7
dec
0

Welcome to the club – the rise of Leg Clubs

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Guest Blog by Amanda Brookes, Locality/Projects Manager – Bradford-On-Avon and Melksham

Anyone working in general practice cannot fail to be aware of the misery that leg ulcers bring to their patients; regular attendances and multiple medications, legs wrapped like the Michelin man, the discomfort and the smell. No wonder so many patients end up with depression and social isolation.

But, as I discovered, it doesn’t have to be that way.

In 2008 the practices I worked for established a provider company and won a bid to provide the Level 2 Leg Ulcer Contract to sixteen practices in West Wiltshire. As we developed our specialist team of nurses and HCAs it became clear to me that the treatment of leg ulcers was a neglected area and that patients were suffering unnecessarily; there had to be an alternative. At the same time, with my Business Manager head on, I was concerned with the costs of multiple attendances and the rising cost of specialist bandaging.

Although I am not a clinician, in 2010 I attended the annual conference of the Lindsay Leg Club Foundation and was immensely inspired by Ellie Lindsay OBE and the model for Leg Clubs which she had developed in the mid-nineties.

Ellie was an ex-District Nurse and had set up around 25 Leg Clubs, led by District Nurses who invite housebound, potentially socially isolated patients into a social setting for care and chat. Her results on healing and recurrence rates were excellent. I invited her to talk to our Leg Ulcer team and we were so impressed we began talks locally on how this model might be made to work in primary care.

For those who don’t know, a Leg Club is an evidence-based initiative which provides community-based treatment, health promotion, education, ongoing care and social activities for people of all age groups who are experiencing leg-related problems.

Following a merger with two smaller practices, our original patient base of 14,000 grew to over 20,000 which resulted in more patients with leg ulcers and a lack of space. This was the ideal push we needed and we began to pursue the Leg Club model in earnest.

The doctors and nurses I worked with were incredibly enthusiastic but it was difficult to gain interest from those who held the purse strings. So we began a very time-consuming and frustrating hunt for sources of money. It was at this time, after running a number of community events with charitable organisations, that I came to the realisation that leg ulcers are not sexy!

It became bit of a running joke with colleagues, every-time I met anyone who could help or would listen, I talked Leg Clubs! I’m afraid I became mildly obsessed and evangelical but it paid off in the end when the Friends of Bradford on Avon Community Health Care gave me £12,000 of funding. Others then followed.

And it turns out the model can very much be made to work in primary care. General practice nurses provide the drop-in clinical support (through six stations) in a local community hall and we have a Doppler machine as part of a patient’s first assessment. A committee made up of Leg Club members is in control of the social side which includes activities such as a Balance and Falls Class, structured short walks program, an arts group, access to a podiatrist, support from a care co-ordinator, dementia advisor and ad hoc speakers such as Carers Support and Age UK – all of which remain accessible to members even once their legs are healed.

We estimate that members coming to the Leg Club have saved the practice around 20 appointments a week. The well-leg regime has no funds attached – but as our recurrence rates fell over two years from 75% to 25% there is evidence that it is a cost effective model. Membership is at 600, and legs are now healed in an average of 12 weeks, whereas in 2014 it was 19-24 weeks.

It is a constant battle to raise funds for the social side but we have regular fund raising events and local industry partners are very important.

The patients love attending the Club and the nurses love it also because they are not constricted by time; consequently the atmosphere is positive and fun. The practice likes it because it has reduced the number of times this group of patients come to the surgery and in many cases, their mental wellbeing has improved.

If you are thinking of setting up a Leg Club yourself then I strongly recommend you contact the Lindsay Leg Club Foundation (information at www.legclub.org– and you’ll see us on there!)

There is a lot of planning, fundraising and awareness-raising to be done before a Leg Club opens. There needs to be a Champion or Lead with the passion to take this project forward; it’s hard work and needs on-going support once the club opens. Nurses need to be trained in the infection control standards for community based care as well as admin staff to learn how the patient record and audits are produced. The Leg Club Foundation carries out an audit once a year by an independent clinical consultant and keeps a check that all the standards are being met and are safe. The Club submits weekly audits and any corrections are fed back to us to rectify.

I know I have become evangelical about Leg Clubs, but for a reason. They do work clinically, they make business sense and they provide a better service for patients. But if you are still not convinced you can either watch our short video on the subject here or contact me via email at amanda.brookes@nhs.net

30
nov
0

Where to start with CCG GPFV plans

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The crisis in general practice has led to individual practices making changes, on their own at first and then increasingly together.  CCGs should be facilitating this process through their GPFV plans rather than introducing big picture change, argues Ben Gowland.

