Developing General Practice:Surviving transformation

Dr Chaand NagpaulChairman, BMA General Practitioners Committee

Where we are today - increasing demographic demands on GPs

• Rising demand from ageing population • 29% population have a long-term condition• Between 2008-2018 no. of people with 3 or more

LTCs predicted to rise from 1.9 to 2.9 million• Patients with LTCs make up 50% of appointments• LONDON- ethnically diverse, non-English speaking,

mobile population, additional deprivation indices

Where we are today: progressive transfer of care out of hospitals

• Chronic disease management• Earlier inpatient discharge• Expansion of day care surgery• Reduced post op follow up• Reduced OP follow up• Increased investigations in the community• “Out of Hospital Care” – explicit policy

direction• LONDON effect- hospital closure

programme

Where we are today - understaffed

Where we are today - understaffed

Centre for Workforce Intelligence

“Our analysis on the available evidence on the demand for GP services points to a workforce under

considerable strain and with insufficient capacity to meet expected patient needs. There is a clear need to

substantially lift workforce numbers to more sustainable levels.”

Where we are today : under-resourced

• Between 06/07 – 10/11– Spending increased on GP services by 10.2%– Spending increased on hospital services by 41.9%

• In 2012/13– £7.8bn spent on general practice– Over £70bn spent on secondary care

• No national investment or strategy for GP premises since 2004

Where we are today : under-resourced

Year % total investment % excluding dispensed drugs

2004/5 10% N/A2005/6 10.41% N/A2006/7 9.83% N/A2007/8 9.17% N/A2008/9 8.74% 8.04%2009/10 8.45% 7.81%2010/11 8.31% 7.68%2011/12 8.16% 7.56%2012/13 8.04% 7.47%

Where we are today – overworked and demoralised

• DH commissioned 7th worklife survey GPs (Aug 2013)

lowest levels of job satisfaction since 2004 contract highest levels of stress since start of the survey series substantial increase in GPs intending retiring next 5 yrs

• BMA GPC GP contract imposition survey (Sep 2013)

9 out of 10 increased workload past year, 100% incr bureaucracy

9 out of 10 say reducing appts and time for patients Nearly 9 out of 10 reduced morale• 1 in 2 GPs less engaged with CCG due to workload

Today’s political context• NO NEW MONEY-austerity - £30b savings by 2020• GP contract changes 2014-15• Workload demands on GP practices continually

rising• “Equitable funding” - LOSERS & GAINERS• Standardisation of care & quality in primary care• Increased scrutiny and performance

management; NHS England, CQC and CCGs• Prime Ministers Challenge Fund: 7/7 opening• Urgent care- Keogh review • Competition; Monitor

Competing in a market• AQP – a reality; APMS, ES, LA commissioning• Competing with commercial providers: advantage

of size, business accumen, able to take risk, loss leading contracts

• Competing with Foundation trusts (“vertical integration”)

• Competing with access and convenience (vs quality)- 8 a.m-8 p.m/7 days a week

• Opportunity costs in competing and tendering• Abolishing practice boundaries; patient choice• Increasing value of global sum £/patient• Challenges of competition greater the

smaller the unit

Planning for the future• No practice immune from external pressures and

threat• Vulnerability increases the smaller the unit• Vulnerability for MPIG and PMS losers• Implications for all GPs-partners and sessional

doctors• London effect: Higher prevalence of: single-handed/small practices, inadequate premises BME GPs, salaried and freelance GPs Greater ethnic diversity; London specific demographic

needs

Securing our future: GP practices working together

• Survival of the fittest: economies of scale, ability to compete, sharing opportunity costs, managing financial risk, security in numbers

• New opportunities: new/expanded services, new income streams, professional development and new roles, peer support and education, managing workload and risk

• Looking after our own, supporting the disadvantaged; supporting small practices; maximising the potential of inadequate GP workforce

The weak or disadvantaged• Poor, inadequate premises (locked in); CQC

vulnerable• Small & isolated• Challenging population demographics• Low GMS funded• Poor historic Health Authority/PCT support,

development and investment• Poor staffing levels• Poor management support• Not policy savvy• Quality and potential of individual GPs obscured

