the future of general practice - why change? how?

The future of general practice

The future of general practiceDr Robert VarnamHead of general practice development

@robertvarnamWorcester14 Oct 15bit.ly/151022future

www.england.nhs.uk@robertvarnam

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www.england.nhs.uk@robertvarnamHad a conversation about future of GP recently?2

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?

www.england.nhs.uk@robertvarnamThe 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. 3

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.

PressureOpportunity

www.england.nhs.uk@robertvarnamSo 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. 4

At the heart of the case for change is not the workload of practices important though that is it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again.

That accounted for the majority of the anticipated work of the NHS. And, for some patients, thats still the kind of care thats needed.

However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase.

And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases.

So the population of people who need what only primary care can offer has grown, the amount of time they need has grown and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients needs.

This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the century of the hospital, and place the emphasis where the populations need is.

Scottish School of Primary CareWhy change?

www.england.nhs.uk@robertvarnamAt the heart of the case for change is not the workload of practices important though that is it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again.

That accounted for the majority of the anticipated work of the NHS. And, for some patients, thats still the kind of care thats needed.

However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase.

And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases.

So the population of people who need what only primary care can offer has grown, the amount of time they need has grown and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients needs.

This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the century of the hospital, and place the emphasis where the populations need is. 5

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

www.england.nhs.uk@robertvarnamIts 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. 6

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.

PressureOpportunity

www.england.nhs.uk@robertvarnamSo 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. 7

What kind of care?What kind of organisation?


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Wave one Wave two57 schemes2500 practices18m patients

www.england.nhs.uk@robertvarnamAn example of this in practice at the moment is the Prime Ministers GP Access Fund. Now covering a significant proportion of the country, practices in this are implementing quite wide-ranging redesign of their services, acknowledging that extended hours are only one part of good access. The practices participating in this programme are already beginning to implement many of the transformational changes envisaged by the Five Year Forward View. This is generating valuable learning about the specific changes required, including the ways in which the system can make progress easier and more sustainable. 10

Right access in the Challenge Fund

Wider primary care at scaleReshapedemandActivefront-endContact modesMatch capacity & demandRapid access modelExtended hoursRelease capacityService redesign teamBroaden skillmixComplex care modelPremisesI.T.Workforce

Service componentsSystem enablersbit.ly/PMCFresources1

www.england.nhs.uk@robertvarnamRight access in the Challenge Fund

Wider primary care at scaleReshapedemandActivefront-endContact modesMatch capacity & demandRapid access modelRelease capacityExtended hoursService redesign team

Broaden skillmixComplex care modelPremisesI.T.Workforce

Service componentsSystem enablers

www.england.nhs.uk@robertvarnamRight access in the Challenge FundAdditional evening hours, weekdaysAdditional weekend opening




www.england.nhs.uk@robertvarnamRight access in the Challenge FundHealth promotionSelf care education (eg primary school, longterm conditions)Signposting (eg online hub)Community pharmacy minor ailment service




www.england.nhs.uk@robertvarnamRight access in the Challenge FundPhone / online: consistent value-adding approachSignposting to education & self-help resourcesDirect booking with most appropriate professional111 as front end to GPGP in A&E




www.england.nhs.uk@robertvarnamRight access in the Challenge Fund



OnlinePhoneVideoSMSFace-to-faceService componentsSystem enablers

www.england.nhs.uk@robertvarnamRight access in the Challenge FundMeasuring demandTitrating capacity to demandScheduling to meet patterns of demandShorter phone & email consultationsLonger face-to-face consultations




www.england.nhs.uk@robertvarnamRight access in the Challenge FundBookable pharmacy consultationsMinor illness nursesLate afternoon children's serviceAcute visiting service (GP / paramedic)




www.england.nhs.uk@robertvarnamRight access in the Challenge FundProactive coordinated careCare navigatorsGroup consultationsSocial prescribing & supportCare home rounds




www.england.nhs.uk@robertvarnamRight access in the Challenge FundMinor illness nursesIndependent prescriber trainingPractice based pharmacistDirect access physioCommunity liaison physicians







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No blueprint

www.england.nhs.uk@robertvarnamAssociationNetworkFederationPartnershipSuperpracticeA federation by any other name

5 yearsContemplation


ClarityBuy-inAgilitySizeAlignmentPrioritiesPartnerships

2300+

www.england.nhs.uk@robertvarnamMonthly colloquiumQuarterly colloquiumCommitteeExecutive teamThe BossDecision makingFace-to-face visitsBulletinOnline forumSurveys

www.england.nhs.uk@robertvarnamOutsourced managementSpare timeNew managersDistributed leadershipLeadership & infrastructureVision-castingData gatheringProgramme managementI.T.ProcurementWorkforceMobilisationGovernancePractice engagementPatient engagementStakeholder partnershipsAnalysis

www.england.nhs.uk@robertvarnamAt an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it wont just happen. Finally, it should like its yours by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.

