8
nov
0

Guest Blog – Six Secrets to Active Signposting Success

Posted by Blogs, The General Practice BlogNo Comments

In Episode 62 of the General Practice podcast (here) Nick Sharples explained Active Signposting; a system of non-medical telephone triage. In this guest blog Nick describes the six keys to successful implementation.

With the GP Forward View strategy now well established, many CCGs, GP Federations and individual Practices are seeking to commission training in the two High Impact Actions (HIA), for which NHS England has provided ring-fenced funding.

Active Signposting is one of these and has the potential to save up to 26% of GP consultation time if fully and effectively implemented. But how do you introduce Active Signposting in such a way that the potential savings are optimised? And what do you need to consider when commissioning such activity?

Here at DNA Insight we have identified six key elements of success:

  1. Preparation is Vital

Introducing Active Signposting brings a change to the way in which the Practice currently operates, and it will affect the entire Practice Community, albeit for the better. It is not just the training of the reception team that is important – but how the system is introduced to the whole team.

You or your training provider should consider:

  • The need, scope and creation of a Service Directory (start small and build over time)
  • The building of an EMIS or SystmOne template to allow signposts to be recorded and exported for analysis
  • The need for Red Flag Protocols to be articulated, written down and available to Receptionists
  • The need for the GPs or the Federation/CCG to decide which of the available alternative services (in-Practice or outside in the community) offer the most potential for early Signposting wins. These services should be amongst the first to be introduced but will almost certainly need some additional consultation to ensure they are ready for the increased flow of patients. (Where available, Pharmacy and MSK/Physio related services top the charts for delivering the greatest numbers of signposting opportunities.)

All of these activities can be developed concurrently while you are going through the procurement process for a training provider, but ideally, they should all be in place before the training of your Reception team starts. In that way, your Receptionists can train on scenarios that will be immediately relevant when the Signposting starts.

  1. Engage the Whole Practice Community

Active Signposting will not happen just because you’ve been on a course. GPs, Practice Managers, Clinical staff and external service providers such as Pharmacists and Physiotherapists all need to be engaged in the programme for the benefits to be realised.

The training programme offered by your provider should be bespoke to your specific needs. They should take time to understand the local dynamics of the Practice and the wider Federation or CCG within which it operates – customising the training accordingly, so that it is both relevant and valuable.

  1. Face to Face or Online?

Whilst some training works well when delivered remotely, in Active Signposting it is the face-to-face practice and the interaction with colleagues that goes a long way to making sure the techniques will be adopted on return to the Practice.

Trying out new techniques in a safe training environment, with a colleague on the end of the phone playing the role of the patient, provides the necessary self-confidence for Receptionists to introduce the techniques when they finish the training.

  1. Bring Everyone to the Training

Encourage your commissioners, Practice Managers and GPs to attend the training, alongside the Reception team. Such high level attendance not only empowers the Receptionists with the authority to apply the techniques they are taught, it also exposes managers and GPs to the realities of life behind the Reception desk.

If training budget is an issue, consider running a pilot with a complete practice team or several. This is far preferable to trying to spread the knowledge across the organisation by training a couple of Receptionists from each Practice, and then hoping that they will magically be able to train their colleagues when they get back. Whilst nice in principle, it almost never works in practice.

  1. Promote the Service to your Patient Community

Active Signposting is a Win-Win for all members of the Practice community, and the patients are no exception. Making them aware of the introduction of Active Signposting/Care Navigation will encourage them to share their symptoms with the Receptionists, which will allow a signpost to be offered.

One of the most effective ways to do this is for the senior GP to record a message on the front end of the Practice phone system encouraging patients to share their symptoms with the reception staff.

  1. Have a Formal Go Live Date

It’s not unusual in our experience for the training of the Reception team, and the separate but necessary preparation of the Service Directory, Data Collection template and consultations with chosen service providers, to get out of sync.

It is important however that all are in place prior to your ‘Go Live’ day. As the saying goes, “You never get a second chance to make a first impression”. With so many stakeholders involved and affected by the change, getting it right first time is essential.

DNA Insight provides support and training to GP Practices in Active Signposting, the Management of Medical Correspondence, Reducing Missed Appointments, and Quality Improvement & Leadership. These High Impact Actions are designed to transform General Practice as part of the NHS England’s GP Forward View strategy. Please contact us on 0800 978 8323, email info@dnainsight.co.uk or visit our website at www.dnainsight.co.uk.

