How I Discovered the Future of General Practice

Looking at solutions for the problems facing general practice and learning from those who have already got it right inspired Ben Gowland and his team at Ockham Healthcare to write a book. In his latest blog Ben explains why the resultant book should be essential reading for anyone with an interest in general practice.

General practice is a difficult problem to solve. Few now dispute the profession is in crisis, and yet despite the publication of the General Practice Forward View (GPFV) we seem no nearer to a consensus on what the future of general practice will look like.

When I left my role in the CCG I started by trying to really understand the problems general practice was experiencing. I visited a range of different practices and spoke to many GPs and found the problems were even worse than I had imagined. You can watch the TV documentary I made about this here.

I then started talking to people; to GPs, practices, and sometimes whole areas, who had found a way through the problems. There are nearly 8000 GP practices in England, and while many are struggling, some have found a way through and are thriving. I wanted to learn from what they had done, and I wanted to share that learning with others. In February this year we started publishing The Ben Gowland Podcast every week – short recordings of conversations I have had with those who have found a way through the problems general practice is experiencing.

As I listened to the experiences of both those who had found answers and those who were struggling, I was struck by the realisation in many cases both had tried to do the same things. Practices who were struggling had joined a federation but it had made no difference. Practices that were thriving had formed a federation and it had had a transformative effect. I realised there is no simple “answer” to general practice, no single solution that can be applied to solve the current crisis. How an answer is implemented is often more important than the answer itself.

So to find a way forward, a future, for general practice, I believe the best place to start is those practices that have made the future a reality already. Rather than starting with a hypothesis and testing whether it will work in general practice, it is better to start with what has worked already and try and capture the learning of how this happened for others. And to this effect we decided to publish a book, one that took real life case studies of what has worked in general practice, and then used those case studies to extract the learning for others.

In the book we have been able to capture the experiences of those who have made operating at scale work, and use these to identify 10 practical steps for other practices to follow. These steps are the difference between practices losing £20,000 each of investment in a new federation that never goes anywhere, to being able to reduce costs, grow income and manage workload better. They are not rocket science. They include things like, for example, ‘being upfront about the commitment needed for each practice’ and ‘ensuring the right motivation’ of each practice who you are going to operate at scale with, but they are critical to ultimate success.

Equally the book contains the same for introducing new roles, introducing new models of care, and it even considers how CCGs and commissioners can have a transformative impact on their local practices. The book starts with the case studies, analyses what they have in common, and distils the learning so that others can do more than find an answer – they can learn how to make the answer work for them.

The Future of General Practice: Real Life Case Studies of Innovation and New Ways of Working is out today (Monday 10th October). You can buy your copy here. The future of general practice requires more than an understanding of what solutions can help. It needs an understanding of how to implement these solutions in a way that will enable a new future to be created. The book provides both.

Community Engagement and Social Prescribing in General Practice

In a guest blog this week, Sheinaz Stansfield, a Practice Manager from Gateshead, gives an insight into how community engagement and social prescribing is making a real difference in her practice. If you want to read more about Sheinaz’s practice they appear as a case study in our new book “The Future of General Practice; Real Life Case Studies in Innovation and New Ways of Working”. The book can be purchased here

It was snowing in Gateshead at 9am on the Friday before the bank holiday. On leaving the surgery I bumped into Jez, a homeless patient, recently released from prison. I was late for a meeting and he followed me out, cold wet and hungry, when he burst into tears. I gave him some money for breakfast and asked him to wait for me in a local café. By this time, I was also cold, wet and very late – but I had a warm car to escape to.

Working jointly with the 3rd sector, the practice had just won some funding to manage people with complex need; those who were too complex for us to manage in primary care, but not complex enough to fit the criteria for other local services. We have many such patients; those who have GP appointments several times a week, because of social issues impacting on their health and cannot possibly be addressed through the health system alone. People who have nowhere else to go.

At Oxford Terrace and Rawling Road Medical Group in Gateshead, our social prescribing is led by two Primary Care Navigators (HCA’S). Having developed an extensive “dynamic” directory of services, they are well respected and known to all of the statutory and non-statutory services within our GP catchment area. Jez and others like him are also known to them and we have worked with a local charity Fulfilling Lives, and won transformation funding (from the local Authority) to test a new model of care. We were meeting that morning to develop a mobilisation plan.

The meeting was attended by our practice based complex care team, who take a patient-centred approach to case management. The team consists of our frailty nurse, care navigators, occupational therapist and community matron. Between us we were able to identify the first half dozen patients for Alex, the co-ordinator. Jez fitted the bill perfectly. I introduced Alex to him as her first patient!

