What does the NHS Planning Guidance mean for General Practice?

Every year CCGs receive planning guidance from NHS England, which tells them what needs to be included in their local plans for the coming year. In his latest Blog Ben Gowland explains in detail what this latest round of guidance means and why this year is different – and not all good news.

This year there have been a few changes to the Planning Guidance. The guidance has been produced earlier, in September, and plans and contracts are to be complete and signed by December, and cover 2 years instead of one. Each CCG has to produce a local GP Forward View plan by 23rd December (regardless, it seems, of whether they have chosen to take on delegated responsibility for the direct commissioning of general practice or not).

So what can general practice learn from the newly published guidance? The detail it contains (along with the subsequent local plan) was only ever going to be one part of a 3-piece jigsaw – the other two parts being the national GP contract award and the local STP plan. Combined these three will give us a really good picture of what the real impact of the GPFV is going to be in the coming years. But a few things stand out.

For a start, the headline £2.4bn uplift, so prevalent and heavily featured in the GPFV, does not get a mention. In some ways I understand this as the £2.4bn was set for 2020/21 and the guidance is only until 2018/19, but nonetheless it is a concern.

This concern is exacerbated when the starting point for investment is the NHS England 5 year allocations for primary care. The final per capita growth in 2017/18 is 2.41% (compared to 3.16% in 2016/17), an amount that varies considerably across the country (from 0.45% in NHS South Norfolk CCG to 10% in NHS Islington CCG). In 2018/19 it is lower still, at 1.75%. Across the 5 years these allocations create a £1.1bn recurrent investment in General Practice, which on its own will not be enough to increase the general practice share of total NHS expenditure nor keep up with inflation of expenses in general practice.

That isn’t of course the end of the story. What was exciting about the GPFV was the other recurrent £1.3bn that would make up the £2.4bn, as well as a promised £508M non-recurrent package of investment in the meantime. The new guidance contains more details of both of these.

£500m of the additional recurrent £1.3bn was always going to come for access.   What the guidance says about this is that in 2017/18 and in 2018/19 the GP access fund sites (formerly the Prime Minister’s Challenge Fund sites) will receive £6 per weighted head of population. The CCGs without GP access fund sites will receive £3.34 per head in 2018/19, and £6 per head from 2019/20. This isn’t great news for 2017/18, because according to the GPC £6 per weighted head of population is less than the GP access fund sites currently receive, and if you are not a GP access fund site you won’t be receiving any additional access money until the year after.

For this money, CCGs have to commission services 8am-8pm during the week, and at weekends, “provide access to pre-bookable and same day appointments… to meet local population needs”. At least 8-8 on Saturdays and Sundays has been avoided. In capacity terms they must provide an additional 30 minutes extra consultation capacity per 1000 population, rising to an extra 45 minutes.

Where the remaining £800m of the £1.3bn is going to come from is still something of a mystery. The guidance says further investment will come from:

  • Increases in funding for GP trainees funded by Health Education England
  • Increases in funding for nationally procured GP IT systems
  • Increases in the section 7A funding for public health services, which support payments to GPs for screening and immunisation services
  • 3,000 new fully funded practice-based mental health therapists to help transform the way mental health services are delivered

But none of that feels like real money coming into practices. It will be interesting to see whether money will come to practices to directly employ mental health therapists, but if that was the plan I think more would have been made of it by now. But maybe this gap provides an opportunity for investment into the core contract, or into general practice via the STP plans. We will need the other two pieces of the jigsaw to find that out.

This still leaves the promised non-recurrent investment of £508m. The headline here is that CCGs have to find £171m of it from their core allocations (i.e. they haven’t been given any extra money for it), and this equates to £3 per head. This money is to, “stimulate development of at scale providers for improved access, stimulate implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice”. CCGs can choose whether to give this to practices in 2017/18 or 2018/19, or spread it across the two years. The guidance also says CCG funding to general practice should increase beyond the level of their core allocations (2.14% in 2017/18 and 2.15% in 2018/19), but I can’t imagine for one minute cash-strapped CCGs will be able to fund this on top of the £3 per head.

This non-recurrent fund also contains a number of other smaller pots:

  • Online general practice consultation software systems – £15m available in 2017/18 and £20m in 2018/19, specification yet to be shared.
  • Training care navigators and medical assistants for all practices – £10m available in each of 17/18 and 18/19, specification yet to be shared
  • General Practice Resilience programme – £8m available in each of 17/18 and 18/19 (compared to £16m this year)
  • Time for Care national development programme – nationally funded, CCGs to identify a senior local leader

At the same time NHS England will be investing (non-recurrently) in international recruitment of GPs, clinical pharmacists in general practice (3 years funding for practices), and expansion of physician associates, medical assistants and physiotherapists. The bids put forward for capital investment are also being considered.

