Who Can Represent General Practice Locally?

To ensure they are adequately heard in the development of STPs, GP practices need a strong and clear voice. But who will represent them? In his latest blog Ben argues that there are a number of options but ultimately local GPs must decide this for themselves.

There is not always strength in numbers. While there are 7875 GP practices, there are only 154 acute trusts, yet the influence of the latter appears far larger in the development of the 44 local Sustainability and Transformation Plans (STPs). Worse, the numbers work against practices: while it is possible for every acute trust to be represented on STPs (there are an average 3.5 acute trusts per STP), the same is not true for every GP practice (there are an average 179 GP practices per STP).

Does this matter? Is representation important? General practice has left many of these things alone in the past and in the main has avoided what would have been a colossal waste of their time. But the world is shifting. Alongside the ever growing pressure on resources, providers are being asked to come together and decide for themselves how what little money there is should be spent. Instead of a series of bilateral agreements between the different providers and a system arbiter, the STPs are looking for a single agreement across all parties.

In the past general practice could ignore local developments, protected by a single, nationally negotiated contract. But now the NHS is shifting to a series of bespoke, local agreements. Much of the promised additional £2.4bn for general practice is coming outside of the core contract. New, local, multispecialty community provider (MCP) contracts are emerging, with much more room for local negotiation than was ever possible with the national GP contract. It is a brave GP practice that will allow the other providers in the system to determine how much funding, and with what strings, they should receive.

So if we accept it is not possible for 179 practices to all represent themselves in local discussions, even if only for practical and logistical reasons, who should represent them? Insufficient thought and effort has so far been put into resolving this question, not only by local systems but also by practices themselves. In many cases the local system has decided how general practice is to be represented. But if I ran a practice, I would want to make that decision myself, along with my fellow practices.

There are a number of options available. First, the CCG could represent its practices. It is after all a membership organisation and each practice is a member of its local CCG. The problem comes because the remit of CCGs extends across all providers, and they continually have to go to extraordinary lengths to demonstrate they are not favouring their member practices. It is more or less impossible for CCGs to both carry out their role as CCGs and simultaneously represent general practice effectively.

Second, the RCGP could represent general practice. The RCGP has appointed RCGP ambassadors for each of the 44 STP areas, whose role (according to the RCGP website) is to “maximise investment in general practice at a local level, track developments, and make sure that GPs have a very strong voice in the GP Forward View across England”. The RCGP is supposed to focus on improving patient care, clinical standards and GP training, and while I am sure the RCGP ambassadors are a good thing for general practice, it is hard to see them having the mandate or infrastructure to be able to adequately represent practices in local negotiations.

There are two more realistic options. The first is the local LMC. Their explicit purpose is, after all, to represent general practice. There is often resistance to their inclusion, as they are seen more as a trade union than as a reasonable representative of GP practices. Their leaders are rarely viewed, for example, in the same way that an acute trust CEO might be viewed. But they are statutory bodies, funded by a statutory levy on practices. Tracey Vell, leader of the LMCs in Greater Manchester, argues it is essential LMCs talk for GP practices in STP discussions, and also recounts how it was only through grit and determination that she was able to ensure they gained a voice around the table in Manchester.

Second, the local federation(s) could represent general practice. This is tricky because federations vary so significantly in the way they are set up and what they have been established to do. Where their role is to generate and deliver additional services across a group of practices, local practices can become resentful pretty quickly if the local federation leaders are seen to overstep the mark and assume they can talk on behalf of their member practices. But equally where one of the reasons for the local federation is to strengthen the voice of the member practices then this can work really well.

Nothing of course is stopping GP practices setting up a federation just for this purpose. If they don’t feel (for whatever reason) that the way they are being represented is satisfactory, they can create a federation, appoint a spokesperson, and all they would need to fund between them is the cost of that person’s time.

It is also not unreasonable for there to be more than one voice for general practice. If the 3.5 acute trusts in each STP area each have their own voice, then general practice can reasonably expect to have more than one voice. In Manchester they have a “GP Advisory group” which contains the federation and LMC leaders, and then this group has a voice on the main board, mirroring arrangements for the acute trusts.

We are at a point in time when local representation of GP practices, and the establishment of a strong voice for those practices, is more important than ever before. Unusually, GP practices need this representation more than the system needs it. If effective representation has not yet been achieved, it is GP practices themselves who now need to take responsibility for making it happen.

