The Independence of General Practice Series – 5

Throughout August we’ve run a series of blogs where Ben has considered various aspects of the independence of general practice. In this fifth and final blog in the series he asks

Is operating at scale necessary to protect the independence of general practice?

There is something counter-intuitive about the notion that practices would operate at scale to protect their independence. Many GPs resist any notion of operating at scale precisely because of the restrictions they feel it places on their autonomy. The perceived wisdom is at-scale general practice is a step away from independence, not a move towards it.

But is it? I was struck by the tale of the practices in Wolverhampton. Recently a ninth local practice has handed over its list to the local hospital trust there, taking the total population now under the hospital’s control to 70,000. Now, I am not close to what is happening in Wolverhampton but local GP leaders said the GP partners were motivated by financial ‘non-viability’ and workforce shortages, with the move viewed as ‘handing over the problem to someone else’.

One of the practices put this on its website as it announced it was joining the hospital, “Without the help of The Trust we would definitely have left and would have had no option but to close the practice and split our list up amongst other local Practices. The Trust have been able to find us new Partner GPs, a new site and the funding to refurbish it into a modern GP Practice.”  The local practices, it seems, felt like there was no alternative.

I am sure everyone reading this is aware of the pressures currently facing general practice. Those pressures are not going away. There are no new GPs. Demand is continuing to rise. The financial pressures remain significant. At some point, almost inevitably, practices (like those in Wolverhampton) will reach the point where they decide to hand over the pressure of running the practice, to let someone else take on the responsibility, and to simply focus on the patients in front of them.

In a period of sustained pressure on general practice, where salaried doctors are increasingly earning more than the GP partners, more and more practices will reach this ‘enough is enough’ point. And if the local hospital, or community trust, or whoever, offers to take on the responsibility, increasingly practices will make the decision to trade their independence for the relative security and simplicity of salaried life.

If we take the practices in Wolverhampton back 3 or 4 years, would they have made the same decision then? Could they have envisaged then that things would get to the point where this was the choice they would make? And if they had known this would happen would they have chosen to do things differently?

But what could they have done? Well, the opportunity that practices working together (“operating at scale”) presents is for practices to support each other, and to work together to tackle the workforce, demand and financial pressures all are experiencing.

Here is the irony: practices resist operating at scale in the name of keeping their autonomy, but by doing so are keeping themselves on a track that is taking them to the ‘enough is enough’ point when they will hand their list over to whoever will take it. The status quo is unlikely to remain an option for much longer. However counter-intuitive it feels, it is choosing to work together with other practices that is most likely to protect the independence of general practice.

The Independence of General Practice Series – 4

Throughout August we’ve been running a series of blogs dedicated to the independence of general practice. In this fourth blog Ben looks at why independence matters.

At-Scale General Practice Must Stay Independent

The BMA has found GP practices with a higher CQC rating earn more income. My PhD wife regularly pulls me up for mistaking correlation with causation, so I wonder whether outstanding practices earn more income (i.e. the cause is that they are outstanding), or whether they are outstanding because they receive more income (i.e. the cause is that they receive more income)[i].

More research is required to test these hypotheses, but my money would be on the former. I know many areas where the opportunity for income is equal across practices, yet the better practices earn more (through better recovery of QOF income, through delivery of a wider range of enhanced services, and through private income streams).

So in the independent world of general practice, the practices that provide a better service to patients earn more money, while the less well run practices earn less. Independence, of course, means there is no bail out. The risk sits squarely with the GP partners as business owners. Compare this with those leading statutory bodies, such as CCGs. They will earn the same amount of money regardless of how well the CCG does. Salary is not linked to performance. There is no meeting with the accountant where the slow realisation descends on all of the partners that they are going to have to take a pay cut. Instead the CCG goes into deficit and money is spent on management consultants to “help” the CCG get back into balance.

I was fortunate enough recently to spend some time learning about how the system of general practice works in New Zealand. There, a key component is that each practice is part of a network. These networks are not statutory bodies. They were formed by practices nearly 30 years ago, essentially as a protectionist manoeuvre by practices, and their purpose is to strengthen and improve general practice.

The great thing about non-statutory bodies is that they cannot be abolished or reorganised. While in this country we have seen PCGs, PCTs and now (probably) CCGs come and go, in New Zealand over the same period the networks have been constant. They have been able to adapt and thrive over that time, and provide better and better support to their member practices. Indeed, the government has even channelled the contracts for practices through the networks, enabling the networks to take on the role of improving quality across their member practices.

