10
may
0

The impact of the new models of care on general practice

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“Remind me what they are again” the GP responded. I was asking what his thoughts were on the new models of care. I jogged his memory with a few choice acronyms (MCP, PACS, PCH etc). “Oh those. Hard to say really…”. He trailed off, interest clearly waning, and then visibly winced as he saw the message on his screen indicating the number of patients waiting to be seen.

The concept of new models of care has not really taken off as a driving force for change in general practice since they were first proposed in the five year forward view (5YFV) in 2014. Certainly not within the specific frameworks outlined within that document. Frankly, general practice has been too busy. But some of the principles underpinning the models can be seen in some of the recent developments in general practice.

The relative isolation of GP practices has changed more in the last few years than at any point in its history. Practices are far more prepared to work with each other. We have seen mergers, super-practices, federations and networks proliferate. Practices are also more willing to work with other health and social care organisations, in particular those from community and voluntary sectors. A team based approach is both building resilience and creating a more attractive proposition for incoming staff.

Practices are also far more open to reviewing their governance model. The pressure the partnership model places on individual GP partners has led many to explore other options. There has not been a wholesale move away from the GP core contract in the way that maybe some envisaged when the 5YFV was published, but the desire to retain the “independent contractor” status is no longer as strong as it once was. We may well have only seen the beginnings of the rise of at-scale general practice entities like Modality, Our Health Partnership and Lakeside, as well as acute/primary care collaborations like those in Wolverhampton and Yeovil.

General practice has also shown signs of wanting to tackle the wider determinants of health, rather than simply meeting the ever-increasing presentations of health concerns. There is a dawning realisation that something has to be done to tackle the drivers of demand growth. This sits under much of the primary care home movement, and places like Fleetwood are leading the way in taking this on.

These changes have been framed far more by the challenges the profession is experiencing than by the 5YFV. If I had asked my GP colleague about the impact of the pressures on general practice in recent years, rather than about the new models of care, he would have been much more forthcoming.

But moving away from crisis can only be half a story. We know what we are moving away from, but where are we going? What will be the impact of the new models of care going forward? Do they offer a destination for the journey on which many have already embarked?

The emergence of STPs is the current manifestation of the 5YFV implementation. There is something of a battle around size within STPs, when it comes to integrated care systems. Is the local model to be built around primary care home sized units of 30-50,000 as the focal point of change efforts, driving improvements to health as well as health care in local communities? Or is it to be driven at STP level or acute hospital sized units, with primary care homes operating as sub-localities of sub-localities, languishing at the bottom of the health ecosystem? In many places both are still possibilities, but the window of influence isn’t going to stay open for long.

Much of this depends on voice. There is a challenge for general practice to create a coherent and cohesive voice for general practice as a provider within the STP arena. Some places (like Manchester) have worked hard to create this, but for others the primary care seat is still empty. Without a voice, let alone a unified one, it is hard to see the impact of the new models being a positive influence on the future of general practice, despite the opportunity they represent.

2
may
0

Why is the GP Forward View not working?

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It is now two years since the publication of the GP Forward View (GPFV). Do things feel any better? Not for most GPs. In a recent Pulse survey 80% reported their workload had worsened over the last two years. So why has the promised £2.4bn recurrent investment, with all the trimmings alongside, failed to have any impact so far?

Looking back, I wonder what the GPFV was. Was it a strategy document? Not really, because there was no clear sense of direction. A recovery document for a service in crisis? Maybe, although it was written at arm’s length from GPs as providers. I think it was a commissioning plan, or commissioning intentions at a stretch. It was what NHS England, and the CCGs, would do to support a service in crisis. It was also a public, political document designed to demonstrate the concerns of GPs had been heard and were being addressed.

Understanding what the document was gives an insight into why it is not working. The headline investment figure of £2.4bn was an overstated figure. The real five-year investment plan was under £1bn. But the figures were extrapolated back to 2013 (the details are here) to inflate the figure to £2.4bn. Promising more than is going to be delivered is a sure-fire recipe for underwhelming results.