18
oct
0

Collaboration in general practice

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The Nuffield Trust have published a new report[1] on how collaboration between GP practices has developed over the last 2 years. It is based on a survey of 565 GPs and practice based staff, and 51 CCG chairs and accountable officers. It makes for fascinating reading. But what can we learn from it?

The first point is the findings have been skewed slightly by the availability of funding for extended access to general practice, including recurrent funding from this year onwards. As a result, over half of collaborations made improving access one of their priorities, and it was also the highest ranked potential benefit. The access funding has not been available to individual practices, and even if it was few were keen to take it up. Consequently, it has ended up almost as a system lever to provoke more joint working between practices. The concern is that its success in that regard may lead to similar types of “incentives” in the future.

But that aside there is much to consider. I have two hypotheses about federations. The first is that the current crisis in general practice is driving collaboration between practices to support delivery at practice level. In the past, federations were primarily about transferring services to the community, but I would suggest this has changed to a focus on practice-sustainability over recent years.

Does this hypothesis stack up in light of these survey results? It would seem so. 67% of respondents identified improving the financial and organisational stability of practices as a potential benefit of collaboration, higher than the 53% who identified the transfer of services into the community.

But interestingly only 46% of respondents reported their collaboration had identified improving the financial and organisational stability of practices as a priority in 2016/17 (the exact same percentage who identified transferring services into the community).

Why might this be? If GPs and practices are joining federations to improve the stability of their own practice, why is there this discrepancy in the number of federations who then prioritise it? Other survey responses provide clues. Smaller collaborations, covering less than 100,000 population, were much more likely (47%) to have it as a priority than larger collaborations of 100,000 population plus (37%). And collaborations formed more than two years ago were more able to fully or partially achieve the aim of improving practice sustainability.

It is because the ability to improve practice sustainability requires trust. It requires practices to trust the federation enough to allow them to take control of parts of the business that have historically always been within their control, right through from ordering supplies to employing staff and managing their visits. Smaller groups of practices, and practices that have been working together for a longer period, are more likely to trust each other (because they know each other), and as a result encourage and enable the federation to take steps that might benefit them, even if it means ceding bits of control.

If federations really are going to make a difference to member practices then this journey of building trust is one they and their practices will need to go on together.

My second hypothesis is that federations are needed to ensure GP practices as providers have a voice in the emerging new models of care. Well at present, it would seem, GPs don’t agree, with less than 9% of respondents identifying it as a potential benefit of a collaboration, and an even lower percentage reporting it as one of their collaboration’s 2016/2017 priorities.

At the same time over half of GPs responded that general practice had been not at all influential in shaping their local Sustainability and Transformation Plan (STP).

Maybe GPs don’t see it as the federation’s role to represent them in discussions about new models of care. But if it is not the role of the federation, whose role is it? The GPs in the CCG have to go to great lengths not to be seen to be favouring practices over other providers in their role as local commissioners, so it can’t be them. LMCs are the only other option, and other providers do not see LMCs as a fellow-provider they can collaborate with in an accountable care set up. Like it or not, it has to be the federation.

In summary we have learned that clear financial drivers like the access funding can successfully drive collaborative working across practices. Practices want collaborative working to help them with the challenges they are facing, but the reality of making that happen is proving difficult. It relies on trust, which is a hard won and easily lost currency. And finally the need for practice leadership within the accountable care arena by federations is one that has not yet been fully recognised.

[1] Kumpunen, S. Curry, N. Farnworth, M. Rosen, R. (2017) “Collaboration in general practice: Surveys of GP practice and clinical commissioning groups” Nuffield Trust, Royal College of General Practitioners survey www.nuffieldtrust.org.uk/research/collaboration-in-general-practice-surveys-of-gp-practice-and-clinical-commissioning-groups

4
oct
0

What does accountable care mean for general practice?

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The NHS world is changing. I wrote last week about the impact of commissioning on general practice, and this week I consider what the move towards accountable care organisations and systems means for GPs and practices.

What is accountable care? The Kings Fund has helpfully described it as comprising of three core elements,

“First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.”