I was the Chief Executive of Nene Commissioning, one of the leading practice based commissioning groups. We were a non-statutory body, but we worked with the PCT, with our member practices, and with many others to drive some impressive innovations across the system. With the advent of CCGs we transitioned into a statutory body. There is no doubt in my mind that becoming part of the NHS system, hounded by layers of hierarchy and regulation, strangled the innovation out of the organisation. It is precisely because CCGs are statutory bodies that ultimately they have not been able to fulfil their promise.

Meanwhile the networks in New Zealand have thrived and continued to innovate. Pinnacle, one of the leading New Zealand networks, has developed an improvement programme for its member practices. It funds it itself, it tests it on practices that it directly manages (the equivalent of our APMS contracts), and is working with its members to make them fit for the future. Not because it has to, not in response to a government initiative, but because its role is to strengthen and improve general practice. It only answers to its member practices, and because it is independent it cannot be abolished or reorganised.

This is an important lesson for us. Moving to at-scale general practice in many areas is the right thing to do. But finding ways to do it that maintain the independence of general practice, and the independence of any at-scale organisations it creates, is absolutely critical. Independence rewards success, and penalises failure. It fosters and encourages innovation. Most important of all, it creates stability and strength for the long term.

[i] My wife informed me after reading the blog I had missed out a third option: that there might be other variables affecting both results. I have vowed never to do a PhD.

The Independence of General Practice Series – 3

This is the third in a five-part series of blogs discussing the independence of general practice. This week Ben looks to the Nigel Watson-led review of the partnership model and considers the possible threats this poses to that independence.

Why the review of the GP partnership model makes me nervous

In February Jeremy Hunt announced there would be a review of the partnership model of general practice, and that it would consider “how the partnership model needs to evolve in the modern NHS”. This review makes me nervous.

The number of GP partners is falling. As all practices are only too well aware, the number of applicants for a GP partner post has fallen dramatically, with many adverts not attracting a single serious application. General practice has to be attractive to the GPs of the future. The review will need to look into this, and discover nuggets such as “the prospect of unlimited personal liability in a hugely under-funded sector has limited appeal to new GPs”.

I am nervous about this review because it is very easy to conflate the issues facing general practice as a whole (the workload, workforce and financial pressures) with the partnership model. It is easy to imply it is the partnership model causing the challenges rather than the historic underfunding etc. etc. Correlation, regular readers of this blog will recall, is not the same as causation. If general practice was still receiving 11% of NHS expenditure would we still be having this review?

A review of the partnership model is also a review of independent contractor status. General practice is currently very difficult to control. The independent contractor status affords it an ability to act only according to what is negotiated within its contract. Changes to NHS rules don’t directly affect it. Persuasion rather than coercion is required, and for politicians seeking rapid change in general practice I can imagine this is hugely frustrating.

There is a widely-espoused view that the small business, or “corner shop” model of general practice is no longer fit for purpose. As the NHS seeks to move into a world of integrated care a new, bigger version of general practice is required that can partner with the rest of the system. Most sectors of the NHS can be instructed to actively participate in integrated care arrangements (or individuals moved on), but not so general practice. The sheer number of practices is making progress painfully slow, and there is no direct command lever that can be pulled to make integration happen any faster.

However, size and form are two different things. GP partnerships, operating as independent contractors, can operate at any scale. They are not limited in size. Our Health Partnership has done an admirable job of demonstrating how the partnership model can work at a population scale of over 300,000. Conflating the relatively small size of general practice organisations with the partnership model of general practice when they are two distinct issues is, at best, unhelpful.

The review makes me nervous because although the partnership model does not need to change for general practice to operate at greater scale, it does need to change if the system is to exercise greater control over general practice.

The only thing making me less nervous about the review is the appointment of Dr Nigel Watson, Chair of Wessex LMC to lead it. He appears to be a supporter of the partnership model. He recently said,

“My personal view is that the partnership model has not reached the end of the road, it can still have an important role to play in the future of the NHS but we need to make it a better place to work, which will encourage more GPs to remain working in general practice, address the concerns about the unlimited personal liability and with the move to a more population based approach to healthcare ensure that general practice is truly able to play a leadership role in the local NHS.”

The review does indeed need to consider these things, and build on the strengths and freedoms of the partnership model as it looks to the future. Let’s hope my nervousness (and, I admit, my cynicism) is unfounded.