A cynical view of the document is that it was also a very clever way of packaging the extended access agenda to make it palatable to GPs, at a time when many were close to breaking point. While the share of funding for general practice within overall NHS expenditure has not really changed, the challenges of GP recruitment have not been addressed, and workload continues to rise, the one clear “success” of the document is that extended GP access is being introduced across the country. Ask any CCG which of the targets in the GPFV they are most closely monitored on and they will tell you it has been all about access. While the problems in general practice have not been alleviated, the government’s primary agenda for the service is being delivered.

There are some good things in the GPFV. The Releasing Time for Care programme and the work of Robert Varnum on the 10 high impact actions, which I admit I was initially sceptical about, I now think is possibly the most impactful part of the document. Practices changing themselves is the only realistic way out of the crisis, and this programme empowers and enables practices to do this. The support for indemnity looks like it is heading in the right direction, and the funding for new roles such as pharmacists has definitely helped.

But the reality is the workforce crisis persists (1,300 full time equivalent GPs left between September 2015 and September 2017), the workload continues to grow, the capital investment through the elusive ETTF simply has not materialised, and funding remains insufficient. Worse, the rhetoric around the GPFV has put general practice to the back of the queue when further funding is announced, e.g. the chancellor’s pledge of an additional £2.8bn to the NHS at the last budget had nothing earmarked for general practice.

Our collective failure to understand what the GPFV as a document was means we are now left without a clear plan or sense of direction for general practice. We initially thought (wrongly) the GPFV provided this, but what it needed (and what it still needs) is a provider led response to say this is how we will use the commissioner promises made in the GPFV to deliver a new future for general practice, and this is what it will look like. There are enough green shoots out there (the primary care home, the great work of NHS Collaborate, and the 108 episodes of the GP podcast are all testament to that) for this to be possible. But without it, either at a local or a national level, I fear the situation will be worse in 2021 than it was when the GPFV was published.

25
apr
0

The Millennial Opportunity for General Practice

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I am not a millennial. I am not a baby boomer either. To be honest with you, I don’t really know what I am (although apparently I am part of the “lost generation”). How could this possibly matter? Aren’t they just analytical constructs marketing people have developed to try and categorise different age groups?

Broadly speaking millennials are those currently aged 18-35. The first concrete example of the importance of this generation to general practice has been the startling growth of the GP at Hand service, where the practice of offering video consultations grew by 20,000 in 4 months. 85% of the patients joining were millennials.

So maybe there is something in the “millennials are different” mantra after all. This South African analysis resonates:

“The nature of the digital age is to prioritise speed, convenience, and value. The millennial, being digitally native, is exactly the same. This extends from their interactions online to their experiences in healthcare. Doctors do need to look at ways to adapt their practice to meet these expectations in order to meaningfully connect with their patients. From online bookings to …SMS alerts and online calendars, practices already have a multitude of digital solutions to choose from. It is OK that you make changes incrementally, but it is vital that practices start thinking about ways to increase the convenience and speed of the new doctor-patient process.”

Millennials: Getting to know the Patients of Tomorrow, Healthbridge, South Africa

The consensus is that the number of millennials is about to surpass the number of baby boomers, and the differential between the two will grow in the coming years. It is not only our patients but also our doctors who will increasingly be millennials.

Millennial doctors may well be less a product of a technological age, and more a group affected by the junior doctor dispute, the Bawa-Garba case, and training in a system where both they and their senior role models are struggling to cope. It is hardly surprising they feel unsupported, under-valued, and uninspired.

Add to that the growing rejection of the “deferred life plan”, of putting off what you really want to do for what is expected of you, of the idea of working hard until you are 65 to enjoy the benefits later. This is evident in the conflict between a generation of doctors who accepted intolerable conditions when they were training with a new generation who simply will not.

Lucy Cohen, in her article Why Practices Must Engage Millennials, writes,

“As a business owner, millennial, and employer of millennials, I see how different our lives are to that of previous generations. Expect to see them sitting at their desk for set hours of nine to five? Those days are long gone. And if you want millennials to engage with you, then you need to get on board with that idea. We’ve grown up accustomed to communicating and receiving answers almost instantly. So if your (practice) wants to engage with us, we need you to have systems in place to keep us posted on things.”