A core component of this service will be to identify peer mentors as volunteers for befriending and support. Fortuitously, my next engagement was a training session for Practice Health Champions. We have 39, who work with us as volunteers leading various groups including knit ‘n’ natter, reading, walking and others. They also host events for patients including a flu fair, summer health fair and an annual Christmas dinner on Christmas day. A new event for this year will be a veteran’s engagement event and a full WW2 re-enactment on 11th November! Such is the power of unleashing energy to connect patients’ skills and passion with staff commitment.

This morning we were welcoming 10 new volunteers into the fold. The training was developed and led by other champions, facilitated by the practice, hosted by a local charity. Therefore, there was no additional cost to the health and wellbeing system. We were connecting local resources, building alliances around patient need and supporting each other to help the most vulnerable and dispossessed people in our community. There is no funding in the GP contracting mechanism for us to do this work, we do it because we care, it adds value and we are passionate about our people.

We have many Practice Health Champions with enduring mental health problems running these groups. Two champions, recovering alcoholics, run the men’s group and the Practice Facebook page. With training and support, they will become our first two peer mentors, for this new service.

My afternoon was spent back at the desk, trying to navigate my way through the tangled bureaucratic mess that is the transformation fund (GP Premises). I was interrupted by a phone call from a neighbouring Practice Manager, wondering how she was going to manage demand with two partners retiring and no applicants for the vacancies. We talked about social prescribing and the complex care team.

At this point I decided to call it a day. At 6pm as I left the practice, one patient was waiting in the waiting room, the sun was shining. Reflecting on my day, I smiled at the patient on my way out, looking forward to the long weekend ahead. My day job as a Practice Manager is full of “bad” NHS rules that block and frustrate most of our attempts to care for people the way they need to be taken care of. Today though, we had made a difference to at least one person, who might have otherwise spent the long weekend on a park bench, tired, cold and hungry.

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What does the NHS Planning Guidance mean for General Practice?

Every year CCGs receive planning guidance from NHS England, which tells them what needs to be included in their local plans for the coming year. In his latest Blog Ben Gowland explains in detail what this latest round of guidance means and why this year is different – and not all good news.

This year there have been a few changes to the Planning Guidance. The guidance has been produced earlier, in September, and plans and contracts are to be complete and signed by December, and cover 2 years instead of one. Each CCG has to produce a local GP Forward View plan by 23rd December (regardless, it seems, of whether they have chosen to take on delegated responsibility for the direct commissioning of general practice or not).

So what can general practice learn from the newly published guidance? The detail it contains (along with the subsequent local plan) was only ever going to be one part of a 3-piece jigsaw – the other two parts being the national GP contract award and the local STP plan. Combined these three will give us a really good picture of what the real impact of the GPFV is going to be in the coming years. But a few things stand out.

For a start, the headline £2.4bn uplift, so prevalent and heavily featured in the GPFV, does not get a mention. In some ways I understand this as the £2.4bn was set for 2020/21 and the guidance is only until 2018/19, but nonetheless it is a concern.

This concern is exacerbated when the starting point for investment is the NHS England 5 year allocations for primary care. The final per capita growth in 2017/18 is 2.41% (compared to 3.16% in 2016/17), an amount that varies considerably across the country (from 0.45% in NHS South Norfolk CCG to 10% in NHS Islington CCG). In 2018/19 it is lower still, at 1.75%. Across the 5 years these allocations create a £1.1bn recurrent investment in General Practice, which on its own will not be enough to increase the general practice share of total NHS expenditure nor keep up with inflation of expenses in general practice.

That isn’t of course the end of the story. What was exciting about the GPFV was the other recurrent £1.3bn that would make up the £2.4bn, as well as a promised £508M non-recurrent package of investment in the meantime. The new guidance contains more details of both of these.

£500m of the additional recurrent £1.3bn was always going to come for access.   What the guidance says about this is that in 2017/18 and in 2018/19 the GP access fund sites (formerly the Prime Minister’s Challenge Fund sites) will receive £6 per weighted head of population. The CCGs without GP access fund sites will receive £3.34 per head in 2018/19, and £6 per head from 2019/20. This isn’t great news for 2017/18, because according to the GPC £6 per weighted head of population is less than the GP access fund sites currently receive, and if you are not a GP access fund site you won’t be receiving any additional access money until the year after.

For this money, CCGs have to commission services 8am-8pm during the week, and at weekends, “provide access to pre-bookable and same day appointments… to meet local population needs”. At least 8-8 on Saturdays and Sundays has been avoided. In capacity terms they must provide an additional 30 minutes extra consultation capacity per 1000 population, rising to an extra 45 minutes.

