Ockham Healthcare: Supporting innovation in General Practice

General practice at the precipice

According to a recent article, in as many as 1500 practices (nearly 20% of all practices) the partners are earning less than the salaried doctors. If this is true (and I have no reason to suspect it is not), then it means the business model that has served general practice for so many years has finally run its course.

If salaried GPs earn can earn more than partners, without the responsibility, risk or workload of being a partner, then there is very little incentive for GPs to become partners. Instead there is a strong incentive for existing partners to become salaried.

But the existing business model requires partners in order to continue. If all GPs choose not to be partners, no one is left running the business. The obsessive focus on the total number of GPs is blinding us to the critical demise in the number of GP partners.

There are two schools of thought as to how this developing crisis should be handled. One is to take the line that GP practices are in fact private businesses, and that the NHS should leave it to the market to resolve the challenges of ownership. If GPs no longer want to run their own businesses, then let’s see who does. This will leave us with a smorgasbord of private providers (Virgin and the like), acute trusts (building on the example in Wolverhampton where the acute trust is now running a number of practices via APMS contracts), community trusts (like the Willow Group, in Gosport, Hampshire), general practice “chains” (such as Modality and Lakeside), alongside general practice operating within the new MCPs and PACS of the new models of care.

Is this the future we want? Attempts to introduce a market to the NHS have not impressed to date, and it is hard to believe this diaspora of provision will serve the population well, and provide a solid foundation for the delivery of transformed out of hospital care.

The second school of thought is that there should be some form of intervention. This would require a clear definition of what current/future sustainable general practice looks like, including the business delivery model, and support provided for this to be delivered. We change the model of general practice in order to make partnership attractive again.

The impact of the GPFV has been limited because it has lacked a clear vision for the future of general practice. It has shied away from defining what the future needs to look like – presumably in an attempt to preserve the autonomy of practices (or even the market) – and has not been brave enough in its delivery of support (practices can choose the bits of support they want from whom they want etc).

This is in stark contrast to the Midlands Health Network in New Zealand. Their response to the challenges facing general practice was a to create a very clear model of care, that included patient call centres, a different skill mix, use of technologies, and improvements to the business model. They recognised the management skills in practice were primarily in operations rather than in transformation, and so they provided support to their member practices to introduce the changes over a six month period.

Helen Parker, one of the local leaders, describes this process in more detail here. They called the programme the Health Care Home and practices have to graduate to become a Health Care Home (they can’t simply decide to be one). The programme is systematically creating a sustainable future for the member practices.

The current model of general practice is at the precipice and hanging on by its fingernails, and it won’t be long before it lets go altogether. Carrying on the way we are now is a default decision to allow the market to decide the future form and structure of general practice. Instead, action is urgently required to create our own version of the Health Care Home, to support practices to implement it, and to preserve and strengthen the general practice service that forms the cornerstone of our NHS.

Guest Blog – My Introduction to Collaborative Working

Liz Carter is a Locality Manager for NHS Horsham and Mid Sussex CCG. In a guest blog this week she writes about her experiences in trying to develop collaborative working between practices in Haywards Hearth and Burgess Hill – and how she was supported by Ben Gowland and the Ockham Healthcare approach…

I joined both the NHS and Horsham and Mid Sussex CCG in September 2016, having spent most of my working life as a Partnership Manager in a Local Authority. I was to be the new Locality Manager for Haywards Heath and Burgess Hill. At first, I was keen to get started on introducing the Primary Care Home / primary care at scale approach to Haywards Heath and Burgess Hill.

The plan seemed simple enough: bring groups of practices together (with a combined population of between 30,000 – 50,000) and enable them to work collaboratively to address the health needs of the local area.   The practices would benefit from the potential to address common workforce and capacity issues, share best practice, and look at how the new extended access requirements could be met.   The plan also seemed to make perfect sense. This collaborative approach would enable the newly established Communities of Practice (extended primary care teams) to wrap around the practices, providing a joined up approach to health and wellbeing which would ensure that the patient receives the right care from the right person in their town, and GPs could find some breathing space.

And then reality hit. What looks like a sensible plan on paper isn’t necessarily perceived in quite the same way by all!

Ben Gowland was employed by the CCG to support the process of collaborative working and was asked to support the practices in Burgess Hill. When I met Ben I was under some pressure to describe how the towns I work with were planning on meeting the extended access requirements, so I thought that would be the hook we would use to engage the practices. After all, they needed to do it, we needed them to do it, and Ben could help us scope how they’d do it. Again, simple and sensible.

