1. 1. www.england.nhs.uk @robertvarnam Can practice managers save the NHS? Dr Robert Varnam Head of general practice development robert.varnam@nhs.net @robertvarnam CHEC 25 June 2015 bit.ly/20150625chec
2. 2. www.england.nhs.uk @robertvarnam
3. 3. www.england.nhs.uk @robertvarnam One of the things motivating me as I first looked outside the walls of our practice, to lead some local service redesign for diabetes, was fear. A fear that general practice, despite being a service depended on by the country, had a very uncertain future. In fact, I was afraid that general practice was being run into the ground. Although NHS spending was rising, with growing amounts of staff and money, the majority was going elsewhere in the system. Even though we were talking increasingly about the importance of providing more care outside hospital, the investment was going inside hospital. What future for general practice?
4. 4. www.england.nhs.uk @robertvarnam What future for general practice? workforce premises
5. 5. www.england.nhs.uk @robertvarnam The founding principles of UK primary care are admired the world over, and rightly so. General practice is a jewel in the crown of this country. Right now, general practice feels in a bad place. Constrained, hemmed-in and, to some, marginalised. Whatever the state of things in your part of the country, in general, I think its fair to say that, at the very least, general practice is currently constrained from delivering its full potential. We need to see increases in funding, a growth in the workforce, and improvements to premises. Without those, existing services may not be sustainable. What future for general practice?
6. 6. www.england.nhs.uk @robertvarnam But something else has been happening in general practice, too. People are working on some quite new approaches to care and the very organisations we work in. This too was a big theme in the Call to Action. We asked what practices were working on, and what would need to be done for improvements in care to be sustained. And we heard a very big set of messages about the future bit.ly/c2aGP bit.ly/nhs5yfv How are things? Where are you heading? How could the system help?
7. 7. www.england.nhs.uk @robertvarnam Actions to strengthen primary care Stabilising core funding for general practice nationally Co-commissioning to shift care from acute to community Improving access to services and supporting new ways of working Expanding number of GPs: recruitment, return to work schemes and retention & investing in other new primary care roles Expanding funding to upgrade primary care infrastructure and scope of services offered to patients New initiatives to provide care in under-doctored areas Building the publics understanding that pharmacies and online resources can help them with minor ailments Identifying practical solutions to reduce bureaucracy and reshape appointment demand. Taking existing primary care strengths, we will build a firm foundation for the future and deliver a new deal for primary care by:
8. 8. www.england.nhs.uk @robertvarnam ?
9. 9. Its too easy to approach challenges just by thinking we need more. The NHS has a well established habit of this new initiatives, new challenges or opportunities are usually met by us talking about more. More money, more staff or both. And, we know that, in general practice, we do need both more money and more staff. BUT and its a big but just doing more of the same is simply not going to cut it any longer. Not just more of the same
10. 10. www.england.nhs.uk @robertvarnam It is very clear that everyone is talking about change. In many parts of the country, change is already underway in a wide range of areas. This actually makes it even more important to ensure were clear about why. What is the case for change? Where are we heading with it? If youre currently engaged in a programme of change in your practices, are these two things really clear?
11. 11. www.england.nhs.uk @robertvarnam Why change? Scottish School of Primary Care
12. 12. www.england.nhs.uk @robertvarnam So why are people talking about change? Its partly about the pressure were under right now, and partly about the huge opportunity to do something better. And, for once, the same changes that would help with one are also necessary for the other. Pressure Opportunity
13. 13. Health & wellbeing-promoting care Right access Consistently high quality Holistic, personalised, proactive, coordinated care
14. 14. Phone first. Community diagnostics. Practice based paramedics. Pharmacy first. Web consultations. Primary care led urgent care centre. Minor injury service. Physio first
15. 15. Direct specialist advice. Condition management training. Shared records. Care coordination. Hospital in-reach. Care home ward rounds. Virtual ward. Primary care-employed specialists.