Make General Practice your CCG’s Priority

What will the GPs working in CCGs leave behind when clinical commissioning has been dismantled? Ben Gowland argues that now is the time for them to consider this legacy and to act swiftly and single-mindedly…

This week Simon Stevens exhorted GPs on CCG Governing Bodies to ensure the money promised to general practice reaches its intended destination. He condemned the compounded impact of a decade of disinvestment in primary care, and reaffirmed the necessity of changing the trend to one of investment above the rate of the rest of the NHS. Mr Stevens declared the final destination of the GP Forward View money the responsibility of GPs.

At the same event Professor Steve Field, CQC Chief Inspector of Primary Care, declared an inspectorate for general practice is only needed because local GP leaders have not done their job properly. The CQC is a necessary evil caused only, according to Professor Field, by the failures of local GP leadership.

These declarations will rankle with GPs. CCGs in many areas do not have, and never have had, responsibility for the commissioning of general practice. They are castigated on an almost daily basis for their failure to monitor conflicts of interest thoroughly and effectively, and for allowing their particular part of the system to slide into financial imbalance. And now suddenly we have bewilderment expressed at a national level as to how GPs in the form of CCGs could have been given the purse strings and at the same time allow general practice to fall into its current parlous state.

At the same time, clinical commissioning is being discreetly dismantled. STPs, local accountable care organisations, and devolution are working together to diminish the role of commissioning. Ever since the shift from competition to integration with the publication of the Five Year Forward View, power has been stripped from those attempting to use contractual levers and plurality of provision to effect change. Unachievable financial pressures have been added to CCGs to “even up” the playing field between commissioners and providers, so all can “share the pain equally”.

What is a GP on a CCG Governing Body to make of all of this? What should they do?

It is time to think legacy. It is time to look forward 5 years and think what impact did I have on local general practice? What did I do that made a real difference?

The door has been opened. Simon Stevens and Steve Field are telling you, explicitly, it is your job and your responsibility to support general practice. Take them at their word. Do everything in your power to ensure the GP Forward View money reaches general practice. Reverse the trend of disinvestment and ensure funding for general practice reaches 10 or even 11% of local NHS expenditure.

Hold your own CCG to account for increasing its investment in general practice. Use delegated commissioning to shift the focus of the CCG away from the acute trusts and onto the stated national priority of general practice. Be single minded. Use the opportunity.

Time is limited. You are now being berated at a national, as well as (I assume) a local, level for not using the situation you are in to make a difference to general practice. Stop listening to those who are persuading you the right thing is to forego investment for the sake of financial balance, or that the CCG can’t afford to create its share of the £171m earmarked from core CCG allocations for general practice.

The time for self-sacrifice is over. It is not serving you or your local population. However uncomfortable it feels to say to a room of stakeholders, all desperate for commissioner money, that you have weighed up all their needs and have decided to give it to yourself and your colleagues, that is what you have to do. Putting general practice, primary care and all of out of hospital care first is a national priority. Make it yours.

How I Discovered the Future of General Practice

Looking at solutions for the problems facing general practice and learning from those who have already got it right inspired Ben Gowland and his team at Ockham Healthcare to write a book. In his latest blog Ben explains why the resultant book should be essential reading for anyone with an interest in general practice.

General practice is a difficult problem to solve. Few now dispute the profession is in crisis, and yet despite the publication of the General Practice Forward View (GPFV) we seem no nearer to a consensus on what the future of general practice will look like.

When I left my role in the CCG I started by trying to really understand the problems general practice was experiencing. I visited a range of different practices and spoke to many GPs and found the problems were even worse than I had imagined. You can watch the TV documentary I made about this here.

I then started talking to people; to GPs, practices, and sometimes whole areas, who had found a way through the problems. There are nearly 8000 GP practices in England, and while many are struggling, some have found a way through and are thriving. I wanted to learn from what they had done, and I wanted to share that learning with others. In February this year we started publishing The Ben Gowland Podcast every week – short recordings of conversations I have had with those who have found a way through the problems general practice is experiencing.

As I listened to the experiences of both those who had found answers and those who were struggling, I was struck by the realisation in many cases both had tried to do the same things. Practices who were struggling had joined a federation but it had made no difference. Practices that were thriving had formed a federation and it had had a transformative effect. I realised there is no simple “answer” to general practice, no single solution that can be applied to solve the current crisis. How an answer is implemented is often more important than the answer itself.

So to find a way forward, a future, for general practice, I believe the best place to start is those practices that have made the future a reality already. Rather than starting with a hypothesis and testing whether it will work in general practice, it is better to start with what has worked already and try and capture the learning of how this happened for others. And to this effect we decided to publish a book, one that took real life case studies of what has worked in general practice, and then used those case studies to extract the learning for others.