There is something going on in general practice. Change is afoot. While nationally all of the talk and rhetoric is around STPs, new models of care and operating at scale, practices seem to be taking a different approach. CCGs should take note.

At the risk of stating the obvious, general practice is not one organisation. It is 7800 independent, individual business units, all operating in their own way. While the contract they deliver against is (essentially) a national one, how they choose to deliver against that contract is up to them. And it varies significantly. No two practices work in the same way.

Despite its obvious drawbacks, this variation has created a huge opportunity. For every single practice there are better ways they could be doing at least some things. For some practices there are better ways they could be doing most things. And as the crisis in general practice has started to bite, the response has been (as is the way of general practice) pragmatic. Practices are starting to focus on how they do things internally. “How we have always done things around here” is no longer good enough, because it no longer works.

What is starting to emerge are changes with quite astonishing results. Hours of administration time removed because of changes to the way documents are handled. Huge reductions in DNA rates because of changes to the way appointments, and cancellations, are handled. Swathes of clinical work moved from GPs as a result of the introduction of different types of clinician into the practice team. New types of appointment creating more efficient ways of meeting the ever increasing demand. The lives of the duty doctors being literally transformed by internal re-shaping of how appointments are handled.

Making the first real change is always the most difficult. But once achieved it often creates a thirst for more. Practices that were previously impenetrable islands suddenly let the drawbridge down, keen to share their success with others, and are newly open to learning from the success of others. This sharing brings mutual success, builds trust and strengthens relationships that had grown cold through the winter of the crisis.

And out of this trust and these relationships further improvements and changes are found to be possible. Accountancy fees, indemnity fees, regulation costs (and more) are starting to be reduced by practices working together. More new roles are introduced. GP-led multidisciplinary teams enable practices to tackle the workload in different ways, freeing up GP time for the patients who need it most. Once the rock is moving, it develops pace, energy and impact, and more and more is achieved.

All around the country (but not everywhere) this is starting to happen. The hard bit is the first step – recognising there are other ways to do things, and then making the first change happen inside the practice. Talking about big picture change in locality or CCG meetings is not what is important. Arguments about the rights or wrongs of MCPs won’t help. It is only doing something differently at the individual practice level that has an impact, that can get things moving.

Which brings me to CCG GPFV plans. General practice is still in crisis. Don’t turn the plan into a strategic template for the introduction of MCPs, or a way to fulfil a requirement for 7 day working when 5 days is currently out of reach, or the creation of complex bidding processes for limited pots of money in the name of “equity”. Instead, use the plans to help practices take the first step, or if they have taken the first step the second, or the third, or whichever is the next step to build the momentum local practices need to find a way out of their current predicament.

23
nov
0

What the Changes to General Practice Mean for Primary Care Premises

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The secret to what will happen in the future to primary care premises lies in the past. Understanding the current crisis in general practice provides vital clues as to the impact the new models of care and the like will have on estates.

The growth in demand on general practice (the number of consultations per head of population has more than doubled in recent years, in addition to the overall population growth) has not been matched by a similar growth in resources. The general practice estate is no longer big enough. Worse, the growth in regulation and the shift to NHS Property Services means the existing estate is becoming more and more of a cost pressure. Even though new, bigger premises are desirable, they are not necessarily affordable.

There are also less and less GP partners. In the last 10 years the number of GP partners has dropped by 9% while the number of salaried GPs has increased by 260%. As GP partners have become harder to recruit, many places have had to look at how to drop the requirement to buy into the property in order to attract new partners. As a result, GPs and GP practices are increasingly looking to “cash in” their property.

To cope with the pressures, general practice is making changes to the way it operates. New roles, such as pharmacists, physiotherapists and paramedics are being introduced to the practice; but only, of course, where they have the space. Less commonly, but increasingly representing the overall direction of travel, a number of places such as St Austell, Plymouth and Hampshire, are operating an urgent care “hub” – a single site where all of the on the day demand is seen by a multidisciplinary team, freeing up space on the other sites for longer planned and follow up appointments. And bigger practices are considering whether consolidation onto a smaller number of sites is possible in future.