Where the remaining £800m of the £1.3bn is going to come from is still something of a mystery. The guidance says further investment will come from:

  • Increases in funding for GP trainees funded by Health Education England
  • Increases in funding for nationally procured GP IT systems
  • Increases in the section 7A funding for public health services, which support payments to GPs for screening and immunisation services
  • 3,000 new fully funded practice-based mental health therapists to help transform the way mental health services are delivered

But none of that feels like real money coming into practices. It will be interesting to see whether money will come to practices to directly employ mental health therapists, but if that was the plan I think more would have been made of it by now. But maybe this gap provides an opportunity for investment into the core contract, or into general practice via the STP plans. We will need the other two pieces of the jigsaw to find that out.

This still leaves the promised non-recurrent investment of £508m. The headline here is that CCGs have to find £171m of it from their core allocations (i.e. they haven’t been given any extra money for it), and this equates to £3 per head. This money is to, “stimulate development of at scale providers for improved access, stimulate implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice”. CCGs can choose whether to give this to practices in 2017/18 or 2018/19, or spread it across the two years. The guidance also says CCG funding to general practice should increase beyond the level of their core allocations (2.14% in 2017/18 and 2.15% in 2018/19), but I can’t imagine for one minute cash-strapped CCGs will be able to fund this on top of the £3 per head.

This non-recurrent fund also contains a number of other smaller pots:

  • Online general practice consultation software systems – £15m available in 2017/18 and £20m in 2018/19, specification yet to be shared.
  • Training care navigators and medical assistants for all practices – £10m available in each of 17/18 and 18/19, specification yet to be shared
  • General Practice Resilience programme – £8m available in each of 17/18 and 18/19 (compared to £16m this year)
  • Time for Care national development programme – nationally funded, CCGs to identify a senior local leader

At the same time NHS England will be investing (non-recurrently) in international recruitment of GPs, clinical pharmacists in general practice (3 years funding for practices), and expansion of physician associates, medical assistants and physiotherapists. The bids put forward for capital investment are also being considered.

And that is it. The significant investments are essentially those for access and the £3 a head by CCGs. What we are left with is a sense that the two year planning timeframe could work against practices in areas that don’t have a GP access fund site, and so won’t be receiving any additional access money next year, and whose CCG chooses to invest its £3 per head in 2018/19. For them, unless there is significant assistance coming via the STP plan or the national contract negotiation, 2017/18 could well be an even more difficult year than the one we are currently in.

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5 Steps to Introduce Innovation in a GP Practice

Knocked back at every turn when you try to introduce innovation into your practice? You are not alone. But, in his latest blog, Ben Gowland clears a bit of wood so you can see the trees and presents five steps to introducing change…

Everyone in general practice agrees things need to be different, but as soon as specific changes are mentioned barriers go up. Words from Sir Sam Everington declaring the need for Skype consultations to become the norm in general practice send shivers down the spine of most GPs. Likewise declarations that the traditional partnership model is dead, and that “super-practices” and their ilk must become the new norm.

GPs readily admit the need for change, for innovation, but not Skype consultations or super-practices. Or telephone consultations. Or physicians associates. Or social prescribing (whatever that is).

How do practices wanting to make change overcome this particular problem? In the flat decision-making structure that makes up most GP partnerships, overcoming this type of resistance is especially challenging, because not everyone wants to take risks, not everyone is on board, and focus on the bigger picture easily gets lost.

Let’s take an example: the employment of a clinical pharmacist by a GP practice. Let’s say one partner is particularly in favour, and puts forward the case. Some partners are not going to want to take the risk. They are going to see the (definite) financial outlay with an only probable financial return. Some will be against the idea on the grounds that a pharmacist can’t possibly do the job of a GP (I know they are not trying to, but you can picture the discussion).

The discussion goes on. The longer it goes on, the less it is about tackling the problem of unmanageable workload, and the more it is about whether taking a risk on a pharmacist is a good idea. The vision is lost, and the focus is on the detail. Eventually, after a long discussion by the partners, the practice decides to pass on the opportunity to employ a pharmacist. Everyone still agrees innovation is needed, just not this one.

