6
jun
0

Why the review of the GP partnership model makes me nervous

Posted by Blogs, The General Practice BlogNo Comments

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.

30
may
0

Practical advice for moving ahead in the new environment

Posted by Blogs, The General Practice BlogNo Comments

Even the most successful people and organisations can be caught out when the world around them changes. For Ben Gowland this was brought home by his personal transition from Chief Executive of a small successful federation employing 20 people to a large Clinical Commissioning Group employing over 200. He quickly discovered that the behaviours and approaches that had made him successful no longer worked in the new world. This week, in a “talking blog” he uses this revelation and his years of working with challenged general practices to advise how general practice can move forward in the new environment. Watch his presentation below (you’ll need your sound turned “on”):

16
may
0

Who is to blame for the current crisis in general practice?

Posted by Blogs, The General Practice BlogNo Comments

Who is to blame for the current crisis in general practice? NHS England? The government? Jeremy Hunt? Workforce planners? The bankers because of what happened in 2008? Millennials, because of their demand for instant-everything? Somebody else?

Whose job is it to sort out the crisis that general practice is in? Is it the same people whose fault the crisis is in the first place? Or is it Simon Stevens, NHS England, Jeremy Hunt, the government, or maybe even the BMA and the national general practice organisations?

These will not be unfamiliar questions for GPs. The injustice of the current situation pushes them into almost constant consideration. But focussing on them does not help individual GPs and practices find a way through the challenges they have to contend with on a day to day basis.

I am sure many readers will have at some point come across Stephen Covey’s book, “The Seven Habits of Highly Effective People”, first published in 1989 with over 25 million copies sold. Within the very first habit that Covey identifies of very successful people (“be proactive”), he introduces the Circle of Concern and the Circle of Influence.

The Circle of Concern contains all those things we focus our energy and efforts on over which we have little or no control, such as the weather, Iran’s nuclear programme, or national debt. For GPs it includes working out who to blame for the crisis afflicting the profession, and considering how much of the soon to be announced additional NHS funding will make it to front line general practice.

The Circle of Influence contains all of those things that we can directly control or influence, such as our actions, our behaviours, our family and our colleagues. For GPs this includes their own individual practice.

The habit successful people have, according to Covey, is focussing their energy and effort in the Circle of Influence where they can make a difference, and not wasting it in the Circle of Concern over which they have little or no influence.

I see this difference regularly in GP practices. The factors causing the crisis are outside of the control of practices. The local response to them, however, is within their control. Some GPs and practices focus their energy on the former, and some on the latter.

The barrier that stops many GPs focussing on the Circle of Influence and the changes they can make is this question of who is to blame for the challenges the practice faces, and whose job it is to sort it out. If it is not my fault, and I am essentially a victim of a system failure, why should I be the one who has to sort it out? Letting go of the unfairness of the situation is far easier said than done.

But the practices who are thriving and doing best in the current environment are those focusing their energy within their Circle of Influence; the ones who are looking at how their own behaviours and actions and relationships can influence and change the current situation for the better. They have not waited to react to changes that others will make at a national or policy level, but have taken things into their own hands.

I recently visited Thistlemoor Medical Centre in Peterborough. The majority of their local population do not have English as a first language, and recruiting GPs has been a longstanding problem. But they have focussed on what they can control, and have created a really innovative model so that instead of relying on Language Line they have trained HCAs recruited from the local community to both interpret and take work off the GPs (you can find out more about their model in an upcoming episode of the General Practice Podcast). The practice is thriving and continues to grow at well over 1,000 patients a year.

In Plymouth three practices merged in 2014 to form Beacon Medical Group, and they created a new multidisciplinary team to manage the on-the-day demand. Since then, in the midst of a really challenging local environment, the practice has grown and continued to prosper.

These are just a couple of examples, and there are many across the country. What they have in common is that local GPs focussed on what they could control not what they could not, and took action. They did not waste their energy assigning blame or hoping for national solutions, but instead channelled their efforts within their own Circle of Influence to change the direction in which they were heading.

Thinking about who is to blame for the crisis in general practice is considering the wrong question. It is operating in the wrong circle. The real question to consider is what can I do, what can I influence, to create a vibrant and positive future for my practice, and to focus all my energy and efforts there.

10
may
0

The impact of the new models of care on general practice

Posted by Blogs, The General Practice BlogNo Comments

“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.

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