And that is it. The significant investments are essentially those for access and the £3 a head by CCGs. What we are left with is a sense that the two year planning timeframe could work against practices in areas that don’t have a GP access fund site, and so won’t be receiving any additional access money next year, and whose CCG chooses to invest its £3 per head in 2018/19. For them, unless there is significant assistance coming via the STP plan or the national contract negotiation, 2017/18 could well be an even more difficult year than the one we are currently in.

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5 Steps to Introduce Innovation in a GP Practice

Knocked back at every turn when you try to introduce innovation into your practice? You are not alone. But, in his latest blog, Ben Gowland clears a bit of wood so you can see the trees and presents five steps to introducing change…

Everyone in general practice agrees things need to be different, but as soon as specific changes are mentioned barriers go up. Words from Sir Sam Everington declaring the need for Skype consultations to become the norm in general practice send shivers down the spine of most GPs. Likewise declarations that the traditional partnership model is dead, and that “super-practices” and their ilk must become the new norm.

GPs readily admit the need for change, for innovation, but not Skype consultations or super-practices. Or telephone consultations. Or physicians associates. Or social prescribing (whatever that is).

How do practices wanting to make change overcome this particular problem? In the flat decision-making structure that makes up most GP partnerships, overcoming this type of resistance is especially challenging, because not everyone wants to take risks, not everyone is on board, and focus on the bigger picture easily gets lost.

Let’s take an example: the employment of a clinical pharmacist by a GP practice. Let’s say one partner is particularly in favour, and puts forward the case. Some partners are not going to want to take the risk. They are going to see the (definite) financial outlay with an only probable financial return. Some will be against the idea on the grounds that a pharmacist can’t possibly do the job of a GP (I know they are not trying to, but you can picture the discussion).

The discussion goes on. The longer it goes on, the less it is about tackling the problem of unmanageable workload, and the more it is about whether taking a risk on a pharmacist is a good idea. The vision is lost, and the focus is on the detail. Eventually, after a long discussion by the partners, the practice decides to pass on the opportunity to employ a pharmacist. Everyone still agrees innovation is needed, just not this one.

It is not always like this. I have spoken to a large number of practices that have successfully introduced innovations and changed the way they have done things. I have asked them how they did it, and how they managed to overcome the barriers others could not. I have grouped what they said into 5 steps to introduce innovation in a GP practice:

  1. Don’t start with the solution, start with the problem. Any practice looking to make changes will be doing so for a reason. If the workload is unmanageable, the workload is unmanageable. Focus the initial discussion on this as the problem, and establish a sense of urgency that something must be done. Be clear that no change is not an option.
  2. Develop options. Giving a choice of options empowers decision makers. Listening to the arguments of those against an option can help develop even better options. In our pharmacist example we could offer a range of different roles, or reduced drawings to fund extra GP sessions, or merger with another practice as ways of coping with the unmanageable workload. Keep the focus on solving the problem, not on any specific solution.
  3. Create a critical mass of support. There will nearly always be someone in any GP practice who is against whatever the change is. Once it has become clear which is the best option it may be that those most in favour of the change need to do some work outside of the meetings to firm up support for the change. It is all too common for one all powerful voice to continually veto the introduction of any meaningful change. Where this is happening others need to work together and plan how to get the final approval required.
  4. Create a worked up solution that reduces risk.  A good way of getting the change to happen is to provide a way out, whether that is a review after 6 months or a short term contract before offering a permanent one. At this point the work of those in favour of the change is only beginning. They need to mentor and support the new recruit, manage their introduction into the practice, support their professional development, and problem solve with them. The experience of those who have done this is that 6 months later the practice can’t imagine how it ever coped without the new member of staff in place.
  5. Use one successful change to enable further change. When practices agree to make one big change, and have a positive experience of it, they are much more likely to take a risk on the next one, and make further and further innovations. It is no coincidence that practices who introduce new roles are often larger, building whole system partnerships, and looking for ways to make the new models of care work for them.

Identifying innovations is relatively easy. Getting them to happen in your practice is not. The innovation problem in general practice is not a lack of ideas, but the difficulty of adoption, and of changing the behaviour that goes with it.

