28
mar
0

I am a Consumer of Health, and Why this Matters

Posted by Blogs, The General Practice BlogNo Comments

Are patients consumers? It is a question that has vexed those trying to introduce a market into healthcare for many years, and I think it is fair to say the consensus view is captured in Dr Jordan Shlain’s article, “There are no consumers in healthcare, get over it”.

He summarises that this is a consumer:

  1. They have freedom to make choices based on their resources and their numerous options
  2. They can decide not to make a choice
  3. They add something to their lives (material or experience) after a purchase
  4. They have a trust psychology based on being excited, not anxious
  5. Consumers get immediate or near immediate benefit from their purchase

And this is a patient:

  1. They often do not have freedom to make a choice and the options are limited
  2. They must make a choice
  3. They are trying to get rid of something (pain, nausea) and have no idea of the cost
  4. They have a psychology based on anxiety
  5. Patients often have no line of sight into whether they get a benefit or not

According to Wikipedia, a patient is “any recipient of health care services”. But how does prevention fit in to this? If a GP surgery undertakes preventative activity with its local population, is it doing that with them as patients or as consumers? When I as an individual decide to go for a run to improve my health, am I a patient or a consumer?

Let’s apply Dr Shlain’s criteria for consumers to my choice to go for a run:

  1. I can choose whether or not I go for a run
  2. I can decide to stay at home watching TV on the sofa instead
  3. I feel more healthy (as well as slightly smug and self-satisfied) after I have been on a run
  4. I am excited to lose weight, improve my fitness, and to (feel like I) look better
  5. I feel great as soon as I have completed my run. My phone tells me how far I have run, at what speed, and how long it took. I can share it on social media and gain feedback from my own network.

So while there may not be consumers in healthcare, there are certainly consumers of health. Why does this distinction matter? It matters for two reason. First, if general practice is serious about changing the pattern of demand, of shifting the focus from healthcare for the sick to wellness for all (as described by Dr Amit Bhargava in our recent podcast), then the nature of the interactions need to be consumer-focussed rather than patient-focussed. We will need something very different from our current system of patient participation groups, something more along the lines of the “Beat the Street” initiative described by Dr William Bird.

Second, the big technology companies (e.g. Amazon, Apple etc) already understand that individuals are consumers of health. Their moves into healthcare are predicated on being able to reduce total expenditure by empowering individuals to manage their own health.

“Apple, Google, and Amazon are trying to lower the cost of health care for their employees by steering them toward outpatient clinics and wellness programs that they own or control…There is a potential convergence going on now. Electronic medical records, mobile phones, and wearables have achieved widespread adoption, creating new opportunities.”

Technology can make a real difference to us as consumers of health. But the opportunities for Apple, Amazon and Google are also opportunities for general practice. The risk is if general practice does not take them, it might be superseded by the technology companies who do.

Dr Shlain may be right that there are no consumers of healthcare, but there are consumers of health. The aging population and the rapid advancement of technology mean this distinction is more important than ever before, and its impact upon primary care is likely to be huge.

21
mar
1

What does GP at Hand mean for General Practice?

Posted by Blogs, The General Practice Blog1 Comment

The world is changing. The days of popping down to Toys ‘R’ Us for a present for the kids are over. Last week Toys ‘R’ Us announced it was closing all of its stores. According to toy industry analyst Jim Silver, “They lost online and they didn’t adapt.”

It is not just the toy industry that is changing. It is everywhere. Earlier this month Countrywide estate agents reported significant ongoing financial difficulties. In a statement they acknowledged they had not yet learned how to deal with the challenge from digital property services (such as Purple Bricks).

General practice is not immune to these changes. Lillie Road Medical Centre practice in Fulham, which last year started to offer the GP at Hand video consultation service to anyone outside its area living or working in London, has seen startling growth. Taking up the service requires patients to leave their existing practice and register as an out of area patient. The list size of the practice has grown from 5,000 to almost 25,000 in 4 months, and 85% of registrations have been patients aged 20-39.

The GP at Hand experience means the digital threat to general practice has just become real. The capitated payment system of reimbursement for general practice means losing the younger, healthier patients on the list, and being left with patients who are older with more complex health needs; and could result in income not matching costs. It could well be the final straw for many practices already experiencing financial pressure.

