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Why is the GP Forward View not working?

Posted by Blogs, The General Practice BlogNo Comments

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.

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The Millennial Opportunity for General Practice

Posted by Blogs, The General Practice BlogNo Comments

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.

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Technology: Opportunity or Threat for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

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.

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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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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.

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