7
jul
0

The future of General Practice is a jigsaw – will all the pieces fit?

Posted by Blogs, The General Practice BlogNo Comments

I am worried. I worry that the General Practice Forward View (GPFV) does not fit with everything else that is going on. I worry that while on the one hand there is a small national team desperately trying to do the right thing by General Practice, most people haven’t even read the key document.

Recent events (and not just the obvious) have compounded my fears. Two things have happened. First the new CCG assessment and improvement framework has been published. It is not a fun read. The upshot of it is that there are 57 indicators across 29 areas by which CCGs are going to be assessed. One of these 29 areas is primary medical care, and it has a total of 4 indicators. These are:

  1. Management of long term conditions: unplanned hospitalisation rates for patients with chronic ambulatory care sensitive conditions.
  2. Patient experience of GP services: weighted percentage of people rating their experience of GP services as “fairly good” or “very good”.
  3. Primary care access: percentage of practices within a CCG where patients have the option of accessing pre-bookable appointments outside Monday to Friday 8.30am to 6.30pm. Access may be through a hub or federation rather than the individual practice.
  4. Primary care workforce: number of GPs and practice nurses (full time equivalent) per 1000 weighted patients by CCG.

I won’t waste the next 500 words explaining just why these in no way reflect the ambitions for General Practice outlined in the GPFV (but feel free to get in touch if you want the debate!). Suffice to say the measures by which CCGs are to be judged do not reflect the GPFV stated intentions around investment, workforce, workload, infrastructure and care redesign. Instead it is two steps backwards with tired measures that feel increasingly distant from the reality of most GP practices.

Second is the growing role of Sustainability and Transformation Plans (STPs). Recent guidance on STP allocations stated that this funding, “represents the full amount of funding expected to be available for local health systems from all sources in 20/21. They include an indicative fair share of the sustainability funding, primary care access and transformation funds, and other transformation funds including technology…. This includes taking forward the programmes set out in the General Practice Forward View and delivering extended GP access.”

The guidance goes on to say, “STPs will be the single application and approval process for being accepted onto programmes with transformational funding from 2017/18 onwards. Phasing of funding by areas in years 2017/18 – 2019/20 will be subject to consideration of STP plans submitted and subsequent decisions on how to target and deploy funding”.

The implication is that the financial plan for investment in General Practice actually sits within the local STP plan. While this contains a certain logic, the risk of the General Practice funding not finding its intended target becomes much higher. There is already guidance about the requirement of STP money to be passed through to acute providers, alongside a paucity of core General Practice provision representation in the development of STP plans in many areas.

The GPFV can’t sit in splendid isolation. It needs ownership across the system. It has to be the basis for how CCGs and primary care commissioners are assessed. It has to become the framework for local investment in, and the development of, General Practice. It has to materially impact local STPs. When we see the STPs we will find out exactly how reflective they are of the GPFV, and I really hope I will discover I have been worrying over nothing.

30
jun
0

10 Reasons Why Your Area Needs a Local Locum GP Chambers

Posted by The General Practice BlogNo Comments

Locum Chambers are groups of local locum GPs who work together through a shared management structure to support GP practices in a local area. If your area does not have one, here are 10 reasons why you should! Local locum GP chambers:

 1. Keep local GPs in the local system. Many GPs are leaving because of the stress levels in General Practice. Local GP Chambers create an opportunity for GPs who simply want to be able to focus on seeing patients to be able to do so without the pressure of working in a specific GP practice. They also provide peer support, and remove the burden of booking and invoicing that becoming a locum entails. In a recent survey by the National Association of Sessional GPs (NASGP) a number of members commented they would have left the profession altogether had chambers not existed.

2. Offer an accessible route back into General Practice. Similarly, there are large numbers of GPs who have already left because of the pressures they were experiencing. Operating as a locum within a chambers allows GPs to take more control over their workload and work-life balance, without the isolation that some locum GPs experience. As such, it offers an accessible route back into General Practice for those who may consider a return, but are concerned about operating independently as a locum.