What I see in all of this is a tremendous opportunity for general practice. The NHS, and its constituent statutory bodies, is not going to be able to respond quickly to the demands of the new generation. The entrenched culture runs too deep. But general practice is far more agile. Individual practices can find ways of letting go of the past and of creating a new, different future that caters for the changing needs of the patients and the staff coming through the doors.

By strengthening the connection with their local community, by valuing individuals over traditional structures and ways of working, and by embracing the opportunity of technology, general practice can become the destination of choice for millennial doctors. It can also harness the growing engagement of millennial patients in their own health to improve health outcomes.

Understanding the changing needs of millennials is important because understanding the needs of our staff and our patients is important. It is an important place to start as we try and shift our thinking from “how do I get out of this crisis?” to “how do I build a sustainable future for this business?”

I will be exploring this issue in much more detail with a panel of experts this month. Watch out for the podcast episodes of these discussions which we will publish over the summer.

18
apr
0

Technology: Opportunity or Threat for General Practice?

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The world is changing. We know it. We read books on a Kindle, download films, order just about everything online. Everyone has, and is permanently attached to, a smartphone. The NHS and healthcare has so far remained relatively unscathed, unlike many other industries. But that is starting to change. What will the impact of technology be on general practice?

A number of new reports have come out recently, heralding the changes. One of these, The Promise of Healthtech by Public, describes the rising impact of digital innovators and technology on healthcare.

The report identifies 9 trends where there is significant growth in technological innovation, the areas the report describes as “low hanging fruit”: procurement and productivity; recruitment and training; prevention; winter pressures and supported self-care; Artificial Intelligence (AI) in pathology and radiology; patient safety; mental health; social care; and research. It then maps the growing number of tech start-ups against each of these trends

You may think the report is overstating the pace of change, in its desire to encourage more tech start-ups to follow suit. But I don’t think so, because at the same time the big technology firms, like Apple, Amazon, Google and Facebook, are all moving into healthcare. According to this article published in March in Vox, “The most proven, forward-thinking, and, dare I say, disruptive companies in our country have decided health care should be their next big move.”  So whether it is the healthcare equivalent of Uber or Fitbit, or one (or more) of the more established tech companies, the current (relative) status quo is not going to last long.

Early stirrings are starting to have tremors through primary care. The GP at Hand service led to (mainly young) patients deregistering from their practice to sign up in London. Echo enables online ordering and delivery of prescriptions.

The Public report identifies numerous barriers that have slowed the introduction of technology: lack of clarity about the evidence; fast evolving regulation of digital health products; slow procurement; partial interoperability; unclear data security standards; and limited change management and digital skills. A quick reflection on the reaction to the introduction of GP at Hand within general practice and the size of these barriers becomes apparent.

I don’t think, however, these barriers will stop the tide of digital health development (disruption?) from coming in. Instead, overcoming them may well be the catalyst for greater and quicker advances. The use of blockchain looks set to empower individuals to control their own clinical records, as it can guarantee single ownership without requiring a central trusted authority, which in turn will start to shift power from the NHS as an institution into the hands of patients. The benefits of bringing together health and social media data, of enabling professional and community resources to interact effectively, is at the heart of the argument that is persuading Facebook to enter the health space.

General practice, sitting at the cusp between individuals managing their own health and accessing healthcare when they need it, is ripe for technological disruption. A recent Harvard Business Review article entitled, Virtual Healthcare Could Save the US Billions Each Year outlined it was changes to primary care that could deliver these savings. It says, “Without expanding the primary care workforce, virtual health technologies can augment human activity, expand clinical capacity, and improve efficiency by ushering in a new health care model where machines and patients join doctors in the care delivery team.”

The independent contractor status of general practice means the barriers to entry are not as great as those that exist in the statutory NHS sector. Changes can happen rapidly in a small area and grow, without the need for national decision making. General practice has always prided itself on its ability to respond and act quickly.

The crisis engulfing general practice means the willingness to take risks is much higher than ever before. The incentive for a hospital within the NHS to take a risk on a new “carebnb” discharge option is simply not as great (given the potential for backlash) as for a practice facing financial hardship to try something new, however controversial.

