Does the PACS model mean the takeover of General Practice by the local hospital?

When the new models of care were first introduced in the Five Year Forward View, there was concern in some quarters of General Practice that the PACS model (Primary and Acute Care Systems) could herald the takeover of General Practice by local hospitals. Ben observes that this is far from what is actually happening…

When I read of the Symphony Programme in Yeovil, one of the PACS vanguards, it looked like this indeed was what was happening. A number of local practices – initially 3, then 6, and potentially 10 – were reportedly joining a company, Symphony Healthcare Services, which is wholly owned by Yeovil hospital.

I contacted Dr Berge Balian, a GP and the Chair of the South Somerset Symphony Programme Board, to find out whether the rumours were true, and if so why the local GP practices were allowing this to happen. We spoke, and what I discovered was surprising. He kindly agreed that we could use the conversation as a podcast, which you can find here.

The first surprising point is the focus on General Practice, and developing it to play a leading, sustainable role in the delivery of care, through an enhanced primary care model. This includes incorporating health coaches within practices, as well as extending the care team to include mental health, pharmacy, and therapists.

The second is the starting point for working together: both General Practice and the acute hospital are experiencing the same pressures, of demand, recruitment, and finances. There was a realisation in conversations between the two that by combining they could more effectively meet these problems. As Berge puts it, ‘The ultimate outcome is that the hospital is going to shrink’, as it focuses on doing only what it absolutely needs to do. Working together provides the mechanism for moving resources, whether money or personnel, from secondary to primary care, in ways that could alleviate pressure on both sides.

Berge was an LMC chair. He knows General Practice inside out, and has its best interests at heart. Inspired by the vision of the Chief Executive at Yeovil Hospital he took on a role there as Associate Medical Director for Primary Care. Together with the Chief Executive they began building bridges between the hospital and the local practices. Berge knew change in General Practice starts by building trust, and he recounts 18 months of conversations that they had with all of the local practices, strengthening relationships and ironing out problems. A key part of the battle, Berge recounted, was convincing the practices this was not a clandestine way to negatively impact General Practice.

What happened next was most interesting. A number of local practices became so overwhelmed with their own problems they approached the hospital directly wanting to formally merge with them. The hospital considered this, but Berge wanted to ensure the valuable G/PMS contracts, which are contracts in perpetuity, were protected. As a result, they set up a complicated set of arrangements (under the banner of Symphony Healthcare Services) that means the existing contract is preserved, the organisation is at arms-length from the hospital, it is led by primary care clinicians, and the lead partners have a ‘right to return’ to their original contracts in future.

Impressed by the hospital’s commitment to making this work for General Practice, another 6 or 7 practices have expressed an interest in fully integrating with the hospital through Symphony Healthcare Services. And not just the ones in trouble. As Berge says,

About half are motivated by some challenges they are having, but another half really just see the future of General Practice being in a different model to the historical smaller partnership model.”

The integration of the practices with the hospital is built on what are described as “three pillars”: to preserve the individual identity of each practice; to share administrative and back office functions across the practices and the hospital; and to redesign the healthcare system, through the enhanced primary care model and shifting how care is provided for patients.

When asked about the future, what Berge sees as key is keeping primary care at the centre. His focus is on ensuring that those practices that have chosen not to ‘integrate’ with the hospital will stay at the centre of this work, shaping how resources are shifted from secondary to primary care.

At the end of the conversation I was not left thinking the local hospital had taken over local General Practice. Rather I was impressed by the way the hospital had enabled integration to take place by working to meet the needs of the local practices, and ensuring practices remain in the driving seat.

Three steps to CCGs supporting the development of local locum GP chambers

Ockham Healthcare is running a series of podcasts and blogs on local locum GP chambers because of the impact they can have on an area struggling with GP recruitment. In this second blog in our series Ben Gowland calls on CCGs to do what they can to support their development – but warns against trying to control them.

The idea of having a local locum GP Chambers in the patch can be very attractive for Clinical Commissioning Groups (CCGs). The advantages are clear (see my previous blog “10 reasons why your area needs a local locum GP chambers” here.), and it is a tangible way in which CCGs can be seen to be actively supporting local practices cope with the shortage of GPs.

