20
dec
0

What is new in General Practice – Late 2017

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The end of 2017 marked something of a watershed for general practice. For the first time, the focus seemed to shift away from the crisis general practice is in, to what the future that awaits general practice will be.

And threaded throughout the free content from Ockham Healthcare, we saw glimpses of this future. There was outrage (in some quarters) at the growth of e-consultations – and I spoke to Mark Harmon from e-consult about where we really are currently. We saw the continued growth of the super-partnership and I spoke to Mark Newbold for the latest update from Our Health Partnership as they continue to develop. There was the continued development of new roles in general practice and I spoke to Jenny Drury about paramedics undertaking the majority of GP visits. Jonathan Serjeant and Mark Spencer from NHS Collaborate shared pictures of the future with general practice bringing whole communities together, and we learned of a new style of management leader in general practice from Claire Oatway at Beacon Medical Group.

3 important questions for the future of general practice were identified: Will general practice remain independent? What scale will general practice operate at? What will the role of federations be? In the end it became clear that it is ultimately all going to be about collaboration. The Nuffield Trust produced a report on collaboration in general practice, and federations have come back into vogue. We identified good reasons for practices to join (and not to join) a federation. No longer just needed to subsidise meagre general practice earnings with additional revenue streams, now (and in the future) they will also need to support the delivery of core general practice and to give general practice a voice around the accountable care table.

All the more important because “accountable care” has developed into the potential new game-changer for general practice. Nick Hicks explained what accountable care means, and how an outcomes based contract might actually work. The new ACO contract was published back in August, but the involvement of general practice is more likely to come from leaders getting out and talking to practices. Anna Starling shared lessons the Health Foundation has distilled from the work of the vanguard sites, and Nick Hughes explained first-hand what it is like to lead a federation within a PACS vanguard. We thought about the impact commissioning has had on general practice (overall, not good), and highlighted the importance of a proactive transition from CCGs to accountable care for general practice (here and here).

In the end, we concluded the general practice forward view is not going to change general practice, STPs are not going to change general practice, the revitalised federations are not going to change general practice – it is GPs themselves accepting the situation they are in and making the necessary changes that ultimately provides the only way general practice can move into its new future.

Merry Christmas and a Happy New Year to you all from everyone here at Ockham Healthcare, and I look forward to sharing the continuing journey with you in 2018!

13
dec
0
Here and there

What got general practice here won’t get general practice there

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There’s a tricky issue at the heart of the general practice crisis. Ostensibly, those working in general practice need to do things differently. It’s tricky because if I accept I need to do something differently, it means I am taking responsibility for the difficulties I am facing, even though the situation is not my fault.

To try and pick a way through this, I am going to lean heavily on a book by Marshall Goldsmith, “What got you here won’t get you there: How successful people become even more successful” (2008). I found this a really helpful book when I was a newly appointed CCG accountable officer. Previously, as a middle manager and running a small organisation, I had always been successful by being very task focussed, by making things happen, and by delivering results. What soon became clear was that this style of managing was not effective when I was the leader of a larger organisation.

It turns out what I needed to do was spend less time trying to force things to happen, and more time communicating what the organisation was about and where it was going, and listening and talking with those who worked in and with the organisation. I needed to be visible, and trust the managers working in the organisation to make things happen, whilst I focussed on making sure the direction and priorities were clear and understood by all.

It might sound obvious, but it was a very difficult personal transition. As Marshall Goldsmith explains, it was difficult because of my personal beliefs. He describes it like this, “One of the greatest mistakes of successful people is the assumption, “I behave this way, and I achieve results. Therefore, I must be achieving results because I behave this way.”

It was hard to change the way I behaved because it had always worked for me in the past. But the world around me had changed, and to be successful I needed to do things differently. The difficult bit was really believing that it was me that needed to change, rather than falling into victim mode and blaming the people and organisations around me. Marshall Goldsmith puts it like this,

“Many people enjoy living in the past, especially if going back there lets them blame someone else for anything that’s gone wrong in their lives. That’s when clinging to the past becomes an interpersonal problem… When we make excuses, we are blaming someone or something beyond our control as the reason for our failure. Anyone but ourselves.” 