Technology can help general practice become more efficient, but more importantly it can enable much stronger links between practices, their patients, and their local community. Shifting the demand curve is key to general practice emerging from its current predicament. The Public report, describing the trend for the development of technology in the area of prevention, states, “the need for digital solutions for wellness, supported self-care for patients with chronic conditions, AI driven behaviour change models and personalized patient education solutions is only going to increase.”

There is now an opportunity for general practice, given its current crisis, to reinvent itself as the supporter of communities and individuals to actively manage their own health, to act as a guide through the new environment as it evolves, and in doing so to make its own workload more manageable. The paternalistic “gatekeeper” role is unlikely to survive the changes that are coming, but the need for the expert generalist to empower, encourage and enable individuals and their decision making will be greater than ever.

The threat technological innovation presents is to the existing model of general practice. But given it is widely accepted that the current model of general practice is no longer sustainable, and in the absence of any meaningful investment in general practice, the opportunity technological innovation provides for general practice to reinvent itself seems to far outweigh the threat.

11
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Book Review – Perspectives by Judith Harvey

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In his latest blog Ben reviews GP Judith Harvey’s latest book “Perspectives: A GP reflects on medical practice and, well, just about everything…”

There are not many non-autobiographical books where you feel like you get to know the author, but Perspectives by Judith Harvey is definitely one.   There is something compelling about getting inside the mind of a doctor, not just as a doctor but as a person, and getting a sense of how they see the world.

Judith Harvey is a GP, a patient, a charity founder, and a unique individual. She is also a very talented writer. “Perspectives” is a collection of articles she has written over a 10 year period. Her articles have been published each week in the National Association of Sessional GPs newsletter, as well as other GP publications. While they were written primarily for GPs, I am not a GP and I still found them highly accessible, as well as insightful, stimulating and challenging at the same time.

Her writing is characterised by her honesty. In “It’s a knockout!” she describes her own experience of having concussion, of how it impacted her ability to think clearly, to work effectively and to sleep properly. In “Sleeping with the patient” we find out why she spent the night sharing a bed with one of her patients. In “Giving up… or stopping?” she shares what the prospect of retiring from clinical practice is like in real time.

As the book progresses you start to sense her underlying frustration with the system, borne out of a deep concern about health inequalities. In many ways, Judith was always ahead of her time: a proud portfolio GP when the voice was not as loud as it is today; writing about the impact of employment on health as a medical student and being summoned to the Dean to be reminded she wasn’t training to become a social worker; to advocating walking (for staff and patients) as a route into cutting the NHS budget back in 2009, well before the social prescribers had moved into town. Her passion for learning from others systems is clear (Judith founded Cuba Medical Link, a registered charity which enabled medical students to travel to Cuba for their electives), as is her frustration that we are not learning more from the system that exports doctors and achieves some of the best outcomes at a fraction of the cost of systems we frequently refer to.

When it comes to dealing with difficult issues, no stone is left unturned. She tackles self-prescribing by doctors (an issue rarely considered by non-clinicians), whether placebos can (and should) be morally prescribed, and the impact discussing an elderly patient’s driving ability can have on the doctor-patient relationship. She talks about the problems of evidence based medicine, about the social pressure put on potential organ donors, and questions whether it is ethical to provide a new face to a healthy person whose face is damaged when the price is premature death.

Ultimately, what I enjoyed most was the sense I was starting to get to know Judith as a person, as someone who loves travel and film festivals and the paintings of Goya, as someone who embraces all of life, rather than choosing to be defined by her profession or one particular aspect of it, and as someone prepared to share some of her innermost thoughts so that we, the readers, can better understand the points she is making, simply because she cares.

Maybe the book would have been even better if it had included more of a biography at the beginning or end. The only thing missing for me was a more direct insight into Judith’s life, into where she has been and what she has done, as a canvas to enrich the colour of the articles.

That said, this book is much more than “a GP reflecting on medical practice and, well, just about everything” as it says on the front cover, which hopelessly undersells it. It is a rare insight into what the world looks like through the lens of someone who is both a GP and a fascinating individual, and as someone who had never previously read any of her articles, I found it captivating.

Judith’s book can be purchased via Amazon here. We will be talking to Judith about her life and career in a future episode of the General Practice Podcast

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