It is not always like this. I have spoken to a large number of practices that have successfully introduced innovations and changed the way they have done things. I have asked them how they did it, and how they managed to overcome the barriers others could not. I have grouped what they said into 5 steps to introduce innovation in a GP practice:

  1. Don’t start with the solution, start with the problem. Any practice looking to make changes will be doing so for a reason. If the workload is unmanageable, the workload is unmanageable. Focus the initial discussion on this as the problem, and establish a sense of urgency that something must be done. Be clear that no change is not an option.
  2. Develop options. Giving a choice of options empowers decision makers. Listening to the arguments of those against an option can help develop even better options. In our pharmacist example we could offer a range of different roles, or reduced drawings to fund extra GP sessions, or merger with another practice as ways of coping with the unmanageable workload. Keep the focus on solving the problem, not on any specific solution.
  3. Create a critical mass of support. There will nearly always be someone in any GP practice who is against whatever the change is. Once it has become clear which is the best option it may be that those most in favour of the change need to do some work outside of the meetings to firm up support for the change. It is all too common for one all powerful voice to continually veto the introduction of any meaningful change. Where this is happening others need to work together and plan how to get the final approval required.
  4. Create a worked up solution that reduces risk.  A good way of getting the change to happen is to provide a way out, whether that is a review after 6 months or a short term contract before offering a permanent one. At this point the work of those in favour of the change is only beginning. They need to mentor and support the new recruit, manage their introduction into the practice, support their professional development, and problem solve with them. The experience of those who have done this is that 6 months later the practice can’t imagine how it ever coped without the new member of staff in place.
  5. Use one successful change to enable further change. When practices agree to make one big change, and have a positive experience of it, they are much more likely to take a risk on the next one, and make further and further innovations. It is no coincidence that practices who introduce new roles are often larger, building whole system partnerships, and looking for ways to make the new models of care work for them.

Identifying innovations is relatively easy. Getting them to happen in your practice is not. The innovation problem in general practice is not a lack of ideas, but the difficulty of adoption, and of changing the behaviour that goes with it.

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On the Day Demand

We don’t really understand demand in general practice.  The big message from the Kings Fund report earlier in the year, Understanding Pressures in General Practice, was the need to create the ability to measure this demand.  The West of England AHSN published Measuring Demand in General Practice which found,

A lack of research in this area and a lack of continuity in national projects aimed at supporting GP practices to understand demand… Work with GP practices revealed no definitive or widespread approach to measuring demand in primary care. However, it confirmed that practices and CCGs were struggling to cope with apparently increasing demand and were very keen to engage in further activities that might help understand and manage it better.” p3

We do, however, know some things.  We know the population is growing.  We know people are living longer and morbidity is increasing.  We know people are becoming more demanding.  We know there is a GP recruitment crisis.  We know 71% of GPs identify workload as the top factor negatively impacting on a career in general practice.  We know waiting times for an appointment are going up.

Clearly there are no straightforward answers to the challenge growing demand presents, but is there anything that can help?  In the past we had ‘advanced access’ (you can find the evaluation of this here), then came telephone appointments, and more recently based web-based systems, Skype and e-consultations.

I always find starting with the answer to be a mistake.  Better to understand the problem as best we can, and develop solutions from there.  There is a limited capacity (and shortage) of GPs, which cannot meet the totality of the demand.  Demand is rising faster than the population or its underlying morbidity, which means demand is presenting now that previously patients would have managed themselves.  There is a growing cohort of patients with complex multimorbidity.  Continuity of care is needed for some patients but not for all, but is particularly important for this complex group.  All this suggests efforts to access additional or different capacity to meet the less complex demand, and free up GP time to focus on the more complex demand, are those most likely to be successful.

The other place to look is to see what others are doing.  The practices I have seen that are dealing with the pressures best all seem to split demand into two.  They split the demand that presents on the day (on the day demand) from the demand that comes from the management of patients with ongoing chronic conditions, some of whom are highly complex (ongoing demand).  They find demand for the former constitutes a large proportion of the demand on a practice, and they have found different ways of creating capacity to meet this demand.

Some have introduced new roles in to practices specifically to help meet this demand.  Some have gone as far as creating a multidisciplinary team, led by a GP, for this specific purpose.  Some have used joint working with other practices to enable a collective approach.  They have set up ‘urgent care hubs’ or the like to manage on the day demand across multiple practices in one place, with an extended team and a range of roles.  Some have used partnerships with the local community trust, ambulance service or acute trust to access the additional skills and capacity they need to help meet this demand.

Many of these sites have found by making these changes they have been able to free up more GP time for the ongoing demand, for the more complex patients, and some have been able to increase appointment times for these patients to 15 minutes, or even longer.

Changing how on the day demand is dealt with can do two really important things.  It can ease the overall pressure on the practice, and it can create more capacity for GPs to focus on the ongoing demand and provide continuity of care where it is most needed.  The specific changes individual practices choose to make will always need to be tailored to the individual local circumstances.  But the principles behind the changes remain the same: consider on the day demand and ongoing demand separately, find new ways of creating capacity to meet the on the day demand, and this in turn will free up more expert GP capacity to meet the ongoing demand.

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