3. Attract locum GPs to your area. Finding a locum is becoming increasingly difficult. A 2015 BMA survey reported that 46% of practices have trouble finding locum cover ‘frequently’. Local locum GP chambers establish a group of locum GPs to work in your local area. As the chambers grows the availability of locums for local practices improves.

4. Improve the quality of local locum GPs. Traditionally the quality of locum GPs is variable. However, local locum chambers build in audit, education, peer support and complaints procedures to enable quality and performance to be monitored and continuously improved. They also make appraisal and revalidation much more straightforward.

5. Enable locum GPs to be effective quickly in each local practice. Local locum GP chambers develop systems to make it easy for each of their locum GPs to get to know the different ways of working in each practice. One of the biggest challenges facing a locum GP is to become effective quickly within a new environment, and by working with a specific number of local practices the chambers is able to share information and support its members to do just this.

6. Ensure locum GPs operate as part of the local system. The only system interactions that many locum GPs have is with the individual practices they support. A local locum GP chambers provides a contact point between the CCG, the local healthcare system, and the locum GPs. This means that where new systems, such as new referral pathways, are introduced, the local locum GPs can be informed and be part of the process of implementation.

7. Reduce expenditure on locum GPs. Chambers are entirely funded by charging each member a percentage of their income, instead of charging the practice. There is no additional agency fee that is incurred. Locums from GP Chambers are typically 25%-40% cheaper than the those accessed from agencies.

8. Make finding locums GPs easier for local practices. Chambers provide an easy point of contact (usually one email) that results in a high quality locum attending at a set price. This is stark contrast to the experience of many practice managers, who can spend hours and even days chasing and negotiating with agency after agency to try to find a locum.

9. Allow local systems to access the talent and skills of locum GPs. Locum GPs have plenty to offer local systems. They have a unique perspective as they have seen first-hand how many of the different practices within an area operate. They can identify and facilitate the spread of best practice between practices. In many areas locum GPs from local chambers have even taken up leadership positions within the local CCG.

10. Create an opportunity for partnership working between the CCG and the local locums GPs. Where a local locum GP chambers is established, CCGs can explore with them ways of working together to strengthen local delivery of General Practice. This can include support for specific GP practices, targeted support for local General Practice at busy times, and even enabling the CCG to ensure support is focussed on the local GP practices that need it most.

23
jun
0

We need a Financial Plan for the GP Forward View

Posted by Blogs, The General Practice BlogNo Comments

Increasing GP cynicism about the Government’s Forward View is understandable, argues Ben Gowland and, without a clear financial plan, the criticisms can only increase.

There is a growing temptation for many GPs following the recent criticism of the GP Forward View (GPFV) to dismiss it completely. However, the GPFV is a published policy document by NHS England. It makes many promises. Regardless of whether or not you believe the promises to be sufficient, they are real, written down promises. As such they need to be identified, monitored and those who made them held to account for keeping them. Especially the financial ones.

The complexity of the GPFV makes unpicking these promises, in particular the financial ones, very difficult to do. The RCGP has recognised the importance of this task, and has taken steps to establish what financial promises have actually been made to General Practice, and in particular how close these come to the RCGP’s campaign for General Practice to receive 11% of NHS funding (you can find this here).

What financial promises have NHS England actually made? What can we monitor and hold NHS England to account for? Ultimately there are only two that I think we should focus on: the promise to increase recurrent expenditure on General Practice by £2.4bn a year by 2020/21; and the (separate) promise to create a £508m “Sustainability and Transformation Package” that will be invested between now and 2020/21.

It is stated in black and white headline terms that recurrent funding for General Practice will increase from £9.6bn a year in 2015/16 to £12bn a year in 2020/21. It is not, however, broken down. The financial plan is missing. This I suppose provides room for manoeuvre, but at the same time is leading to confusion, mistrust and the growing lack of enthusiasm for the whole document.