Rune reading, particularly in the NHS, is a difficult game. But all the signs point to accountable care organisations and systems (often used interchangeably to describe very similar arrangements) as the direction of travel. STP plans, NHS leaders and politicians are all making noises to suggest it is exactly where we are heading, despite the reticence to create new legislation with the disaster of the last NHS legislation so fresh in people’s minds.

If accountable care is where we are going, what does it mean for general practice? To help answer that, there are three further questions for us to consider.

1. What role will general practice play in an accountable care system?

Here the options appear to be threefold. General practice could choose simply not to engage. Indeed, some of the early accountable care pilots report engaging GPs to be one of their key challenges. The problem here is some of the budget for general practice will transfer from local commissioners to the accountable care system. If this is dominated by the acute hospital and other large provider organisations there is an obvious risk some funding streams will dry up.

Conversely, for accountable care systems seeking to deliver outcome rather than activity goals within a fixed funding envelope, international examples such as the Canterbury Health Board in New Zealand have shown the rate of growth of hospital activity can be moderated by investing in services in the community. There is opportunity for general practice within accountable care systems, meaning active engagement could well benefit the profession as well as the local population.

General practice could choose to play the role of “strong voice around the table”. It could ensure it is involved in accountable care system decision making, and almost take on an LMC type role to ensure risk to practices is minimised and funding streams are maintained and, where possible, developed.

Or it could attempt to play a leading role. Accountable care systems are very much at the developmental stage. There is no fixed blueprint for how they will look or how they will operate. Active leadership now could drive the evolution of these systems to ensure they are built around core general practice and the delivery of joined up and effective prevention and out of hospital care.

2. What scale will the accountable care system operate at?

Equally, the answer to this question is not clear yet. On the one hand we have the devolution project in Manchester creating an accountable care system spanning the whole of Greater Manchester. On the other, the primary care home (PCH) initiative is promoting accountable care for populations of 30-50,000.

In most places, size has not been determined. It may be that “layers” emerge, with smaller local areas where they exist (maybe PCH size) feeding in to larger areas (maybe acute hospital catchment area size), in turn feeding into even larger areas (whole STP size, a la Manchester). What “feeding into” in this context means is anybody’s guess.

For general practice, the scale chosen is likely to be important. If an accountable care system operates at acute hospital catchment area size, general practice would need to be well led and organised to be able to match the voice of its acute counterpart. At STP level, how does it prevent its voice being drowned out by the multitude of other big voices around the table?

Even operating at a locality or neighbourhood level of 30-50,000, practices will need to find a way of working well together and creating a strong single voice. To influence the scale at which accountable care operates locally practices will need to be involved at an early stage of the discussions. Once final decisions are taken, they will be hard to undo.

3.How will general practice build the relationships it needs to participate in accountable care?

It is clear a system reliant on collaboration between providers is going to be a challenge for general practice which is currently organised into nearly 8,000 individual business units. Practices will first and foremost need to build relationships with each other. Some practices are merging themselves into a size that means they will individually be ready. Some are forming federations. For others the currently existing CCG localities may provide a platform practices can build on. Key here is if practices want accountable care systems to work for them, as opposed to simply becoming their new masters, the ability to work effectively together is undoubtedly task one.

Equally, GP groups (whether it be large practices, federations, or localities) have to find a way of working together. Ultimately there is going to be one GP voice in an accountable care system. For that voice to be effective it will need to be unified. The acute trust, for example, will have a single, clear voice. If general practice cannot create the same level of cohesion, its voice will be diluted, and influence correspondingly diminished.

Finally, GP groups will need to be able work collaboratively with other providers. The aim is not that these systems become the fora within which providers fight each other for their share of the fixed amount of funding available. Rather, it is for barriers between organisations to be removed and for more effective ways of delivering care to be developed for patients. This requires productive relationships based on trust. For general practice it will require strong local leadership that practices believe in and are prepared to back when decisions are made – there will not be the time or opportunity for every decision to go back to each practice for a vote.

The overriding message for general practice is accountable care is coming. As such, practices may want to consider how they want accountable care to work locally, to identify what role they want to play in both shaping and delivering this future, and to reflect on how ready they are for this new system which has significant implications for the future of general practice.

27
sep
0

The impact of commissioning on general practice

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At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future.   The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.

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