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On the Day Demand

We don’t really understand demand in general practice.  The big message from the Kings Fund report earlier in the year, Understanding Pressures in General Practice, was the need to create the ability to measure this demand.  The West of England AHSN published Measuring Demand in General Practice which found,

A lack of research in this area and a lack of continuity in national projects aimed at supporting GP practices to understand demand… Work with GP practices revealed no definitive or widespread approach to measuring demand in primary care. However, it confirmed that practices and CCGs were struggling to cope with apparently increasing demand and were very keen to engage in further activities that might help understand and manage it better.” p3

We do, however, know some things.  We know the population is growing.  We know people are living longer and morbidity is increasing.  We know people are becoming more demanding.  We know there is a GP recruitment crisis.  We know 71% of GPs identify workload as the top factor negatively impacting on a career in general practice.  We know waiting times for an appointment are going up.

Clearly there are no straightforward answers to the challenge growing demand presents, but is there anything that can help?  In the past we had ‘advanced access’ (you can find the evaluation of this here), then came telephone appointments, and more recently based web-based systems, Skype and e-consultations.

I always find starting with the answer to be a mistake.  Better to understand the problem as best we can, and develop solutions from there.  There is a limited capacity (and shortage) of GPs, which cannot meet the totality of the demand.  Demand is rising faster than the population or its underlying morbidity, which means demand is presenting now that previously patients would have managed themselves.  There is a growing cohort of patients with complex multimorbidity.  Continuity of care is needed for some patients but not for all, but is particularly important for this complex group.  All this suggests efforts to access additional or different capacity to meet the less complex demand, and free up GP time to focus on the more complex demand, are those most likely to be successful.

The other place to look is to see what others are doing.  The practices I have seen that are dealing with the pressures best all seem to split demand into two.  They split the demand that presents on the day (on the day demand) from the demand that comes from the management of patients with ongoing chronic conditions, some of whom are highly complex (ongoing demand).  They find demand for the former constitutes a large proportion of the demand on a practice, and they have found different ways of creating capacity to meet this demand.

Some have introduced new roles in to practices specifically to help meet this demand.  Some have gone as far as creating a multidisciplinary team, led by a GP, for this specific purpose.  Some have used joint working with other practices to enable a collective approach.  They have set up ‘urgent care hubs’ or the like to manage on the day demand across multiple practices in one place, with an extended team and a range of roles.  Some have used partnerships with the local community trust, ambulance service or acute trust to access the additional skills and capacity they need to help meet this demand.

Many of these sites have found by making these changes they have been able to free up more GP time for the ongoing demand, for the more complex patients, and some have been able to increase appointment times for these patients to 15 minutes, or even longer.

Changing how on the day demand is dealt with can do two really important things.  It can ease the overall pressure on the practice, and it can create more capacity for GPs to focus on the ongoing demand and provide continuity of care where it is most needed.  The specific changes individual practices choose to make will always need to be tailored to the individual local circumstances.  But the principles behind the changes remain the same: consider on the day demand and ongoing demand separately, find new ways of creating capacity to meet the on the day demand, and this in turn will free up more expert GP capacity to meet the ongoing demand.

Recent Developments in General Practice

There has been something of a frenzy of activity over the summer, following the publication of the General Practice Forward View (GPFV) earlier in the year, and if you have been away it is easy to have missed what has been going on!

Arguably the biggest development was the publication of the new MCP (multispecialty community provider) contract framework.  This, potentially, represents the end of the independent contractor model for General Practice.  Our 15-minute guide tells you all you need to know, but essentially it is about creating new organisations that general practice are part of, as opposed to new general practice organisations.

They are entirely voluntary, which begs the question why would GP practices choose to join.  I spoke to Tracey Vell, the LMC GP lead for the implementation of the new contract in Manchester, and she told me practices are falling over themselves to join for three main reasons: a way out of the current pressures; because they will be bought out of their building; and because the new organisation will pick up indemnity.

The publication of the MCP contract guidance, which outlines the new contract length will be 10-15 years, coincided with a resurgence in APMS contracts.  North Derbyshire, Blackpool and elsewhere are now introducing these not as a tool for competition to “market test” general practice, but as an enabler of integration between GP practices and other providers.

For some, the MCP is seen as the lesser of two evils because the alternative new model of care, the Primary and Acute Care System (PACS), is regarded as the takeover of general practice by the local hospital.  However, Dr Berge Balian, the GP lead at Yeovil Hospital for the local PACS, contends instead it provides an opportunity for general practice to be paid for work transferred from the hospital.  As a result, practices in Yeovil are choosing to give up their contracts to join Symphony Healthcare Services, an organisation wholly owned by the hospital.