What kind of organisation?BiggerPersonalCapableConnected

www.england.nhs.uk@robertvarnamBUILDING on existing strengths . the MORE list28

Delivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it wont just happen. Finally, it should like its yours by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.

What kind of organisation?BiggerPersonalCapableConnectedStep change in partnership workingacute & specialistcommunity servicesvoluntary & community sectorpublic healthhousingeducation

www.england.nhs.uk@robertvarnamDelivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. 29

The creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it wont just happen. Finally, it should like its yours by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.

What kind of organisation?BiggerPersonalCapableConnectedHighly capable infrastructure & leadersTransformational system leadershipEngaging, inspiring & supporting the teamService redesign, innovation & improvementOps management, HR, etcBusiness intelligence

www.england.nhs.uk@robertvarnamThe creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. 30

All of the above requires primary care to operate at larger scale. This may provide economies of scale which will sustain providers through the current workload challenges. More fundamentally, working at-scale is necessary to generate the kind of critical mass required for working in greater partnership as a credible system partner in the local health and care system. In operational terms, it allows financial and staff headroom to be created, making service improvement easier, and it increases the attractiveness of primary care as an employer for staff from other parts of the health and care system. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it wont just happen. Finally, it should like its yours by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.

What kind of organisation?BiggerPersonalCapableConnectedAt-scale organisational formAttractive system partnerSustainable platform for expanded servicesIntrinsic headroomCredible NHS employer

www.england.nhs.uk@robertvarnamAll of the above requires primary care to operate at larger scale. This may provide economies of scale which will sustain providers through the current workload challenges. More fundamentally, working at-scale is necessary to generate the kind of critical mass required for working in greater partnership as a credible system partner in the local health and care system. In operational terms, it allows financial and staff headroom to be created, making service improvement easier, and it increases the attractiveness of primary care as an employer for staff from other parts of the health and care system. 31

In the course of the transition to being more corporate entities, it will be important for primary care providers to include measures to preserve and even enhance aspects of the status quo which are essential to the value of primary care. The role of primary care at the heart of the local community, and connected with people and their families throughout their life, is a valuable aspect of its ability to contribute to wellbeing and population health. Similarly, the personal continuity of care provided in general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally, the small scale nature of traditional practices creates a level of personal commitment and discretionary effort which the NHS can ill afford to lose.

It should be noted that all three of these potential benefits of the traditional cottage industry model of primary care organisations are already waning in England. Patients at larger GP practices already report lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement of many salaried GPs.

Providers will need to ensure there are specific measures in place to ensure that the personal touch is not only preserved but enhanced. This is likely to have implications for ownership models, organisational culture, structures and processes, as well as the design of teams and clinical care models.

At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it wont just happen. Finally, it should like its yours by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.

What kind of organisation?BiggerPersonalCapableConnectedDeliberate design to stay personalLifelong family careIntegral part of the communityPersonal LTC & EOL careSense of commitment & ownership for all staff

www.england.nhs.uk@robertvarnamIn the course of the transition to being more corporate entities, it will be important for primary care providers to include measures to preserve and even enhance aspects of the status quo which are essential to the value of primary care. The role of primary care at the heart of the local community, and connected with people and their families throughout their life, is a valuable aspect of its ability to contribute to wellbeing and population health. Similarly, the personal continuity of care provided in general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally, the small scale nature of traditional practices creates a level of personal commitment and discretionary effort which the NHS can ill afford to lose.

It should be noted that all three of these potential benefits of the traditional cottage industry model of primary care organisations are already waning in England. Patients at larger GP practices already report lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement of many salaried GPs.

Providers will need to ensure there are specific measures in place to ensure that the personal touch is not only preserved but enhanced. This is likely to have implications for ownership models, organisational culture, structures and processes, as well as the design of teams and clinical care models. 32

eg Whitstable medical practice

www.england.nhs.uk@robertvarnam34k33

eg Cotswolds PMCF

www.england.nhs.uk@robertvarnam34k34

Top tips

www.england.nhs.uk@robertvarnamPurpose > function > form Purpose > function > form Purpose > function > form Purpose > function > form Pick something to improve for patientsImprove it togetherBuild infrastructure to enable, accelerate & sustain

bit.ly/151022future

www.england.nhs.uk@robertvarnamHigh Impact Actions to release capacityActive signpostingReduce DNAsNew contact modesDigital primary careBroaden the workforceProductive work flowsIncrease personal productivityPartner with other practicesCare & support planningSupport self careDevelop quality improvement expertisebit.ly/RCpress151004


the future of general practice - why change? how?

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