Should these changes be resisted? Are video consultations a “good thing”? In a paper published in the Journal of the Royal Society of Medicine, the team from the Department of Primary Care and Public Health at Imperial College London said that while there is evidence that video consulting is acceptable to patients and offers many potential benefits, at least to those of younger age, its safety and efficacy in primary care currently remains largely untested. It raises concerns that while online consultations may help practices manage demand more easily, it may conversely increase pressure through supply-induced demand, or defensive practices.

In our new society, video consultations are more about allowing patients to access services in the way they want to, and less about reducing workload for GPs. Increasingly, it is patients who are going to set the pace for changes like this. The early results from GP at Hand demonstrate for some there is an impatience to see these changes now. Our recent technology panel ultimately felt the profession would not be able to keep control of the use of technology, and it would be driven by patients, if not now then certainly at some point in the future.

We are only at the start of the “digital journey” in general practice. Technology is evolving all the time. Jim Forrer on the technology panel talked about an app currently in development that can monitor blood pressure, pulse rate, oxygen saturations and respiratory rate through the camera function on a smartphone. Technology will change the doctor patient interaction and the way patients manage their own health. Google and Amazon are entering the health space, using global cloud-based health platforms and data, and this is going to have an impact on general practice.

We may think in a tax funded system based on needs not wants that market forces won’t apply. But the reality (as demonstrated by GP at Hand) is they will, because people will not accept what they perceive to be a second class service when it comes to their health, and will demand that health services evolve in the same way as every other aspect of the world. Resisting the implementation of technology will, at best, be a short term strategy. The risk of that approach is that others will move in to fill the void and the opportunity to respond positively may be lost.

If we can’t stop the march of technology, and given the significant potential financial impact, can general practice survive the changes that are coming? Well, established players in other industries (unlike Toys ‘R’ Us and Countrywide) have. Take the experience of the supermarkets. Online grocery shopping is the fastest growing area in the sector, but it is the major supermarkets who understood the change was coming and set up their own services. While new entrants have come into the market, Sainsbury’s, Asda, Morrison’s and Tesco are the major players. Morrison’s are now building partnerships with those with better distribution networks such as Amazon and Ocado to further cement their place.

The world is changing. GP at Hand is simply the indicator that general practice is not immune to these changes. Right now the onus is on general practice to respond, to respond quickly and to respond positively. Part of the opportunity of the move to scale in general practice is precisely for this, as it enables practices to invest in technology or partner with technology firms, to test and develop its usage and to evolve the model of care. By working together, practices can meet this challenge. The other option, to resist the changes, to pass motions that “more needs to be done” by commissioners and policy makers to preserve the status quo has the whiff of King Canute on the beach, and may leave current GP practice businesses in a position like Countrywide or Toys ‘R’ Us, rather than evolving with the changes like the supermarkets.

14
mar
0

Where is general practice going?

Posted by Blogs, The General Practice BlogNo Comments

We all know what general practice is trying to move away from (a crisis), but where is it going?

Anger, irritation, fear, or frustration with the current situation can be a great motivator to get change started, and provide an initial impetus to motivate a practice to take action. But if your only motivation is ‘away-from’ the current crisis, then your attention is consistently drawn to the negatives in your experience, filtering out the positives in the process.

It is also not sufficient motivation for sustainable change. For example, if a GP’s goal is ‘not to be in crisis’ (by their own definition of the term), then they have achieved this goal when they reach the level they decree to mean ‘not being in crisis’. They then lose a significant portion of their motivation so run the risk of dropping back down to a point at which they become motivated by their ‘moving away from being in crisis’ goal again. ‘Moving away-from’ goals produce inconsistent motivation levels which are rarely satisfying at any stage.

Sustainable change requires an element of ‘towards’ motivation as well; a vision of where you want to get to. Creating a vision based on aspirations and positivity and not on barriers or avoidance is both empowering and inspiring.

Where is the vision for the future of general practice? I don’t think it really exists. The GP Forward View seems to be more a public acknowledgement of the challenges general practice is facing while ploughing on with extending access, rather than the development of an inspiring picture of what is to come. So here at Ockham Healthcare (with help from whoever will give it!) we aim to put that right. We want to help build excitement and anticipation about the future of general practice, and to shift the focus from the crisis around and behind us, to an inspiring and attractive future ahead.

