Why making change in general practice is difficult

I wanted to leave my job as a CCG Chief Executive for a long time. But it took many months until I finally handed in my notice. I was nostalgic about the past, and clung to memories of a time when I had loved the job. My attachment made leaving difficult. Despite the relentless, day to day pressure there was always this nagging concern; if I left I would no longer be needed in the same way. And I was not 100% clear what my new future would look like. In many ways a bleak certainty was easier to cope with than the uncertainty of the unknown.

I don’t think I am alone. Letting go (of control, of certainty, of routine) is difficult for all of us. Unfortunately, nearly all of the things that can make a difference for general practice seem to involve GPs “letting go” in some guise or other. So, for example:

  • Practice mergers. These involve GPs “letting go” of the control of their (smaller) practice for a lower amount of control in a bigger practice.
  • Introducing new roles. Bringing in clinical pharmacists, paramedics, physician associates and the like involves GPs “letting go” of some of their workload so others can take this on.
  • Workflow redirection. If you have not come across this yet you should (listen to this), but effectively it involves GPs “letting go” of their post, and trusting much of it to be handled by others.
  • New models of care. Okay, not yet a common solution but a designated national direction of travel, and it involves GP partners “letting go” of their independence and becoming salaried employees or, at best, board members in an NHS organisation.

This is why making change in general practice is difficult. It is why practices don’t merge, don’t introduce new roles, don’t make changes to how they operate, and don’t jump into bed with the local hospital just because they are under pressure. The changes may be logically sensible to an outsider, but if they are not underpinned by a strong desire to take whatever action is needed they won’t be implemented.

The big mistake made by those trying to lead change in general practice is starting with the solution, with a description of the change that is to be implemented. Taking the desire to actually make the change for granted, on the basis of the parlous state of general practice, is a fast track to failure.

Professor John Kotter, regarded by many as the leading contemporary expert on change, believes[1] assuming people know they are in trouble and need to change, and focussing instead on strategy and solutions, is what kills most change efforts. He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change.

Ultimately I made my decision to leave based on a strong desire to create a new future for myself. After many months of anxiety, frustration, and (frankly) inaction, I reached a point of determination to make a change, however hard it would be. It was only then I was able to actually resign. To be successful, those leading change in general practice must first focus on establishing a sense of urgency for change, before ploughing into the details of the uncertain future they want to create for their GP colleagues.

[1] A Sense of Urgency, Kotter J.P. Harvard Business Review Press, 2008

Why the new GP contract is disappointing

There has been a cautiously positive reaction to the GP contract. But for at least one enthusiast for general practice, it doesn’t live up to its promise. Here, Ben Gowland explains his huge disappointment…

The GP Forward View was published in April last year. It promised an additional recurrent investment of £2.4bn into general practice. But for all its rhetoric, the finances have been hard to pin down. After a raft of national pots of money that have all translated into very little at local level, all hopes were pinned on additional money arriving in the core contract.

And has it? Well in 2015/16 the contract was uplifted by £220m, the equivalent of 3.2%. That was pre-GPFV. So what was the outcome of the 2016/17 contract, the first one after the publication of the GPFV? An uplift of £239m, or 3.3%. An almost identical award.

What does it mean for the promised additional £2.4bn? Well at the current rate of uplift, which does not like it will change, an additional £1.3bn will have been added by 2020/21. The global numbers sound a lot, but the reality is last year’s contract award did little to assuage the problems faced by general practice, and there is no reason to believe that similar uplifts next year and for three years afterwards will have a greater impact. The rises continue to be offset by a parallel growth in costs.

The tinkering with the elements of the contract, and moving money from one part of the contract to another, really only acts as a smokescreen for the overall failure to invest. It creates opportunities for people who don’t understand general practice to complain about specific elements (e.g. funding the cost of CQC registration), and leads to odd behaviours (e.g. locums increasing their fees by 2% because of the indemnity reimbursement).

The only significant recurrent additional funding in the GPFV, on top of the contract awards, is the funding for additional access. This is £500m, and we know it translates into £6 per head of population. But it is not funding for individual practices. The sites involved in the prime minister’s challenge fund, which receive the money recurrently from April onwards, have to bid for a large single contract. So it is only really available to large organisations. Plus, individual practices just don’t want to do it. As one GP explained to me, if a practice receives what amounts to £115 per patient for 8 – 6.30 Monday to Friday, why would they extend that to 8 to 8 7 days a week for an additional £6 per patient?

So where is the rest of the GPFV money? £2.4bn has been promised. £1.3bn will be in the core contract. £500m is for extended access. Where is the other £600m? I have not yet met anyone who can answer this. It begs the question as to whether it will ever arrive.