Tiers of collaboration• Primary medical services (G/PMS)

and enhanced services• New provider models for expanded

services in the community; out of hospital care

• Avoiding “tears” of collaboration

Primary Medical Services (GMS/PMS)• GMS/PMS – flexibilities for informal & formal

alliances• Sharing human resources, cross-cover, training• Subcontracting & sharing services across

practices • Back office functions e.g. PAYE, bulk purchasing• Improved access: extended hours DES; Xmas

closing • Supporting statutory functions/HR/information

governance, CQC registration etc• Quality assurance and professional development:

clinical governance, peer review, education• Succession planning for potential vacancies

Structural options for new provider models• Form to follow function; depends on purpose• Simple alliances; sharing premises and staff• Formal mergers as partnerships• GP co-operatives• Private companies limited by shares• Community interest companies (CICs), social

enterprises • Charity or charitable incorporated organisation

(CIO) • Limited Liability Partnership • Companies limited by guarantee• NEED EXPERT LEGAL ADVICE

Principles of working together• What is purpose? Shared vision, equity of

opportunity and ownership, avoid “corralling” practices

• Preserving the essence & success of general practice

• Benefits to patients• Supporting the weakest and disadvantaged GPs

and practices• Creating synergy vs “takeovers”• Providing true contractual and career

development opportunities

Challenges and risks to collaborative working

• Loss of autonomy, loss of “essence” of general practice (patients like small practices)

• Differences in opinions and philosophies• Different starting points• Sharing unequal historic resources• Developing trust and collective ethos• Legal & liability implications• Setting up costs• TIME to plan

It can happen and work• Derbyshire Health United: Not for profit social

enterprise, 300 GPs covering 1m patients, provides 4 walk-in centre services, OOH triage and call handling

• Midlands Medical Partnership: 33 GP partners, 4 GMS contracts, 60000 patients

• AT Medics: Private company limited by shares, across 8 CCGs in London, corporate structutr providing core and enhanced services, and support for career development

• Suffolk GP Federation: not for profit community interest company, 40 practices, 360,000 patinets

• Sessional Drs: www.pallantmedical.co.uk – a chambers of freelance locum GPs

Making it happen• Can’t afford ostrich approach• Start talking within your practices and between

practices• Premises constraints – estate strategy with hubs• IT infrastructure to support networks• LMC role• CCG role supporting practices and resource shifts

from secondary care• AT role - supporting collaboration, resources• Learn from others - look at what’s working

elsewhere

GPC guidance• “Collaborative GP alliances and

federations” October 2013

• “Guidance for practices on how to employ shared staff” October 2013

• GPC survey of GPs on collaboration (Feb 2014)

http://bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/priorities/gpc-vision

Integrated care, built around the practice“Community health care teams built around GP practices. Collaborative working across localities with practices either singly or collectively employing or directly managing community nurses who, working together with practice nurses, will provide a seamless and more flexible nursing service for patients in the community.”

“Greater collaboration between community pharmacists and practices with a practice- aligned pharmacist undertaking medicines management and other elements of chronic disease management”.

Integrated care, built around the practice

“Secondary care clinicians and GPs working collaboratively to design and provide care pathways for local areas, bringing more diagnostics and specialist care out of hospital and into community settings, including hospital-based specialists visiting nursing and residential homes and working alongside GPs in practices when appropriate.”

Turning solutions in to reality

FUNDING: “Government should set a target for NHS England to invest in a year on year increase in the proportion of funding in to general practice”Ending PbR and perverse funding systems – money to follow changing patterns for careWORKFORCE:National strategy for recruitment & retention nowSupport returners back to work

Turning solutions in to reality:

PREMISES: Fit for the future- 10 year programme of premises development- Create a GP premises development fund- Practices working together to make maximum use of premises- Guaranteeing reimbursement of running costsEMPOWERING PATIENTS AS PARTNERS- Self care, demand management

Changing external mind-sets

• 4 hour+ A&E waits due to demand exceeding supply, pressures, need more resources, more A&E Drs…

• Waits for GP appointments due to fault of GPs not working hard enough, not open long enough, practice creating obstacles…

Changing mind-sets• Investing in hospitals is about investing in

care and services

• Investing in general practice is about paying GPs more

• Is there a way of investing in general practice without necessarily being linked to perceptions of GP pay?