To kick this off we are holding a series of interactive sessions with some of the leading thinkers and practitioners in general practice. We are exploring with them some of the key changes they believe will impact the future of general practice. We will distil the key lessons, and capture the learning as a resource to enable GPs and practices to prepare for what lies ahead.

We are going to consider four questions:

  1. How will technology shape the future of general practice?
  2. What will the infrastructure of general practice look like in 5 years’ time?
  3. How will the new models of care change general practice?
  4. What do GPs (of the future) want?

We recently held the first of these panels, to discuss the technology question. You can listen to the first part of the discussion here. We will publish the second part in a few weeks’ time.

What is already clear from our first panel is there are huge changes on the horizon. There is an opportunity for general practice to embrace these changes and use them to create a future that will enable a greater focus on prevention, on building patient ownership and control of their health and their illness, on a new partnership between doctors and patients, and on new treatment opportunities (e.g. the use of virtual reality in pain management).

Finding a way out of crisis is not a plan for general practice. It is the start of the journey, but to ensure it doesn’t peter out there needs to be a vision, a future, a picture of what it will be like. Our aim, starting with these panels, is to help paint that picture.

7
mar
0

The days of CCG Locality Groups are numbered

Posted by Blogs, The General Practice BlogNo Comments

“But we are a membership organisation!” the newly appointed GP Chair exclaimed. “Member practices have to have a voice. We need localities to ensure each GP practice is represented in the decision making of the CCG. Each locality needs its own GP leader, the support of a locality manager and we must pay for the time of a representative from each practice to attend locality meetings”.

The Finance Director looked sceptical. He could see the £25 per patient management costs rapidly disappearing into these localities. “But where is the return on investment?” he countered. “If we fund all of that, the costs of five localities could be nearly half a million pounds a year!”

“This is what will make CCGs different to PCTs” hissed the GP Chair. “PCTs had no route into the voice of GPs and GP practices. These localities will be the engine for clinically-led change and redesign, they will ensure we connect commissioning policies to change on the ground, and make sure we can put the decisions we make as a Board into practice. Without them, we won’t deliver anything.”

And so it was that locality groups started off in many CCGs as the great hope for the future, as the symbol of what could be different. But, as is the way of the NHS, the local freedom promised to CCGs did not materialise, and the voice of localities was overtaken by directives from NHS England, the pressures of the 4 hour target, and the need for centralised financial control. Locality GP Chair roles on CCG Governing Bodies were replaced by clinical lead roles for urgent care and planned care and the like. Localities have continued, GP Locality Chairs are still in place, some even have managers, and practices are still paid to attend meetings, but more often than not these meetings now consist of a one way flow of traffic where teams from the CCG present the latest clinical pathway, referral guidance or QIPP plan to the GPs.

What hasn’t changed are the questions from the CCG finance director as to the return on investment of the locality funding. Now the embattled GP Chair simply knows removing it would be just one step too far in trying to maintain any sense of support from member practices.

So what is next for CCG locality groups? As STPs develop, and the system moves to the introduction of integrated care, it is becoming increasingly unclear what is the responsibility of the local GP federation (as a provider, and the “provider partner” within the developing integrated care system) and what is the responsibility of the CCG locality.

There will come a time when all of the functions of the CCG locality – input into clinical pathways, liaison with practices, redesign of services, representing practices in system discussions – will fall to the GP federation, as power shifts from the old system to the new, from commissioners to partnerships of providers. For now, we are in a transition period between the two.

But a transition period is problematic. Already overstretched GPs cannot be in two places at once. Do we want practices to spend the limited time resource they have on existing commissioning localities or on establishing a strong GP provider voice for the future? Realistically we can’t expect them to do both, and doing so simply limits the capacity to do either. The funding we have invested in the localities is no longer in the right place, and would be better situated within the developing federations.

The extent to which CCGs and general practice accelerate this transition may determine the strength and influence of the GP voice in the new system. Because GPs do not have the capacity for double running in a transition period, it is now time to accept the end of the locality within a CCG and to create a new future for them, and maybe allow them to fulfil their initial promise, within (or even as) GP federations.