But no, it appears that’s not what works. Ben is against rushing in with ready-made solutions. He avoids the straight forward, ‘here’s the pressing problem and this is the solution’ approach. I learnt that we needed to start with what matters to the practices, not what matters to me. We needed to listen. We needed to understand. We needed to know what they wanted to achieve. We needed to know how they thought they could achieve it.

So how do you do that? We met with all of the practices on an individual basis and talked and listened and reflected back to them what they had said.   We then identified the common issues the practices were facing and provided an opportunity for them to share these issues with their neighbouring practices. This process of building trust and relationships takes time but can’t be bypassed, whatever the CCG deadlines.   The practices met and shared information, and in so doing built new relationships. They considered the common issues they were all facing which gave them a reason to work together. They looked at who was best placed amongst them to drive this work forward and together they chose one Partner from one of the practices and his Practice Manager (paid from the CCG locality budget) to draft a business plan for the town.    Whenever there was dissent or concern, they were brought back to the common issues they had all agreed were troubling them.

During this time I regularly reminded Ben of the CCG deadlines and felt quite anxious about the passing weeks and months. But the end result is that the town identified its own issues, found a common reason to change (not one necessarily based on CCG priorities), identified people within the town to drive it forward, and a way to keep plans on track when there was disagreement. And you’ll never guess what? One of the issues that was highlighted and resolved by the town was how it would address the extended access requirements!

And if you’d like support with introducing collaborative working, don’t forget our Podcast this week which you can find here and information about a new training programme we are running with Kaleidoscope Health which can be found here.

Without GP partners, general practice will lose its Independence

For me, one of the biggest strengths of general practice is its independence. It contracts with the NHS, but is not part of the monolithic NHS structure. For some this may feel like a technical difference (after all GP practices can still access the NHS pension, and they are funded with taxpayer money) but for someone who has spent 20 years working in the NHS like myself the difference feels much more fundamental.

GP practices are bound by the terms of their contract with the NHS. But within the boundaries of those terms they are free to innovate, make changes, and take whatever decisions they want to improve care for their patients and the working lives of their staff. This is in stark contrast to NHS organisations that are bound by NHS-wide restrictions, ways of operating and approval mechanisms that often stifle innovation and directly impact on culture.

It is now widely accepted that GP practices require more money – whether they are funded directly or through a contract. Moving away from the independent contractor model is not the answer; it will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Their independence is not a cause of those problems, but rather is the only reason GP practices have been able to continue the way they have despite the current pressures.

Yet, sadly, the independent contractor model is teetering on a knife’s edge. I visited a practice recently that a year ago was a relatively stable, well-run, 4 partner and 7500 population practice. Within the space of two weeks two of the partners resigned. One was retiring, and one was emigrating to Australia. A few weeks later a third declared they were also resigning as they wanted to become salaried. This left a single GP, who had neither the skills nor the desire to be the sole partner of the practice. She wrote to the CCG informing them of the situation and declared that if a solution was not found she would be forced to hand back the list.

This scenario and others like it are being played out throughout the country. The inability to recruit GP partners is rising to the top of the challenges facing GP practices today. Every resignation of a GP partner creates panic within practices, a sense of being trapped, and a fear of being the one left carrying the costs of closure.

The recent push to secure 5000 new GPs, whilst unlikely to be achieved, has brought new GPs into the profession. But many of these GPs are choosing part time or portfolio careers. The competition for new GPs is pushing up the pay for salaried GPs. The new extended access and A&E based services provide well-paid, flexible alternatives for new GPs, further increasing the challenges of recruitment for practices.

The risk is that, unconsciously, we are creating a system that rewards salaried GPs and punishes GP partners. By not intervening, general practice as a profession is risking its independence. Without GP partners, there are no businesses that can deliver against the contracts, no practices as we know them today. The NHS will have to directly deliver the service. Once independence is gone, it will never be regained.

I do not believe GPs, even new GPs, would actively choose to give up their independence. I believe it is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

We need to make becoming a GP partner more attractive. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. In a tougher financial environment, we need to make sure GPs are given training and support to be confident to take on the challenge of becoming a partner. The one afternoon designated in the current GP training programme is insufficient.

Here at Ockham we are taking a step (albeit small) to fill this training gap. On Tuesday July 4th at 7pm we are holding a free event in Central London on being a GP partner. Join us in person or on twitter (#gppartners) – find out more details of this unique event here. Unless we take action now, general practice will lose its independence.

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