NZ (10.1%)

UK (9.6%)

AUS (9.1%)*

FR (11.6%)

GER (11.6%)

CAN (11.4%)

NETH (12.0%)

SWIZ (11.4%)

US (17.6%)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$3,022$3,433 $3,670

$3,974$4,338 $4,445

$5,056 $5,270

$8,233

Health Spending per Capita, 2010Adjusted for Differences in Cost of Living

30

* 2009.Source: OECD Health Data 2012.

% GDP

Dollars

Sicker AdultsCost-Related Access Problems in the Past Year

31

Percent AUS CAN FR GER NETH NZ SWIZ UK US

Did not fill prescription or skipped doses

16 15 11 14 8 12 9 4 30

Had a medical problem but did not visit doctor

17 7 10 12 7 18 11 7 29

Skipped test, treatment, or follow-up

19 7 9 13 8 15 11 4 31

Yes to at least one of the above 30 20 19 22 15 26 18 11 42

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Sicker AdultsAccess to Doctor or Nurse When Sick or Needed Care

SWIZ UK FR NZ

NETH AU

SGE

R US CAN

0

25

50

75

100

79 79 75 7570

63 59 5951

32

Percent

UKSW

IZ NZ FR AUS

NETH US CA

N

GER

2 4 5 8 10 12 1623 23

Same or next-day appointment

Waited six days or more

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Sicker Adults and Primary Care PhysiciansAccess to After-Hours Care

UKSW

IZNE

THGE

R NZ FR US AUS

CAN

0

25

50

75

100

2126

3440 40

55 55 5663

33

Percent

UKNE

TH NZ

GER

AUS

SWIZ FR

CAN US

95 94 90 8981 78 76

4534

Sicker Adults: Difficult getting after-hours care

without going to the emergency room

Doctors: Have arrangements for patients

to get after-hours care

Source: 2011 and 2012 Commonwealth Fund International Health Policy Surveys.

Sicker Adults with a Chronic ConditionPatient Engagement in Care Management

34

Percent reported professional in past year has:

AUS CAN FR GER NETH NZ SWIZ UK US

Discussed your main goals/ priorities

63 67 42 59 67 62 81 78 76

Helped make treatment plan you could carry out in daily life

61 63 53 49 52 58 74 80 71

Given clear instructions on symptoms and when to seek care

66 66 56 64 64 63 84 80 75

Yes to all three 48 49 30 41 42 45 67 69 58

Base: Has chronic condition.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Primary Care PhysiciansPractice Routinely Receives and Reviews Data on Patient Care

35

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Percent routinely receives and reviews data on:

AUS CAN FR GER NETH NZ SWZ UK US

Clinical outcomes 42 23 14 54 81 64 12 84 47

Patient satisfaction 56 15 1 35 39 51 15 84 60

Hospital admissions and ED use

39 30 9 24 21 43 32 82 55

Primary Care PhysiciansDoctors’ Clinical Performance is Reviewed Against Targets at Least Annually

36

UK NZ US AUS NETH FR GER CAN SWIZ0

20

40

60

80

100 96

83

67

5347 43 43 41 37

Percent

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Primary Care PhysiciansDoctor Routinely Receives Data Comparing Practice’s Clinical Performance to Other Practices

37

UK NZ FR SWZ US NETH AUS GER CAN0

20

40

60

80

100

78

5545

35 34 3225 25

15

Percent

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

General practice as a solution• Pride and confidence - UK GPs and general

practice provide world leading primary care• Bedrock of NHS: 340m consultations/yr vs 21m in

A&E• The most cost-effective part of the NHS? - £130

patient/yr unlimited care vs £200 single OPD PbR appt

• Investing, expanding and enabling general practice makes absolute sense- is key solution to wider NHS pressure and future sustainability

• "Developing General Practice today - Providing healthcare solutions for the future"