28
feb
0

Who Represents Your Practice in Integrated Care?

Posted by Blogs, The General Practice BlogNo Comments

What is Integrated Care?

“Integrated care” is the term used to describe provider organisations in the NHS working together to improve care for patients.  The ambition of the NHS, as described in the Five Year Forward View, is to move away from a system of care organised via contracts between providers and commissioners, towards one in which groups of providers are given the budget to work together to deliver outcomes for a local population.

Why is it important for GP practices?

Within an integrated care system GP practices will have stronger relationships with local community services teams, social care, the voluntary sector and even the local hospital.  It will also change the way that GP practices receive (some of) their money.  Whilst the core contract will remain nationally negotiated and paid directly to practices, other income streams such as enhanced services will ultimately come via the new provider partnership (or integrated care “system” or “partnership”).

When will this happen?

There is no national timetable for the changes, as there has been no new legislation to dictate it.  Each area is implementing changes in line with their local STP (Sustainability and Transformation Plan).  Eight areas nationally are acting as pilot systems to “fast track” the introduction of the new system.

The changes have, however, already started, primarily through a push for practices to work together in populations of 30-50,000.  This is evident in the procurement of extended access for general practice, and CCGs have been explicitly asked to “encourage” practices to work together at this scale.

 

What will integrated care look like locally?

There is no blueprint for what integrated care will look like.  The lack of legislation means there is freedom for each area to determine this for itself.  We are currently in the critical period where each area is deciding and agreeing how integrated care will develop locally.  Providers and commissioners are meeting together to work this out, in meetings with a range of titles but that generally include the terms STP or Accountable Care System/Partnership or Integrated Care System/Partnership.

How is my practice represented in these discussions about integrated care?

This is an important question.  I carried out a quick poll on twitter to find out.  The results are below:

It is not surprising that practices do not think they are represented by their CCG or LMC. CCGs cannot represent practices, as they are a commissioning body that exists to represent their local population not their practices. LMCs have traditionally been the representatives of general practice. The challenge for LMCs is convincing the other providers they are there as a genuine partner rather than trade union. Integrated care is about building partnerships between providers, not negotiating terms. Some LMCs have stepped up into the role (Tracey Vell in Manchester is the obvious example) but many are simply not able to.

This essentially leaves federations (where they exist) to represent their practices, unless practices are of a size (so called “super practices”) to represent themselves. Some federations have been reluctant to take this on, because their relationship with their members is not one where they feel they can speak on their behalf. Some areas have not included GP federations in the meetings about integrated care. Whatever the reason, the absence of a federation around the table means that many GP practices are not currently represented in these important discussions.

What happens if no one represents me?

There are (at least) two consequences of practices not being represented in discussions about integrated care. The first is that general practice, as the provider of by far the largest number of patient contacts, has no voice in determining what the local integrated care system will end up looking like. The second is that acute trusts, community trusts and other large provider organisations will have the greatest influence on how care is organised and how local funds are allocated between providers in the future.

Why is no one asking how I want to be represented?

The representation of general practice is difficult because of the large number of practices, and because it is not a contract negotiation but a building of relationships between providers. It falls to general practice to organise itself so that it can be represented effectively and build relationships with the rest of the system. There is no incentive for other providers to take on this responsibility for general practice. Tracey Vell talks about how she had to fight to secure a place for general practice around the top table making these decisions in Manchester.

How can I ensure I am represented?

Practices need to do two things:

Establish who (if anyone) is representing you in local integrated care discussions. If it is no one, agree with the other local practices who should be representing you, and then push for this to happen.

Create an explicit agreement with this organisation to establish what they can and cannot agree on your behalf, and what requires further discussion and debate with you directly. Don’t make their job representing you impossible, and ensure they have a strong mandate so they can have a powerful voice with the other providers around the integrated care table. Agree the feedback and communication mechanisms to be put in place between the discussions and the practices, and review them regularly.

Who represents your practice in integrated care?

In summary, it is of critical importance for the future that general practice is represented, and represented well, in the local discussions that are taking place now about integrated care and how the future system will be organised. It is up to each practice to ensure they are being represented, and for practices to work together to empower and enable those representing them to present a strong and unified voice. For federations it is vital they establish a mandate from their member practices to undertake this role on their behalf.

 

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