But surely the Estates and Technology Fund has been put in place to address the estates problems in general practice? While the reduction in the match funding requirement is welcome (down from 33% to 0%), few practices so far have been able to benefit from the fund, especially compared to the number who spent hours completing the paperwork to bid for it in the first place.   Revenue consequences of new builds remain a problem for practices and CCGs alike, and the old notion that these simply have to be “absorbed” no longer washes.

The challenges general practice is experiencing mean some are looking to partner with other organisations to more effectively manage the demand. We are seeing more examples of practices joining up with volunteers and voluntary groups to offer more holistic care, and of practices trying to build links with community services. But space is a real barrier for many. Partnership working inevitably means some degree of co-location, and practices are not sat on empty rooms, waiting to be filled.

It may be that as a result of the new Sustainability and Transformation Plans (STPs) we have a reversion to some sensible join up of strategic estates planning, which will incorporate primary care premises. But it will need to happen quickly. In the meantime, the reality is that the new multispecialty community provider (MCP) and Primary and Acute Care Services (PACS) models offer a way out for general practice. When we dig underneath why GP practices are signing up to these new models, it is largely because these new contracts are offering to buy them out of their premises. Without this incentive, it is hard to see much movement towards them.

The pressure on general practice is such at present that if an attractive way out is presented, many are likely to take it. In the future, the trend will be to an increasing split of “hot” and “cold” GP sites, accelerated by the funding on its way for additional GP access. The move to operating at scale will ultimately lead to a reduction rather than an increase in the number of GP practice sites. And the development of MCPs and PACS models will see the estates increasingly owned by the community and acute trusts, within these new organisational forms.

16
nov
0

The one new role every single GP practice should adopt

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In all the work I have done on new roles in general practice, the role I have probably paid least attention to is that of “medical assistant”. They are tucked away within the Releasing Capacity in General Practice programme, under high impact change number 4, “Develop the team”, bullet point 5. It is small wonder they get overlooked!

Plus they are not really new roles. It is actually training for existing administration staff, specifically those who code, to be able to read, code and action incoming clinical correspondence according to agreed protocols, as opposed to passing everything on to the GPs.

But the impact is huge. I visited a practice recently who had implemented this system, and they were evangelical about the benefits! According to them the new system was saving each GP up to an hour a day. When the biggest pressure on GPs is workload it is not hard to understand why a change that can make a difference like this is so popular.

Not only is the GP time saved, but coding actually improves, and the administration staff undertaking the new way of working enjoy it and feel like they are contributing more to the practice.

Here is how it works. A lead GP from the practice is put in charge of working out how the different mail coming into the practice can be processed. The starting point is a set of protocols, worked out from practices where this has already been introduced. They really just require tweaking to reflect the specific needs of each individual practice, and then reviewing over time to continually refine them. The aim is to reduce the number of letters that need to be processed by a GP.

So for example if there is a letter informing the GP a patient has failed to attend a mental health appointment, the agreed action could be “book telephone appointment with the GP”. Instead of the letter going backwards and forwards between the clerical staff and the GPs, the action is implemented straight away. If the practice wants a different process to be followed for this particular pathway, it can set its own rules for the clerical staff to follow. Meanwhile letters that the GP absolutely needs to see, such as a safeguarding issue or a serious or complex diagnosis, are passed straight on to a doctor.

The other key difference is that instead of the letters going to the GP to outline what needs to be coded, and the letter then coming back to the coders, the clerical team will code directly from the letter. After the initial training, the lead GP audits and checks and feeds back very regularly at first, but then increasingly infrequently, as the clerical team develop the skill set. The wasted GP time is cut out of the loop.

The practice I visited, who had been refining the system in their practice over 3 or 4 months, estimated a reduction of 70 to 80% in the correspondence now going to GPs, compared to before the introduction of the scheme.

This new way of working, which I have seen termed “workflow redirection”, “workflow optimisation” and “document handling”, depends very much on the oversight, governance and audit within the practice from the GP lead for it, and the new skills and new way of working of the administration team, or “medical assistants”. The practice I visited did feel that it increased the administration burden on the clerical team, and they had to increase capacity to absorb the additional requirements. The team in Brighton who first developed the change suggest it requires an additional 3.5 admin hours per day per 5,000 patients. You can see the video they have produced about the change here.

Introducing medical assistants might not be the sexiest of changes developed to support the challenges facing general practice at present, but it may well prove to be one of the most useful. If you are struggling to make any change at all in your practice, I would highly recommend you start with this one. Start with just one GP’s letters. Measure the benefits. Others will soon become interested!

9
nov
0

Who Can Represent General Practice Locally?

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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.

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