The challenge comes because the establishment of the chambers lies outside of the control of the CCG. It is not as simple as deciding one is needed, and then charging someone within the CCG with setting one up and persuading a few locum GPs to join to get it off the ground.

This is because the chambers will only work if they are owned by the locum GPs themselves. And for them, the CCG-led model is not attractive. GP locum Dr Caroline Chill puts it like this, “If chambers are controlled by CCGs it makes being a locum less attractive, because it almost becomes a zero-hours contract with the terms and conditions being dictated by the practices using the service”.

All, however, is not lost! The idea of local locum GP chambers is attractive. It is attractive to some existing locum GPs who feel isolated and unsupported, to newly qualified GPs wanting to become a locum, and to GPs working in GP practices who for whatever reason do not want to continue in a specific practice but do not want to stop practicing as a GP altogether.

In all of our conversations with locum GPs working in local chambers, they described how they knew they wanted to be able to locum with peer support, but if they did not already know an existing local chambers they had to search to find out about the model. Unless one already exists locally, most GPs still do not know about them.

Step 1: Publicise the model locally. To start off with, you are unlikely to know who the potential GP members of the chambers will be. The aim is to connect those GPs who would like to be part of a local locum GP chambers (but might not know it yet!) with the idea of it. Publicising the model, and presenting it as something that gives locums control (rather than taking it away) will help make that connection.

Creating something from nothing requires a certain type of person. While some like to join something that already exists, there are those whose preference is to create something new and build it from scratch. It requires a certain level of drive and energy, and from our conversations with members of local chambers it is clear that this generally comes from one individual to start off with, who then draws in others along the way.

Step 2: Identify a leader. In order for the model to take off locally, the CCG will need to use all of its networks and contacts within the GP community to find a locum GP who wants to lead its development. Dr Mark Sage, a GP locum who set up the West Kent chambers, suggested the place to look would be either, “the well-established locums in an area, or the more recently qualified doctors, who are looking for a group they can affiliate with”. He suggested Programme Directors on VTS courses are important contacts, as they know the plans of the GPs leaving the course.

To be clear, this individual is not creating the chambers for the CCG, but for themselves. However, setting up something new is difficult as it requires a leap of faith that it is going to work, and can be challenging for someone who has never done anything like this before.

Step 3: Provide support for the leader. When we spoke to those who set up new chambers about the support they needed or received, this was not financial but rather moral support in terms of encouragement that the new model is going to work. The only practical action they described was help with the business case, in particular establishing the level of demand for locums from each of the local practices so that the newly formed chambers could be clear there would be sufficient demand for their business. Every chambers has since found that demand far exceeds the capacity they can provide!

In conclusion, it is clear from our research that, whilst successful locum GP chambers cannot be set-up nor controlled by a CCG, every CCG has a role to play in creating the environment in which they can flourish.

The future of General Practice is a jigsaw – will all the pieces fit?

I am worried. I worry that the General Practice Forward View (GPFV) does not fit with everything else that is going on. I worry that while on the one hand there is a small national team desperately trying to do the right thing by General Practice, most people haven’t even read the key document.

Recent events (and not just the obvious) have compounded my fears. Two things have happened. First the new CCG assessment and improvement framework has been published. It is not a fun read. The upshot of it is that there are 57 indicators across 29 areas by which CCGs are going to be assessed. One of these 29 areas is primary medical care, and it has a total of 4 indicators. These are:

  1. Management of long term conditions: unplanned hospitalisation rates for patients with chronic ambulatory care sensitive conditions.
  2. Patient experience of GP services: weighted percentage of people rating their experience of GP services as “fairly good” or “very good”.
  3. Primary care access: percentage of practices within a CCG where patients have the option of accessing pre-bookable appointments outside Monday to Friday 8.30am to 6.30pm. Access may be through a hub or federation rather than the individual practice.
  4. Primary care workforce: number of GPs and practice nurses (full time equivalent) per 1000 weighted patients by CCG.