16. 16. Social prescribing. Travelling health pods. Peer-led walking groups Health coaching. Befrienders. Schools outreach. Community development.
17. 17. www.england.nhs.uk @robertvarnam What may the future look like?
18. 18. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
19. 19. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
20. 20. www.england.nhs.uk @robertvarnam 1. What kind of care? Holistic, comprehensive, cradle-to-grave family care Health & wellbeing-promoting care Right access
21. 21. www.england.nhs.uk @robertvarnam 1. What kind of care? Holistic, comprehensive, cradle-to-grave family care Health & wellbeing-promoting care Right access (time, place, person, care) Personalised, proactive, coordinated care Consistently high quality
22. 22. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
23. 23. www.england.nhs.uk @robertvarnam 2. What kind of work? Segmented (one size does not fit all) Multiprofessional teamworking bring new skills work to the top of our skills Partnership with patients & community Longer consultations with fewer patients GP not always 1st port of call Direct access diagnostics Pull-in specialist advice
24. 24. www.england.nhs.uk @robertvarnam Wider primary care at scale Redirecting demand (self care, pharmacy) Intelligent front-end (signposting, self care, coordination) Consultation channel (online, phone, video, face) Match capacity & demand (scheduling, broader workforce) Care model (continuity, proactive & coordinated care) Release capacity Extended hours (evenings & weekends) Capabilities for service redesign PM GP Access Fund Wave one Wave two 57 schemes 2500 practices 18m patients
25. 25. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
26. 26. www.england.nhs.uk @robertvarnam bit.ly/nhs5yfv New types of organisation Multispecialty Community Providers Primary and Acute Care Systems
27. 27. www.england.nhs.uk @robertvarnam Multispeciality Community Providers GP practice GP practice GP practice GP practice GP practice GP practice GP practice GP practice Specialists Pharmacists Community provider SC provider VCS VCS VCS MH Trust VCS VCS VCS
28. 28. www.england.nhs.uk @robertvarnam Primary and Acute Care Systems Community provider SC provider VCSMH Trust Acute provider GP practice GP practice GP practice GP practice GP practice GP practice GP practice GP practice
29. 29. www.england.nhs.uk @robertvarnam Purpose > function > formPurpose > function > formPurpose > function > form 3. Design rules for organisations Purpose > function > form a) Pick something to improve for patients b) Improve it together c) Build infrastructure to enable, accelerate & sustain
30. 30. www.england.nhs.uk @robertvarnam 3. Design rules for organisations
31. 31. www.england.nhs.uk @robertvarnam eg Whitstable medical practice
32. 32. www.england.nhs.uk @robertvarnam eg GP Care federation, Bristol
33. 33. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Bigger Personal Capable Yours
34. 34. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Big enough for: resilience collaboration broader workforce minor illness nurses, pharmacist, MH practitioner, welfare rights, OT, physio, LTC nurses, HCA, physicians assistants pull-in power economies of scale meaningful accountability eg collaboration covering 30,000+ patients
35. 35. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Capable: leadership strategic, transformational, team partnership with patients and the public contribution to & from community, accountability, patients as partners in improvement workforce building & running effective multiprofessional teams, inc CPD an attractive place to work service redesign & improvement high end QI capabilities business operations management, finance, procurement, facilities, business intelligence facilities: comprehensive services in the community governance clinical, financial, organisational
36. 36. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Personal: culture that values people valuing deliberately designed systems, teamwork & processes to promote continuity
37. 37. www.england.nhs.uk @robertvarnam www.biomedcentral.com/1471-2296/11/61/
38. 38. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Personal: deliberately designed systems, teamwork & processes to promote continuity proactive coordinated care connecting patients with non-medical support using tech to promote wellbeing, self-care and management known in the community
39. 39. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Yours: well-designed well-led every GP matters systems to ensure you flourish
40. 40. www.england.nhs.uk @robertvarnam Successful federations