The text does not help. One headline says that the £2.4bn “includes capital investment amounting to £900m over the next 5 years”. How can it? The capital funding is non-recurrent. The promised £2.4bn is recurrent. Even the one year share of the 5-year capital pot in 2020/21 would presumably have to be replaced or matched the year after anyway in order for it to be classified as recurrent.

And what do you make of this statement on p12, “The additional investment we are making in introducing new care models will benefit general practice too – and this will ensure investment rises at least in line with the plans set out above, and potentially even more.”? Does it mean any extra money from the transformation fund is part of the additional £2.4bn, or is it in addition to it? The RCGP sought clarification on this very point and were told by NHS England that it is additional. By the RCGP’s calculations this means General Practice will be receiving an additional amount between £561m and £842m extra (depending on whether you think General Practice will receive a “conservative” 20% of the Transformation Fund or an “optimistic” 30%) by 2020/21. For clarity, this is on top of the additional £2.4bn.

Suddenly the RCGP’s enthusiasm for the GPFV becomes a bit clearer. The money that is needed has really been promised.

But will it materialise? Really, will it? We hear talk of a national ‘reset’ of NHS finances. The funding problems in General Practice are often lost in talk of huge acute provider deficits. Every day we hear reports about the impact of continuing PMS reviews and cuts, alongside the ongoing removal of MPIG. If this level of extra funding was really coming, wouldn’t the approach shift to one of reduced growth payments as opposed to actual cuts? CCGs, even those with the most delegated of primary care commissioning budgets do not know when this funding is coming, how this funding is coming, or what this funding will look like. Can you blame practices for not sharing the enthusiasm of the RCGP?

We need the financial plan. NHS England would not accept a plan from a CCG without the financial plan attached, and General Practice must insist on seeing the financial plan that underpins the GPFV. NHS England needs to do this to build confidence that it will deliver what it has set out in the GPFV. General Practice needs it so that it can hold them to account for doing just this.

16
jun
0

The Two Icebergs Facing General Practice

Posted by The General Practice BlogNo Comments

Guest Blog by John Tacchi, CEO, BIG Practice Ltd

If General Practice was a ship, it would be the Titanic, thundering through the night and on course for disaster. Beyond the well-rehearsed problems, I see two further “icebergs” facing General Practice hidden beneath the surface which could easily lead to catastrophe.

The first of these icebergs is premises and property. I recently had a conversation with a GP that I shall call Dr Average; a GP with an average sized practice (around 4,000 patients) and an average set up. He was very concerned because his latest invoice from the property landlord showed an increase in non-refundable costs from £1,000 to £42,000.

I took a deep breath, and asked Dr Average for his lease. He said he didn’t have one, and indeed there had never been one. As an ex-lawyer I found this staggering. As I told Dr Average, you occupy this building under a bare licence. That is a ‘good news/bad news’ position; good because you could leave tomorrow without the landlord having any recourse, but bad because the reverse applies too.

I suspect that this situation is being repeated across the country. Landlords are trying to achieve the correct market value for their properties, and GPs are facing a big increase in costs not covered by the reimbursement arrangements with NHS England.

Many GPs are in former residential premises that are not fit for purpose. But those that have moved to new purpose-built premises are also facing problems, as the reimbursement monies for premises dries up. According to the GP Forward View £900M is available for new GP premises, but without, it seems, the revenue funding to support this expenditure.

The second iceberg I believe we are facing is the resilience of GP practices as independent businesses. Let’s go back to Dr Average. He was concerned because the balance on the practice account had been declining over the last 15 months and was now a negative number. I looked into his accounts and they showed a relatively profitable business. However, I explained the P&L statement is a backward looking view and that we should examine the notes to the accounts. Dr Average was genuinely surprised; he didn’t know there were any notes to the accounts. I asked him for his cash flow forecast and he clearly didn’t know what I meant.

GPs run a unique type of business which ‘guarantees’ various elements of the income side of the equation, while at the same time provides a simple reimbursement for much of the cost side. In the past, running the business has often been a relatively simple exercise in cash management. But the current challenges facing General Practice require a more sophisticated business and financial skill set that many GPs and GP practices simply do not have.