I won’t waste the next 500 words explaining just why these in no way reflect the ambitions for General Practice outlined in the GPFV (but feel free to get in touch if you want the debate!). Suffice to say the measures by which CCGs are to be judged do not reflect the GPFV stated intentions around investment, workforce, workload, infrastructure and care redesign. Instead it is two steps backwards with tired measures that feel increasingly distant from the reality of most GP practices.

Second is the growing role of Sustainability and Transformation Plans (STPs). Recent guidance on STP allocations stated that this funding, “represents the full amount of funding expected to be available for local health systems from all sources in 20/21. They include an indicative fair share of the sustainability funding, primary care access and transformation funds, and other transformation funds including technology…. This includes taking forward the programmes set out in the General Practice Forward View and delivering extended GP access.”

The guidance goes on to say, “STPs will be the single application and approval process for being accepted onto programmes with transformational funding from 2017/18 onwards. Phasing of funding by areas in years 2017/18 – 2019/20 will be subject to consideration of STP plans submitted and subsequent decisions on how to target and deploy funding”.

The implication is that the financial plan for investment in General Practice actually sits within the local STP plan. While this contains a certain logic, the risk of the General Practice funding not finding its intended target becomes much higher. There is already guidance about the requirement of STP money to be passed through to acute providers, alongside a paucity of core General Practice provision representation in the development of STP plans in many areas.

The GPFV can’t sit in splendid isolation. It needs ownership across the system. It has to be the basis for how CCGs and primary care commissioners are assessed. It has to become the framework for local investment in, and the development of, General Practice. It has to materially impact local STPs. When we see the STPs we will find out exactly how reflective they are of the GPFV, and I really hope I will discover I have been worrying over nothing.

10 Reasons Why Your Area Needs a Local Locum GP Chambers

Locum Chambers are groups of local locum GPs who work together through a shared management structure to support GP practices in a local area. If your area does not have one, here are 10 reasons why you should! Local locum GP chambers:

 1. Keep local GPs in the local system. Many GPs are leaving because of the stress levels in General Practice. Local GP Chambers create an opportunity for GPs who simply want to be able to focus on seeing patients to be able to do so without the pressure of working in a specific GP practice. They also provide peer support, and remove the burden of booking and invoicing that becoming a locum entails. In a recent survey by the National Association of Sessional GPs (NASGP) a number of members commented they would have left the profession altogether had chambers not existed.

2. Offer an accessible route back into General Practice. Similarly, there are large numbers of GPs who have already left because of the pressures they were experiencing. Operating as a locum within a chambers allows GPs to take more control over their workload and work-life balance, without the isolation that some locum GPs experience. As such, it offers an accessible route back into General Practice for those who may consider a return, but are concerned about operating independently as a locum.

3. Attract locum GPs to your area. Finding a locum is becoming increasingly difficult. A 2015 BMA survey reported that 46% of practices have trouble finding locum cover ‘frequently’. Local locum GP chambers establish a group of locum GPs to work in your local area. As the chambers grows the availability of locums for local practices improves.

4. Improve the quality of local locum GPs. Traditionally the quality of locum GPs is variable. However, local locum chambers build in audit, education, peer support and complaints procedures to enable quality and performance to be monitored and continuously improved. They also make appraisal and revalidation much more straightforward.

5. Enable locum GPs to be effective quickly in each local practice. Local locum GP chambers develop systems to make it easy for each of their locum GPs to get to know the different ways of working in each practice. One of the biggest challenges facing a locum GP is to become effective quickly within a new environment, and by working with a specific number of local practices the chambers is able to share information and support its members to do just this.

6. Ensure locum GPs operate as part of the local system. The only system interactions that many locum GPs have is with the individual practices they support. A local locum GP chambers provides a contact point between the CCG, the local healthcare system, and the locum GPs. This means that where new systems, such as new referral pathways, are introduced, the local locum GPs can be informed and be part of the process of implementation.

7. Reduce expenditure on locum GPs. Chambers are entirely funded by charging each member a percentage of their income, instead of charging the practice. There is no additional agency fee that is incurred. Locums from GP Chambers are typically 25%-40% cheaper than the those accessed from agencies.

8. Make finding locums GPs easier for local practices. Chambers provide an easy point of contact (usually one email) that results in a high quality locum attending at a set price. This is stark contrast to the experience of many practice managers, who can spend hours and even days chasing and negotiating with agency after agency to try to find a locum.