41. 41. www.england.nhs.uk @robertvarnam Strong network / federation facilitates service development Not all networks/federations/superpractices are equal GPs dont always like being led, but leadership is key Evidence from PM Challenge Fund Huge variety in legal forms, structure, etc no evidence about superiority for delivering change programme / improved care (but ?other factors, eg economies of scale) Size may matter
42. 42. www.england.nhs.uk Size may matter Category Average time for full mobilisation % of practices offering weekday extended hours provision as a result of PMCF (at full mobilisation) % of practices offering weekend extended hours provision as a result of PMCF (at full mobilisation) Scope Leadership Small (50) N = 4 8 months 55% 66% More likely integrated with system- wide transformation Change slower & harder
43. 43. www.england.nhs.uk @robertvarnam Strong network / federation facilitates service development Not all networks/federations/superpractices are equal GPs dont always like being led, but leadership is key Evidence from PM Challenge Fund Huge variety in legal forms, structure, etc no evidence about superiority for delivering change programme / improved care (but ?other factors, eg economies of scale) Size may matter Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form
44. 44. www.england.nhs.uk @robertvarnam Purpose is pivotal but Not always as clear as people thought Not always as shared as people thought Often self-centred Most effective when commitment to reach across boundaries to collaborate in the interests of patients & population Evidence from PM Challenge Fund
45. 45. www.england.nhs.uk @robertvarnam Deliberate design of: Purpose Leadership Decision making Service redesign capabilities Business infrastructure Governance Successful collaborations These appear important regardless of the form (network / federation / single organisation)
46. 46. www.england.nhs.uk @robertvarnam How? Where to start?
47. 47. www.england.nhs.uk @robertvarnam How? Where to start? Release capacity. Now.
48. 48. www.england.nhs.uk @robertvarnam
49. 49. www.england.nhs.uk @robertvarnam Reduce bureaucracy payment & reconciliation contracts management information flows Reduce demand increase self help & self management reliable hospital appointment systems standard local approach to sick notes, etc Work differently active front end online/phone consultations proactive, coordinated care + continuity + longer appts enhanced clerical roles physician associate care navigator Wider primary care at scale pharmacists physio minor illness nurses social prescribing welfare rights
50. 50. www.england.nhs.uk @robertvarnam Reduce bureaucracy payment & reconciliation contracts management information flows Reduce demand increase self help & self management reliable hospital appointment systems standard local approach to sick notes, etc Work differently active front end online/phone consultations proactive, coordinated care + continuity + longer appts enhanced clerical roles physician associate care navigator Wider primary care at scale pharmacists physio minor illness nurses social prescribing welfare rights
51. 51. www.england.nhs.uk @robertvarnam Reduce bureaucracy payment & reconciliation contracts management information flows Reduce demand increase self help & self management reliable hospital appointment systems standard local approach to sick notes, etc Work differently active front end online/phone consultations proactive, coordinated care + continuity + longer appts enhanced clerical roles physician associate care navigator Wider primary care at scale pharmacists physio minor illness nurses social prescribing welfare rights
52. 52. www.england.nhs.uk @robertvarnam Reduce bureaucracy payment & reconciliation contracts management information flows Reduce demand increase self help & self management reliable hospital appointment systems standard local approach to sick notes, etc Work differently active front end online/phone consultations proactive, coordinated care + continuity + longer appts enhanced clerical roles physician associate care navigator Wider primary care at scale pharmacists physio minor illness nurses social prescribing welfare rights
53. 53. www.england.nhs.uk @robertvarnam Reduce bureaucracy payment & reconciliation contracts management information flows Reduce demand increase self help & self management reliable hospital appointment systems standard local approach to sick notes, etc Work differently active front end online/phone consultations proactive, coordinated care + continuity + longer appts enhanced clerical roles physician associate care navigator Wider primary care at scale pharmacists physio minor illness nurses social prescribing welfare rights
54. 54. www.england.nhs.uk @robertvarnam robert.varnam@nhs.net @robertvarnam
55. 55. www.england.nhs.uk @robertvarnam robert.varnam@nhs.net @robertvarnam