27
jun
0

Is working at scale just a trend?

Posted by Blogs, The General Practice BlogNo Comments

Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.

20
jun
0

It is not the model

Posted by Blogs, The General Practice BlogNo Comments

I had butterflies. It was my first day at only my second placement on the NHS management training scheme. I followed the directions I had been given off the motorway and into deepest Salford. The area had long rows of terraced houses interspersed with small corner shops. I passed a group of youths gathered on a corner, hoodies raised, and I hoped they would be out of sight before I had to park and get out of the car. I turned the corner and drove into the car park of an incongruously new and modern building, with immaculate red brick walls and gleaming windows.

It was the Willows Primary Care Resource Centre. It was run by Salford Community Trust; my placement was working with the manager of the new centre. I was excited by the new model of care being implemented here. The centre was based in a district of Salford called Weaste. It was (and I suspect still is) a deprived area, and the centre was part of a community regeneration scheme. The plan was for this centre, which was also home to a GP surgery, to host a range of community facilities, voluntary services and resources, and to act as a “one stop shop” to meet the needs of local people.

An interesting range of services were delivered from the centre. There was a community based leg ulcer clinic, who were using a maggot based treatment for wound care. The Citizens’ Advice Bureau held regular drop-in sessions. There were twice a week art therapy sessions. Physiotherapy and speech and language therapy were provided. Plus there were a whole host of other providers; the space was there, and was available to be used by the local voluntary groups who needed it.

Looking back, and this was over 20 years ago, the model was not hugely dissimilar to the primary care home model. It was serving a defined local population where health and social care needs were closely linked, and it was trying to bring a range of different skills and roles together in one place so that all of the needs of the individuals could be met in one place.

But something was missing. At the time it was hard to put my finger on it. I had a sense of it because sometimes we struggled to attract some of the voluntary groups in to use the centre, and I didn’t really understand why. The locals also seemed to steered clear of the place unless they had a specific reason to attend.

Looking back now, the problem was really one of ownership. The GPs were happy with their new building but by and large left the rest of the centre to others. The district nurses had their base there, but didn’t really interact with the other services running from the centre. Co-location wasn’t resulting in joint working, let alone joined-up care for patients.

The incongruity of the shiny newness of the building with its immediate surroundings meant that rather than local community being proud of it, they were wary and mistrustful. In all the time I was there it never felt like it became the vibrant hub I think was initially intended. Nobody really owned the vision for the place, there was no one driving with a passion to change the lives of the local community. So while the original plans were followed and put in place, it never took off or had the impact that once had been imagined.

What that whole experience taught me is that however good the “model” is, however well we design it, however shiny the building we put it in, it won’t work on its own. It is all about implementation. Not PRINCE-style implementation. But implementation that is about people, about partnerships and about passion. Implementation that is about leadership from individuals who care. And it needs GPs, community teams and voluntary groups to share a vision for the future, a picture of what can be achieved, and to find a way of partnering with the local population to make it happen.

There was nothing wrong with the primary care resource centre as a model. It was a good model. Equally, there is nothing wrong with the primary care home model. But the model will only ever be one part of the story. It takes people who care and who are prepared to step forward to turn a good model into something that will make a real difference.

13
jun
0

Evolution is not mandatory

Posted by Blogs, The General Practice BlogNo Comments

I recently chaired a panel discussion that was considering the question, “what will the infrastructure of general practice look like in 5 years’ time?”. What was most interesting about the discussion was the debate the panel had as to whether general practice could evolve quickly enough to prevent itself becoming extinct.

I didn’t expect that either. Most of us would agree with the starting point which is that we expect general practice to become bigger in the next 5 years. However, it won’t get significantly bigger. We might make it to the 20-50,000 population primary care home size, but only because that is what one panel member described as the “mentally capable” next step, i.e. the one that isn’t too far away from where we are now to feel doable. Getting to a 300,000 or even 500,000 population size, one where real economies of scale can be achieved and system leadership exerted, feels like a distant dream in most places because it is too far away from where general practice is right now.

As one panel member explained, the reason anything like this can’t happen quickly is because getting practices to work together is hard work, and takes what he describes as “hand-to-hand combat” – tackling one practice at a time. That is why getting universal population coverage at a scale of 20-50,000 is challenging, and why getting to something bigger than that is simply out of reach.

This pace of change may simply not be fast enough. For two reasons: one, the system wants to drive integration at a greater scale faster than general practice can keep up with; and two, the technological disruption we have seen from GP at Hand is likely to only be the start and it remains to be seen whether general practice in its current form can survive it.

One panel threw in the example of dinosaurs, as a telling reminder that “evolution is not mandatory”. As another said, “all innovation is a generational war, and we know who wins that one…”

Which all then led to an existential discussion about the value that general practice adds. Do we really know what it is? One GP panel member stated he is not clear which patients he adds the most value to – the data simply is not there. The starting point for general practice to move into the future is to prove the difference it makes to people, and then to do more of that.

If the primary role of general practice is the place we take our symptoms to find out what is wrong with us, won’t that at some point in the (near) future get replaced by technology? If it is to act as a gatekeeper to the rest of the system will that role continue to be accepted by the coming generations who demand instant access to everything?

In a 2015 article in the NEJM, Martin Marshall argued that in the future general practice, “will have to get the support they need to continue to provide person-centred care and to deal with the complex and delicate balance among an individual’s health, illness (the perception that something is wrong), and disease (a confirmed diagnosis). General practices will have to facilitate the increasingly important interface between people’s management of their own health and the care that is delivered in partnership with, or by, health care professionals. And they will have to find ways to negotiate the complex trade-offs among the sometimes conflicting expectations and needs of individuals, populations, and taxpayers, whose continuing support for a publicly funded health system is essential for its survival.” N Engl J Med 2015; 372:893-897

I think the point the panel were making is that if general practice develops further as a place that is about compromise, about trade-offs, about individuals not getting the care they really want or need at the time they really want or need it, then extinction of general practice in its current form is a real possibility. Instead, key to the future is understanding, demonstrating and then developing the part of general practice that is genuinely value adding to individuals, their families and their local communities.

You can listen to part 1 of the panel’s discussion here. Part two will be published here on Monday 18th June.

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”):

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