I remember the point at which I realised it was me that needed to change. We had been a really successful practice based commissioning group, but had struggled in the transition to becoming a CCG. It was easy to dwell on the successes of the past, and blame the challenges we were facing on others. But ultimately that wasn’t going to help. For me it was facing the feedback from our CCG authorisation process (remember that?) – it was as if that was the event I needed, to get me to understand I had to do things differently to change the situation. Back to Marshall Goldsmith,

“There’s nothing wrong with understanding. Understanding the past is perfectly admissible if your issue is accepting the past. But if your issue is changing the future, understanding will not take you there. My experience tells me that the only effective approach is looking people in the eye and saying, “If you want to change, do this.”

Focussing on my own past successes, and how events had conspired against us, was not helping me. In fact, it was holding me back. Which brings me to general practice. Practices are in a difficult position. It is not their fault. But they are the ones in the difficult position. Getting out of this position requires different behaviours to those that were successful in the past.

This is the kind of thing that is easy to say (or blog about!), but hard to act upon. It only becomes possible when an individual really believes things need to change, because without that conviction people take half-hearted steps (or none), or do the same as they have always done, which won’t lead anywhere productive. I don’t know what the equivalent of my ‘authorisation-moment’ will be for individual GP partners, or practice managers, or federation leaders, but the truth of it is that for their situation to change, they are the ones who will need to change. Not to satisfy others, but for themselves.

The environment general practice now finds itself in requires collaboration (with other practices, NHS organisations, the voluntary sector, social care), a willingness to explore new ways of working, and an openness to letting others do what for many years has been the sole domain of GPs. The changes themselves are not that difficult, but personally getting to the point where you are prepared to make them, and adopting the new behaviours that are needed, is.

If we could apply Marshall Goldsmith’s work to general practice directly, perhaps it would read: “What got general practice here won’t get general practice there: How successful practices become even more successful”. Or “What got GP federations here won’t get GP federations there: How successful federations become even more successful”.

The world has changed for general practice, and, like it or not, it is GPs and those working in general practice that will need to change if general practice is to thrive into the future.

6
dec
0
Accountable Care Clinical Commissioning Part 2

Becoming a butterfly…Part Two

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General Practice and the Transition from Clinical Commissioning to Accountable Care –2

Last time (here) I explored the negative impact that dual running the existing commissioning system and the future accountable care system was having both on general practice, and on the success of the new accountable care models themselves. We want GPs to focus on engaging with accountable care, to ensure general practice and the registered list is central to it. But the commissioning system hasn’t stopped, and we still want GPs leading and actively participating in the commissioning system.

By creating an artificial split between general practice as providers through federations and general practice as commissioners through CCG localities we are making it difficult for core general practice to be involved in the new models (How are practices represented? Do federations have a mandate to speak for practices? etc.), wasting valuable general practice time, and unnecessarily limiting the GP leadership capacity available to the new system.

If the heart of the transition is moving where the energy for redesign sits, how might we shift it from the GPs sitting in their commissioning role, to the GPs sitting in their provider role (rather than simply asking two different groups of GPs to do both)?

Could we transfer the responsibility for redesigning services from CCGs to groups of providers now? In practical terms, could we cope now without GPs carrying out their commissioning role, and ask them to take on the redesign role as providers, working with local partners? Could we transfer the resource we spend on our CCG locality structures to the GP federations (and what is the real return on the investment of that money anyway?), against a set of outcomes and outputs that we want in return? Wouldn’t that, in fact, be modelling the future?

Immediately I can feel the unease growing around the dreaded conflicts of interest. How can we give GPs the responsibility to design something they will potentially benefit from as providers? It has been the bane of CCGs in recent years, and this could feel like a step backwards.

But isn’t is true that within an accountable care model of providers working together within a fixed envelope of money, some of those providers sat round the table will end up providing more, and some will end providing less? The prevailing wisdom suggests the likely shift is from secondary care into primary care (a shift the purchaser/provider system singularly failed to enact). The logic of the new system is that, for the new system to be successful, exactly what we fear from a conflict of interest perspective (general practice designing services that shift resources into primary care) is what is needed for the new system to succeed.

If we place the redesign resource for a system into a provider partnership that the GP practices are part (maybe a major part) of, then all we are doing is modelling the future. We have to unlock the creativity of front line clinicians working together to improve the lives of the populations they serve. We can’t do that if we bind them in bureaucracy.

Attempts to develop a contractual approach to overcome the potential conflicts issue (the dreaded ACO contract) has already proven unwieldy and time consuming, focussing energy on form and governance structures and away from the key challenge of making change. In our transition plans from the old system to the new we need to find a way of shifting the energy for redesign as early as possible to make it central to the new way of working.