The Independence of General Practice Series – 2

This is the second in a series of five blogs where Ben is considering the issue of independence in general practice. This week he looks at the distinction between statutory bodies and independent contractors and asks whether the difference is of any consequence.

Can independent contractors be trusted?

During the 2017 Christmas holidays, when you would have thought attention may have been focussed elsewhere, there was something of a debate as to whether organisations that are not NHS statutory bodies, but rather ones that contract with the NHS, can be trusted.

The debate focussed on the pre-cursor of the new favourite (Integrated Care Systems) which was Accountable Care Organisations (remember them?). For example, Dr Phil Hammond, a doctor, radio presenter and NHS commentator, said,

“I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver.” (via Twitter, Jan 1st)

Unfortunately, this debate brought the position of both GP practices and GP federations under the spotlight. If this is true for Accountable Care Organisations, is it not also true for GP organisations?

There is a fine line between being in the NHS and working with the NHS. Back in 1948, amidst the protracted negotiations required to start the NHS, a deal was brokered whereby GPs would not become salaried employees, but rather remain independent, providing services via a national contract with the NHS. This means GP practices provide NHS services, but are not NHS organisations, and “independent contractor” status was born.

Does the distinction between a statutory body and an independent contractor matter? At first it mattered little, but times have changed since 1948. In the 1980s the Conservative government privatised some of our national industries, including steel, railways, airports, gas, electricity, telecoms and water. Although the NHS survived the cut, the purchaser provider split was introduced in 1990. Ever since, fears have remained this was the first step in a plan to privatise the health service, and anything not a statutory NHS body is treated with suspicion.

Over 25 years later, we now approach the end game of the purchaser provider split, in a strange closing manoeuvre whereby the Health and Social Care Act of 2012 seemingly opened the NHS up to more competition, but in practice the NHS itself has closed competition down with a focus on integration through the Five Year Forward View. Fears that accountable care organisations were a Trojan horse to enable the privatisation of the NHS led to their re-badging as integrated care systems.

At some point these integrated care systems will take on a population budget. It seems that rather than allow them to do this as “independent contractors”, the government is prepared to legislate to enable new types of statutory bodies to be created.

Where does that leave general practice? Is the current review of the partnership model an attempt to shift general practice from independent contractor into some form of statutory body status? Are the new, semi-mandated GP networks the first step towards groups of GP practices as statutory bodies? Will the public tolerate at-scale GP organisations that are not statutory bodies, or will the anti-ACO sentiment shift its focus towards federations and the like?

The currency of the new world is trust. People trust their GP, more than they trust their local NHS organisation, and much more than they trust national (statutory) NHS organisations. Being a statutory part of the NHS won’t make the public trust GPs any more. Our experience of CCGs should at least teach us that. My sense is the benefits of being independent (to GPs and to the delivery of health care) outweigh the costs and challenges.

GP practices know it is not the technical difference between an NHS statutory body and an independent contractor that matters, but rather what they do, and the trust they build with the people they serve. The same will be true for at scale general practice organisations. And for integrated care systems. Ironically, it is the relationships integrated care systems develop with their local (independent contractor) GPs that may determine how much their local population eventually choose to trust them.

The Independence of General Practice Series – 1

Ben Gowland introduces an exciting new series from Ockham Healthcare:

In the last couple of years I have written a few articles about the independence of general practice.  The current review of the partnership model being carried out at the behest of government, which is considering what has been the bedrock of general practice for so many years, will inevitably have to consider the issue of independence.  This prompted me to bring together and update what I have produced so far, along with some new thoughts, to create an autumn series of articles on this topic.  Over the course of 5 articles throughout August I will consider the threats to the independence of general practice (from within general practice, from the wider system, and from the review itself), reflect on its importance, and identify what might be needed for it to be preserved.”

In this first blog Ben considers the impact that fewer and fewer GPs choosing to become partners will have on the independence of general practice:

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 an answer in itself to the challenges facing practices. It will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Independence is not a cause of these 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. The number of “zombie practices”, where the salaried GPs earn more than the partners, is reportedly on the rise. 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, by not choosing to be partners are choosing for general practice to relinquish its independent. But I believe that is exactly what 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.

Nigel Watson is leading a review of the GP partnership model. My sense is we need to make becoming a GP partner more attractive. We must provide more training and preparation for GPs who do want to take up the challenge of becoming a partner. 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. With or without the review, unless we take action now, general practice will lose its independence.

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