In the book we have been able to capture the experiences of those who have made operating at scale work, and use these to identify 10 practical steps for other practices to follow. These steps are the difference between practices losing £20,000 each of investment in a new federation that never goes anywhere, to being able to reduce costs, grow income and manage workload better. They are not rocket science. They include things like, for example, ‘being upfront about the commitment needed for each practice’ and ‘ensuring the right motivation’ of each practice who you are going to operate at scale with, but they are critical to ultimate success.

Equally the book contains the same for introducing new roles, introducing new models of care, and it even considers how CCGs and commissioners can have a transformative impact on their local practices. The book starts with the case studies, analyses what they have in common, and distils the learning so that others can do more than find an answer – they can learn how to make the answer work for them.

The Future of General Practice: Real Life Case Studies of Innovation and New Ways of Working is out today (Monday 10th October). You can buy your copy here. The future of general practice requires more than an understanding of what solutions can help. It needs an understanding of how to implement these solutions in a way that will enable a new future to be created. The book provides both.

Community Engagement and Social Prescribing in General Practice

In a guest blog this week, Sheinaz Stansfield, a Practice Manager from Gateshead, gives an insight into how community engagement and social prescribing is making a real difference in her practice. If you want to read more about Sheinaz’s practice they appear as a case study in our new book “The Future of General Practice; Real Life Case Studies in Innovation and New Ways of Working”. The book can be purchased here

It was snowing in Gateshead at 9am on the Friday before the bank holiday. On leaving the surgery I bumped into Jez, a homeless patient, recently released from prison. I was late for a meeting and he followed me out, cold wet and hungry, when he burst into tears. I gave him some money for breakfast and asked him to wait for me in a local café. By this time, I was also cold, wet and very late – but I had a warm car to escape to.

Working jointly with the 3rd sector, the practice had just won some funding to manage people with complex need; those who were too complex for us to manage in primary care, but not complex enough to fit the criteria for other local services. We have many such patients; those who have GP appointments several times a week, because of social issues impacting on their health and cannot possibly be addressed through the health system alone. People who have nowhere else to go.

At Oxford Terrace and Rawling Road Medical Group in Gateshead, our social prescribing is led by two Primary Care Navigators (HCA’S). Having developed an extensive “dynamic” directory of services, they are well respected and known to all of the statutory and non-statutory services within our GP catchment area. Jez and others like him are also known to them and we have worked with a local charity Fulfilling Lives, and won transformation funding (from the local Authority) to test a new model of care. We were meeting that morning to develop a mobilisation plan.

The meeting was attended by our practice based complex care team, who take a patient-centred approach to case management. The team consists of our frailty nurse, care navigators, occupational therapist and community matron. Between us we were able to identify the first half dozen patients for Alex, the co-ordinator. Jez fitted the bill perfectly. I introduced Alex to him as her first patient!

A core component of this service will be to identify peer mentors as volunteers for befriending and support. Fortuitously, my next engagement was a training session for Practice Health Champions. We have 39, who work with us as volunteers leading various groups including knit ‘n’ natter, reading, walking and others. They also host events for patients including a flu fair, summer health fair and an annual Christmas dinner on Christmas day. A new event for this year will be a veteran’s engagement event and a full WW2 re-enactment on 11th November! Such is the power of unleashing energy to connect patients’ skills and passion with staff commitment.

This morning we were welcoming 10 new volunteers into the fold. The training was developed and led by other champions, facilitated by the practice, hosted by a local charity. Therefore, there was no additional cost to the health and wellbeing system. We were connecting local resources, building alliances around patient need and supporting each other to help the most vulnerable and dispossessed people in our community. There is no funding in the GP contracting mechanism for us to do this work, we do it because we care, it adds value and we are passionate about our people.

We have many Practice Health Champions with enduring mental health problems running these groups. Two champions, recovering alcoholics, run the men’s group and the Practice Facebook page. With training and support, they will become our first two peer mentors, for this new service.

My afternoon was spent back at the desk, trying to navigate my way through the tangled bureaucratic mess that is the transformation fund (GP Premises). I was interrupted by a phone call from a neighbouring Practice Manager, wondering how she was going to manage demand with two partners retiring and no applicants for the vacancies. We talked about social prescribing and the complex care team.

At this point I decided to call it a day. At 6pm as I left the practice, one patient was waiting in the waiting room, the sun was shining. Reflecting on my day, I smiled at the patient on my way out, looking forward to the long weekend ahead. My day job as a Practice Manager is full of “bad” NHS rules that block and frustrate most of our attempts to care for people the way they need to be taken care of. Today though, we had made a difference to at least one person, who might have otherwise spent the long weekend on a park bench, tired, cold and hungry.

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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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