I was recently involved in an exercise in the West Midlands led by Sandwell and West Birmingham CCG to gather detailed workforce data, and was staggered to discover that 40% of all GPs in the patch intend to retire in the next 5 years. The data also demonstrated that there are not enough ‘young’ GPs to replace this potential outflow. Many of the younger ones simply have no desire to become partners and take on the reality of sinking capital into a business that offers little guarantee of a return on their investment.

These two icebergs; the premises problem and the business problem are looming ever larger as the NHS changes and financial constraints continue. If the good ship “General Practice” is to survive in any meaningful form and avoid these icebergs then General Practice has to do what lawyers and accountants started to do 30 years ago, i.e. re-invent their ‘corporate’ structure and strengthen their business function and capability.  If it does not, HMS General Practice could well go the same way as the Titanic.

If you would help with any of these issues or would to contact John his e-mail address is john@bigpractice.co.uk

9
jun
0

Five ways CCGs should be supporting General Practice

Posted by The General Practice BlogNo Comments

How can CCGs provide the kind of support that General Practices need to manage the problems they face now and in the future? In this blog, Ben Gowland suggests five key actions they can take.

There is tremendous variation across the country in the levels of support different CCGs are providing for General Practice. Here are the five most impactful actions CCGs can take to support General Practice locally.

One – Introduce a Single Contract to Uplift funding for General Practice

Bolton CCG has invested an additional £3m into General Practice and provided a guaranteed minimum income per practice. By both bringing together the different funding streams for General Practice and investing additional resources CCGs can create an uplift of core funding that will make a real difference to the problems GP practices are experiencing. Listen here to hear how Bolton CCG made this happen locally.

Two – Support the introduction of new roles into General Practice

As recruitment of GPs into practices becomes increasingly difficult, GP practices are being forced to look at the introduction of new roles into practice, such as advanced nurse practitioners, paramedics, pharmacists, physiotherapists, mental health workers and physicians associates. CCGs can support and accelerate the successful introduction of these roles by:

  • Establishing the local availability of each type of role
  • Bringing together into one place the additional funding available to support practices with these different roles
  • Providing information about the availability of local training, e.g. prescribing courses for pharmacists, and information on implementation issues such as indemnity
  • Creating local groups whereby clinical staff taking on these new roles can gain support from each other, and share best practice

Three – Support the establishment of a local Locum GP Chambers

GP locums make up nearly a quarter of the GP workforce, according to the National Association of Sessional GPs (NASGP). GP practices spend inordinate amounts of time finding GP locums, and often have to pay exorbitant rates. Encouraging the local locum GPs to establish a chambers will improve the availability of locum GPs, improve the quality, and reduce the cost. While CCGs cannot set them up directly, they can facilitate their development locally, for example by identifying and working with potential leads for the chambers, and establishing the demand from practices to support the business case for their establishment.

Four – Help local GP practices explore the opportunities of working at scale

Our Health Partnership is the largest ‘super-practice’ in the country. 32 practices in Birmingham came together to establish a single partnership, covering a population of 280,000. The origins of this came from the CCG providing some facilitation support and opportunities for local GPs to come together to explore what working together at scale might mean for them. Hear more about the origins of Our Health Partnership here and here.

Five – Facilitate the development of partnerships between GP practices and other local providers

Joint working between GP practices and other health providers, such as community trusts, acute trusts and local councils have enabled some GP practices to develop new staffing models, introduce new systems for managing on-the-day demand, and create an innovative approach to managing estates. The joint work between Southern Health and the practices in South Hampshire is a good example (find out more here). What GP practices lack is an understanding of the enthusiasm of different local organisations for this work, what type of joint work they are prepared/keen to consider, and who the best contact point within each organisation for practices is. CCGs can establish this information and make it easily accessible to practices, and then actively support joint initiatives as they develop.

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