassadors are a good thing for general practice, it is hard to see them having the mandate or infrastructure to be able to adequately represent practices in local negotiations.

There are two more realistic options. The first is the local LMC. Their explicit purpose is, after all, to represent general practice. There is often resistance to their inclusion, as they are seen more as a trade union than as a reasonable representative of GP practices. Their leaders are rarely viewed, for example, in the same way that an acute trust CEO might be viewed. But they are statutory bodies, funded by a statutory levy on practices. Tracey Vell, leader of the LMCs in Greater Manchester, argues it is essential LMCs talk for GP practices in STP discussions, and also recounts how it was only through grit and determination that she was able to ensure they gained a voice around the table in Manchester.

Second, the local federation(s) could represent general practice. This is tricky because federations vary so significantly in the way they are set up and what they have been established to do. Where their role is to generate and deliver additional services across a group of practices, local practices can become resentful pretty quickly if the local federation leaders are seen to overstep the mark and assume they can talk on behalf of their member practices. But equally where one of the reasons for the local federation is to strengthen the voice of the member practices then this can work really well.

Nothing of course is stopping GP practices setting up a federation just for this purpose. If they don’t feel (for whatever reason) that the way they are being represented is satisfactory, they can create a federation, appoint a spokesperson, and all they would need to fund between them is the cost of that person’s time.

It is also not unreasonable for there to be more than one voice for general practice. If the 3.5 acute trusts in each STP area each have their own voice, then general practice can reasonably expect to have more than one voice. In Manchester they have a “GP Advisory group” which contains the federation and LMC leaders, and then this group has a voice on the main board, mirroring arrangements for the acute trusts.

We are at a point in time when local representation of GP practices, and the establishment of a strong voice for those practices, is more important than ever before. Unusually, GP practices need this representation more than the system needs it. If effective representation has not yet been achieved, it is GP practices themselves who now need to take responsibility for making it happen.

Inspired by Indemnity (seriously)

Occasionally you talk to people who are inspiring, and I am very lucky that through the podcast I have the opportunity to speak to inspiring people more frequently than most. Recently I spoke to one such individual – Tawhid Juneja, founder and director of Primary Care People, who got me excited about professional indemnity for GPs. I know! You can hear the conversation here

Indemnity is one of those issues you either understand because you have to (ie you are a GP) or you simply consign to the “too complex and not interesting enough to spend time understanding” box. But for anyone involved in general practice it is becoming increasingly difficult to ignore. Costs are spiralling. The average cost is up from £5200 in 2010 to £7900 in 2016, a rise of over 50%. This in itself masks the real rise as in that period GPs have reduced their number of sessions. NHS England in its 2016 GP Indemnity Review estimated the real inflationary cost is 10% per year. As costs rise GPs reduce their sessions further, the profession becomes less and less attractive, and the staffing crisis will continue to deepen.

The NHS England report was disappointing in that it accepted the claims of the three medical defence organisations that cover 99% of GPs, who argued there is sufficient competition (based on the fact that 40% of GPs have switched between the three in recent years), and concluded the only real long term solution is operational measures to reduce negligence claims in primary care. The cost is the cost etc.

But having spoken to Tawhid, I don’t agree. He has spent the last couple of years establishing his own commercial indemnity support scheme for the GPs working for his organisation. He has been able to reduce the cost of indemnity by employing interims rather than locums (ie GPs prepared to sign up to a minimum of 6 months with one organisation), guaranteeing a certain number of GPs to be covered under the scheme, agreeing an excess that he then pays on behalf of the GPs he employs, and introducing certain quality standards both to the GPs he employs and the placements to which he assigns them to reduce the risk of claims.

Tawhid pays for the indemnity of the staff he employs and places. As a result, he can make it cheaper for the practices, enable the GPs he employs to have a greater take home pay, and turn a profit for his own organisation. He has singlehandedly demonstrated that something can be done!

Think of the possibilities this creates for general practice operating at scale. What is to stop super-practices from developing their own scheme, just as Tawhid as done? They could operate the same conditions: minimum 6 months with one organisation; guarantee a certain number of GPs to be covered; and agree quality standards and placement standards across their practices with the underwriters to secure a better deal for their members. It could be for all the salaried doctors across the practices to start off with, or the ambition could even be for all the GPs.