9. Allow local systems to access the talent and skills of locum GPs. Locum GPs have plenty to offer local systems. They have a unique perspective as they have seen first-hand how many of the different practices within an area operate. They can identify and facilitate the spread of best practice between practices. In many areas locum GPs from local chambers have even taken up leadership positions within the local CCG.

10. Create an opportunity for partnership working between the CCG and the local locums GPs. Where a local locum GP chambers is established, CCGs can explore with them ways of working together to strengthen local delivery of General Practice. This can include support for specific GP practices, targeted support for local General Practice at busy times, and even enabling the CCG to ensure support is focussed on the local GP practices that need it most.

We need a Financial Plan for the GP Forward View

Increasing GP cynicism about the Government’s Forward View is understandable, argues Ben Gowland and, without a clear financial plan, the criticisms can only increase.

There is a growing temptation for many GPs following the recent criticism of the GP Forward View (GPFV) to dismiss it completely. However, the GPFV is a published policy document by NHS England. It makes many promises. Regardless of whether or not you believe the promises to be sufficient, they are real, written down promises. As such they need to be identified, monitored and those who made them held to account for keeping them. Especially the financial ones.

The complexity of the GPFV makes unpicking these promises, in particular the financial ones, very difficult to do. The RCGP has recognised the importance of this task, and has taken steps to establish what financial promises have actually been made to General Practice, and in particular how close these come to the RCGP’s campaign for General Practice to receive 11% of NHS funding (you can find this here).

What financial promises have NHS England actually made? What can we monitor and hold NHS England to account for? Ultimately there are only two that I think we should focus on: the promise to increase recurrent expenditure on General Practice by £2.4bn a year by 2020/21; and the (separate) promise to create a £508m “Sustainability and Transformation Package” that will be invested between now and 2020/21.

It is stated in black and white headline terms that recurrent funding for General Practice will increase from £9.6bn a year in 2015/16 to £12bn a year in 2020/21. It is not, however, broken down. The financial plan is missing. This I suppose provides room for manoeuvre, but at the same time is leading to confusion, mistrust and the growing lack of enthusiasm for the whole document.

The text does not help. One headline says that the £2.4bn “includes capital investment amounting to £900m over the next 5 years”. How can it? The capital funding is non-recurrent. The promised £2.4bn is recurrent. Even the one year share of the 5-year capital pot in 2020/21 would presumably have to be replaced or matched the year after anyway in order for it to be classified as recurrent.

And what do you make of this statement on p12, “The additional investment we are making in introducing new care models will benefit general practice too – and this will ensure investment rises at least in line with the plans set out above, and potentially even more.”? Does it mean any extra money from the transformation fund is part of the additional £2.4bn, or is it in addition to it? The RCGP sought clarification on this very point and were told by NHS England that it is additional. By the RCGP’s calculations this means General Practice will be receiving an additional amount between £561m and £842m extra (depending on whether you think General Practice will receive a “conservative” 20% of the Transformation Fund or an “optimistic” 30%) by 2020/21. For clarity, this is on top of the additional £2.4bn.

Suddenly the RCGP’s enthusiasm for the GPFV becomes a bit clearer. The money that is needed has really been promised.

But will it materialise? Really, will it? We hear talk of a national ‘reset’ of NHS finances. The funding problems in General Practice are often lost in talk of huge acute provider deficits. Every day we hear reports about the impact of continuing PMS reviews and cuts, alongside the ongoing removal of MPIG. If this level of extra funding was really coming, wouldn’t the approach shift to one of reduced growth payments as opposed to actual cuts? CCGs, even those with the most delegated of primary care commissioning budgets do not know when this funding is coming, how this funding is coming, or what this funding will look like. Can you blame practices for not sharing the enthusiasm of the RCGP?

We need the financial plan. NHS England would not accept a plan from a CCG without the financial plan attached, and General Practice must insist on seeing the financial plan that underpins the GPFV. NHS England needs to do this to build confidence that it will deliver what it has set out in the GPFV. General Practice needs it so that it can hold them to account for doing just this.

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