Worse, NHS England are predicting a £70m underspend on primary care and public health budgets this year. An underspend that will offset an overspend in the acute sector. Changes to the tariff have pushed many CCGs into financial difficulties, and it seems unlikely all will be able to meet the requirement to provide £3 a head to general practice in the next 2 years. And it is not official, but I am yet to meet someone who does not believe the promised £900m capital fund (the Estate and Technology Transformation Fund, or ETTF) has been cut.

The GPFV made specific promises about putting funding into general practice. This year’s contract award was the last chance for NHS England to demonstrate it was going to meet these promises. But the contract disappoints, and instead reinforces a growing belief these promises are never going to be met.

GP Mergers – A Blessed Union?

In the first of a short series of guest blogs, Robert McCartney warns that the marriage of two practices will only be a success when there is a healthy pre-nuptial agreement between both parties.

Mergers are the ultimate form of marriage between GP practices. When they include the consolidation of the contract into a single patient list it becomes incredibly difficult, maybe impossible, to separate them again. As a consequence, the parties must understand the commitment they are entering into as there is no easy divorce.

During my recent podcast with Ben Gowland at Ockham Healthcare I stated that spending the time understanding and sharing a common vision of the future is essential. This applies to the relationship analogy. The most successful marriages are built upon a shared vision for their future, an understanding that there may be challenges but they will be overcome together and a trust that your partner will support you despite the occasional disagreements.

If the ‘soft’ merger elements linked to developing the relationships, like creating a shared vision and building a framework for the future of the partnership are rushed, the ‘hard’ formal merger steps may still happen but it increases the likelihood that the merger will fail.

Practices are currently under immense pressure and time is not a luxury many GPs have. Whereas a corporate merger may take months or even years to achieve, GP practices are looking to complete the process within a few months.

Fortunately, unlike a marriage there are some firm, definable objectives that all practices will be working towards. By ensuring that the parties focus on these at the earliest possible opportunity the ‘dating’ process can be accelerated with a reduced degree of risk.

The parties need to be willing to be forthcoming and ‘lay their cards on the table’ at an earlier stage than they may otherwise want to do. This openness is essential. In the past year, I have seen proposed mergers fall apart for a range of reasons based on people not being open until far too late in the process. This includes; forgetting significant funding repayment plans on properties; an unrealistic expectation as to equivalent sessional pay; and, despite comments to the contrary in the initial discussions, a complete refusal to consider using allied health professionals.

I have found that practices considering mergers have benefitted from having an independent third party facilitate and structure these discussions. This is especially important where time is of the essence. They are the pre-marriage counsellors focused on ensuring the merged practice is built on firm foundations.

For more information or if you would like support in any merger process you are considering or undertaking please do not hesitate to contact me.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the first of a short series of blogs he will be writing for Ockham Healthcare. If your practice needs a helping hand with its fledgling relationships, you can contact Robert via e-mail at rm@mccartneyhealth.co.uk or call 0203 287 9336.

 

The Future of GP Visiting

In his latest blog Ben reflects on attempts to set up an outsourced GP visiting service and what it taught him about the way GP practices innovate.

A few years ago, when I was working in a GP federation, we set up a GP visiting service. The basic premise of the service was that, because GPs were so busy, they were not able to meet all the patient requests for visits. As a result, we hypothesised, patients were being admitted to hospital when an admission could potentially have been avoided if a visit had taken place. So we funded a pilot in which the out-of-hours service provided a GP to carry out visits during the day that they would not otherwise have been able to carry out.

Do you think it worked? It didn’t. The service was not fully utilised (despite only one GP being available for 30 practices). Uptake was limited to a relatively small number of practices, with many of the practices rarely, if ever, using the service. It was not possible to produce any correlation between the service itself and emergency admission rates (which instead stubbornly continued to rise), and, unsurprisingly, the pilot was stopped.

Contrast this with a practice I visited recently. There they have paramedics for 6 sessions a week, who carry out 5 or 6 visits a day, for a practice that in total undertakes between 7 and 10 visits a day. There are clear parameters in place for visits the paramedic will undertake and those that are best carried out by a GP, e.g. palliative care visits. The practice is extremely happy with the service and is soon to increase the number of paramedic sessions from 6 to 8.

In Shropshire the local out-of-hours provider Shropdoc has developed an Urgent Care Practitioner role in which staff with a paramedic, nursing or physician associate background are trained to be able to offer (amongst other things) home visits for GP practices. The role is proving extremely popular both with staff and practices alike. You can see a video of the service here.

A visit for a GP, with all of the travel involved, is a time consuming activity. While average consultation times may average 8-10 minutes, the total time required for a visit is at least double that, and often much more. Practices vary considerably in the number of visits they undertake. A recent comparison across five practices working in the same town revealed a fivefold difference in visit rates – varying from an average of 0.2 visits per 1000 patient population per day, to 1 visit per 1000 patient population per day.