It won’t be easy. GPs, instead of having cover anywhere for anything, would be covered only for working in specific locations. Because of this some will dismiss it out of hand, but it is no different from indemnity secured by an NHS organisation for its staff through the NHS Litigation Authority scheme. It will require GPs adhering to certain standards of practice, such as minimum consultation times, maximum numbers of consultation per session – but is that such a bad thing? And if that in itself accelerates the introduction of changes to general practice (overflow hubs and the like), again isn’t that exactly what the profession is crying out for?

We have entered a vicious spiral of decline, whereby the worse the working conditions for GPs, the greater the chances of claims, the less GPs will work, and the worse the conditions will become (and so on). The only option is to break the cycle. We can use indemnity to make it happen. Insist on the standards. Reduce the claims. Decrease the cost of cover. Use the absolute requirement to adhere to the standards to accelerate the changes in general practice.

Disruptive entrepreneurs like Tawhid may not be everyone’s cup of tea, but individuals like him are what is needed to shake the profession out of its current predicament. Instead of avoiding indemnity it is time to tackle it head on, and use it as a lever to drive through the changes that no one disputes are necessary.

Make General Practice your CCG’s Priority

What will the GPs working in CCGs leave behind when clinical commissioning has been dismantled? Ben Gowland argues that now is the time for them to consider this legacy and to act swiftly and single-mindedly…

This week Simon Stevens exhorted GPs on CCG Governing Bodies to ensure the money promised to general practice reaches its intended destination. He condemned the compounded impact of a decade of disinvestment in primary care, and reaffirmed the necessity of changing the trend to one of investment above the rate of the rest of the NHS. Mr Stevens declared the final destination of the GP Forward View money the responsibility of GPs.

At the same event Professor Steve Field, CQC Chief Inspector of Primary Care, declared an inspectorate for general practice is only needed because local GP leaders have not done their job properly. The CQC is a necessary evil caused only, according to Professor Field, by the failures of local GP leadership.

These declarations will rankle with GPs. CCGs in many areas do not have, and never have had, responsibility for the commissioning of general practice. They are castigated on an almost daily basis for their failure to monitor conflicts of interest thoroughly and effectively, and for allowing their particular part of the system to slide into financial imbalance. And now suddenly we have bewilderment expressed at a national level as to how GPs in the form of CCGs could have been given the purse strings and at the same time allow general practice to fall into its current parlous state.

At the same time, clinical commissioning is being discreetly dismantled. STPs, local accountable care organisations, and devolution are working together to diminish the role of commissioning. Ever since the shift from competition to integration with the publication of the Five Year Forward View, power has been stripped from those attempting to use contractual levers and plurality of provision to effect change. Unachievable financial pressures have been added to CCGs to “even up” the playing field between commissioners and providers, so all can “share the pain equally”.

What is a GP on a CCG Governing Body to make of all of this? What should they do?

It is time to think legacy. It is time to look forward 5 years and think what impact did I have on local general practice? What did I do that made a real difference?

The door has been opened. Simon Stevens and Steve Field are telling you, explicitly, it is your job and your responsibility to support general practice. Take them at their word. Do everything in your power to ensure the GP Forward View money reaches general practice. Reverse the trend of disinvestment and ensure funding for general practice reaches 10 or even 11% of local NHS expenditure.

Hold your own CCG to account for increasing its investment in general practice. Use delegated commissioning to shift the focus of the CCG away from the acute trusts and onto the stated national priority of general practice. Be single minded. Use the opportunity.

Time is limited. You are now being berated at a national, as well as (I assume) a local, level for not using the situation you are in to make a difference to general practice. Stop listening to those who are persuading you the right thing is to forego investment for the sake of financial balance, or that the CCG can’t afford to create its share of the £171m earmarked from core CCG allocations for general practice.

The time for self-sacrifice is over. It is not serving you or your local population. However uncomfortable it feels to say to a room of stakeholders, all desperate for commissioner money, that you have weighed up all their needs and have decided to give it to yourself and your colleagues, that is what you have to do. Putting general practice, primary care and all of out of hospital care first is a national priority. Make it yours.

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