We are wasting valuable GP resource in dual running a system we are winding down alongside the new system we are trying to put in place. We need to accelerate the shift from the old to the new. The longer we wait, the harder it will be to engage general practice in the new model, and the more disenchanted they will be with the old model as it is dismantled around them. If we don’t do this now, then when?

29
nov
0
Accountable Care Clinical Commissioning Part 1

Becoming a butterfly…Part One

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General Practice and the Transition from Clinical Commissioning to Accountable Care – 1

The NHS is faced with something of a conundrum at present. We have the system of commissioners and providers as laid out in the legislation and statutory architecture, and the system of providers working together as laid out in the Five Year Forward View and STPs. The two are fundamentally different. The conundrum is how to manage the transition from one to another, without any legislation or mandated transition plan.

General practice sits at the very heart of this transition. The new models of care are based on the registered lists of GP practices, yet all the while it remains mandatory for these practices to be part of a CCG. We want GPs to (eventually, at a time yet undetermined) stop doing “commissioning”, and (immediately) to start doing “accountable care”. Unsurprisingly, the early lessons are that general practice needs to be involved in accountable care from the outset.

The transition has of course already started. STP leaders and teams are growing in number and power, and we are starting to see reductions in the number of CCGs and also in the number of CCG Accountable Officers, as CCGs increasingly share management teams. The overall system leaders are no longer exclusively commissioners, and they are grappling with how to make the transition from the existing system to the new one a reality.

At the heart of this transition is the shift of where what I would call the “energy for redesign” comes from. In a commissioner/provider split, the commissioner designs the pathways and ways of working and contracts each provider to deliver their part. Within an accountable care model, the providers work together to redesign the pathways and the interfaces between organisations and clinicians. For me, it is this shift of the energy for redesign from commissioners to providers that is critical to the success of the new system.

If we go back to why we wanted GPs involved in commissioning in the first place, it was because of their unique perspective on the wider healthcare system and how it impacted on their patients, and their ability to use this to drive change for their registered list. Is it any different with accountable care? I don’t think so. We are simply trying to harness the same insights, knowledge and experience within a different system. In truth, we are doing it because the commissioning system has not worked as the driver for the change that the NHS needs.

How, then, do we make this transfer of the energy for redesign from commissioners to providers a reality? How do we empower GPs to start to make the changes we wanted them to make in commissioning, but not through contracts but by building relationships with other providers?

Most places are encouraging the development of federations, or other at-scale general practice vehicles. These are then seen as the GP “providers”, and the sub-structures of commissioning groups, often called localities, are seen as the GP “commissioners”. We then try and talk accountable care and the future with the federations, and commissioning and business-as-usual with the localities. But this has three fundamental problems. First, we are halving the already limited GP capacity available by splitting it between the two. Second, engaging GP federations rather than practices and practice representatives in emerging models of accountable care (unintentionally) limits the general practice input to those activities the federation undertakes and often excludes core general practice. And third, the GPs who have built experience of working in partnership through their CCG work are left in the commissioning camp when they are desperately needed in the accountable care camp.

Dual running general practice as both commissioners and providers suits the system because of the complexity of the current situation, but we are not serving an already overstretched general practice well, and we are diluting the potential impact of the new system right from its very inception. Next time I will explore whether within the transition we can empower general practice to make a fuller shift to the new system earlier, without resorting to the bureaucracy and upheaval of the proposed ACO contract.

 

22
nov
0
Joining A Federation

Seven good (and seven bad) reasons to join a federation

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Joining federations is currently de rigueur in general practice. But is it right for everybody? For federation leaders, is it important that practices join for the right reason, or is it more important that as many practices as possible join? And for a system trying to push for general practice at-scale, does the underlying motivation of practices to work together matter, or should we be pursuing the goal of scale regardless?

As someone who has led a federation in the past, and now works with practices and federations up and down the country, my view is there are good and bad reasons for practices to join a federation. When federations form with practices joining for “good” reasons, federations can fly quickly. Initiatives can get off the ground rapidly, a powerful voice for general practice can be formed, and partners can find the group easy to do business with.

Conversely, when practices have joined a federation for the “bad” reasons, progress can be painfully slow. The group can be beset by internal arguments and in-fighting from the start. Gaining practice agreement for any, even minor, initiative can be extremely challenging and the leaders are often disconnected from their members; unable to speak with any real authority for them.

Here are my seven “good” and “bad” reasons to join a federation:

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