So where did I go wrong with the GP visiting service we instituted, and what are others now doing right? I think I failed to fully understand visits are an integral part of the service a GP practice offers. Any attempts to change the way they are carried out must be fully owned and bought into by the GPs in the practice. Trying to “outsource” visits to a separate agency that does not know the patients is unlikely to work. A more successful approach is to use other roles, as long as they operate under the guidance of the GPs and not separate from them.

Equally, success in the redesign of GP visits cannot in isolation be measured by the number of emergency admissions. It is the continuity of care GP practices offer that will ultimately support patients to manage their conditions effectively. Freeing up scarce GP time to be deployed where it is needed most (which, paradoxically, will sometimes be in a patient’s home) is now a critical factor in enabling this, and would have been a much better measure of success.

It is hard to replace the long hours GPs work (at no extra cost) with a paramedic or nurse practitioner in a small, cash-strapped practice. As practices become bigger they have more freedom and more flexibility to experiment with different systems for triaging requests for visits, with the introduction of new roles, and with new ways of working for visits.

In my attempts to set up a visiting service I should have remembered that most successful change in general practice is generated within the practice itself, not imposed from outside. Changing the system for practice visits proved to be no exception. In future, as practices become larger they will have more capacity to test different ways of working and that is one of the reasons I established Ockham Healthcare; to support and promote the many innovations that will inevitably result.

The New Multispecialty Community Provider (MCP) contract and CCGs

In his second summary of the new MCP contract Ben looks at the likely impact on CCGs – and finds it is a case of “out with the new and in with the old”…

What does the new MCP contract mean for CCGs? Well, for all the range of documents published only two target specific groups: general practice (which was not surprising); and commissioners (which was). This was the first major clue that major upheaval is at hand.

The second clue was the way the document on MCPs and the commissioning system starts, “the new models… will not remove the established boundary between commissioning and provision. CCG statutory functions will not change”. You know trouble is coming when a document begins with what is not going to change.

The document then basically says while the statutory duties of CCGs will remain (so no acts of parliament required), most of what they actually do can (and will) be discharged through MCPs. It provides a list which states the only activities CCGs can undertake that MCPs can’t is: produce an annual commissioning plan; develop outcome measures and monitoring for MCPs; take responsibility for the overall performance of the local health care system; and create a contract to spread risk between the MCP and the CCG, as well as have responsibility for providers outside of the scope of the MCP. I.e. not much.

Interestingly it is in the finance document not the commissioning document where it is explicitly stated that management funding will transfer from the CCG to the new MCP: “an assessment will be made of current CCG and CSU spend on activities carried out by the MCP that will support commissioning. The value of this spend will transfer from CCG admin budgets to the MCP whole population budget”.

As a consequence we will need less CCGs, so the residual statutory functions can be carried out at lower cost. To really understand the following quote, insert “will have to” for “may want to” (it is only existing legislation that precludes the document from being more directive), “CCGs may want to consider whether the establishment of a new care model means that it would be appropriate to pool functions and management arrangements with neighbouring CCGs. This may be the case where an MCP or PACS cover the entirety or bulk of the CCG area; and where key CCG staff and capability will transfer to the new provider. In some cases the CCG may want to consider merger with another CCG.”

Even then CCGs won’t operate separately from the MCPs. “CCGs and new care model providers should maximise opportunities for making shared use of administrative resources. For example, creating and operating successful new care models will require a new set of information management and analytical approaches by both CCGs and providers… CCGs and new care model providers should look at how they might work together to develop a shared business intelligence capability rather than invest in potentially more costly separate functions. The same applies to other back office functions e.g. payroll.”

Of course, in the “virtual” MCP model, the changes are not so drastic. When I was looking at the draft of the alliance agreement for the virtual model, at first I was confused by the inclusion of commissioners on the alliance leadership team. Isn’t the point of an MCP that it is an integration of providers, deciding together how to deliver services? But, the document explains, they are included because their role is to make changes to underlying service contracts as a result of agreements within the alliance.

This makes sense in the context of MCPs taking over the lion’s share of what is currently considered commissioning. The only difference is in the virtual model the staff are still employed by the CCG and have not yet transferred their employment. In the partial and fully integrated models these staff will transfer and be responsible for “sub-contracting” between the MCP and its linked providers.

So MCPs carry out a range of commissioning functions, directly provide community services, include public health, and have a relationship based on section 75 agreements with social care. Is there something familiar here? Indeed, there is. The partially integrated model in particular is extremely similar to the (pre-transforming community services) primary care trusts. Everything above, plus a separate national GP contract but an ability to create local enhanced services, GPs as part of the management team (remember PECs?), and a clear role as system leader (integrator). For all the packaging of the new models of care as new and exciting, the new partially integrated model in particular will have to work hard to explain how it will be different from that particular version of the past.

In summary, the impact on commissioners of the formation of a local MCP is the end of a local CCG, and the creation of larger (more distant) CCGs focussed on a much narrower range of functions, and the creation of MCPs as integrated organisations that will undertake many of the existing commissioning functions, and which may or may not look like the old PCTs.

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