The big question following the publication of the GPFV is where is the money?  This was brought into even sharper focus following the revelation much of the GPFV money would be allocated via the STP areas (cue the introduction of RCGP ambassadors to each STP area).   I spoke to Maureen Baker about the GPFV money to get her take on where it is and what it will really amount to, and for those still in the dark we have produced our own guide on how to find it.

“Primary care access centres” were trailed in the GPFV as a mechanism for extending GP access.  The BMA has since produced its own document, “Safe Working in General Practice”, renaming them “locality hubs” and describing them as overflow facilities for “full” general practice.  Either way, they amount to the same thing and require practices to work together to create them.  Handily, the Nuffield Trust published “Is Bigger Better? Lessons for Large Scale General Practice”.  They found evidence of improvements in quality lacking, but author Rebecca Rosen did conclude bigger is indeed better as a mechanism for enabling general practices to cope with the current challenges.  For those wanting to up their scale, Jenny Stone gave us a guide to practice mergers, and Nigel Grinstead shared the lessons he has learnt supporting federations and super practices to develop.

Meanwhile, the challenges of recruitment in general practice have not gone away.  We looked at the transformational impact paramedic practitioners have had on one practice, and asked the question more broadly as to whether social workers could form part of the practice team.  However, the action that can make the biggest impact locally in our view is the introduction of a local locum GP chambers.  Chair of NASGP Richard Fieldhouse explains what they are, and we heard from an ex-GP partner, a newly qualified GP, and a GP seeking a portfolio career about the impact chambers had on them.  We explained why you need one, how a CCG can support their development locally  , how a CCG can make the most of one they have, and we tackled the difficult questions and dispelled some of the myths about locums.

Finally, the Kings Fund produced a new report, “Clinical Commissioning: GPs in Charge”.  Author Ruth Robertson revealed they had discovered a frequently fragile relationship between CCGs and local practices, and predicted fewer, larger CCGs in future.  Less clear was whether GP leaders would remain in these bigger CCGs or take up residence in the new models of care.

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Locality Hubs: The Perfect Opportunity?

The BMA has produced a new document, ‘Safe Working in General Practice’. Now you might assume, particularly if you have read the accompanying headlines, this is simply a call for a limit to general practice workload and to establish 15-minute appointment times. But you would be wrong.

The document is actually about the introduction of what it terms ‘locality hubs’. These provide additional primary care capacity in a locality, delivered through multidisciplinary teams, and are created as a result of collaboration between practices. They operate as a place where triage can be managed centrally, and on-the-day demand can be managed across multiple practices in one location using a much wider skill mix.

The concept is not new. It was introduced in the General Practice Forward View (GPFV), where they were described as primary care access centres. The BMA say,

The sole initial purpose of locality hubs is the stabilisation and sustainability of general practice. Hubs are not walk-in centres: each hub would help manage demand across a number of practices and their respective patient lists, ensuring that patients in excess of safe working limits can still be seen by a GP or the wider primary care health team.’ p5

While the presentation by the BMA is in terms of a protection of core general practice, the reality is the model they are supporting is highly progressive. It incorporates all the key features of ‘modern’ general practice: the introduction of new roles; general practice operating at scale; the integration of practices with the wider health and social care community; and the development of the new models of care.

There is an unusual alignment in that the profession itself needs exactly what the wider NHS needs, manifested in these locality hubs. At the same time as providing support for core general practice, the system receives better access, more responsiveness, and an ability to deliver more joined up care, particularly between community services and general practice.

The sticking point is normally the funding. But as the BMA rightly point out, the funding has already been identified. The GPFV promises a further £500m per year recurrently from 2020/21 for extended GP access, and £171m between now and then from CCGs to support the development of this capacity. There is no obvious other route for this capacity to be delivered. There are no more GPs. Existing practices cannot take on any more work. This has to be the answer.

In what could be viewed as a once in a lifetime event, the stars are perfectly aligned. The profession wants the hubs, NHS England wants them, they fit perfectly with the introduction of the new models of care, and the funding is already in place. Opportunities like this are exceedingly rare, and must be grasped with both hands. While making the locality hubs a reality will still require conversations, trust, joint working, leadership and hard work, now is the time to do it. Seize the moment, because it may be a long time before another one like this comes along.

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