1. 1. www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development robert.varnam@nhs.net @robertvarnam Tameside CCG 18 June 2015 bit.ly/20150618future
2. 2. www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development robert.varnam@nhs.net @robertvarnam Tameside CCG 18 June 2015 bit.ly/20150618future
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. Does general practice have a future?
4. 4. 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. Does general practice have a future?
5. 5. www.england.nhs.uk @robertvarnam Does general practice have a future?
6. 6. www.england.nhs.uk @robertvarnam I joined NHS England back in the summer of 2013 to help with the newly announced Call to Action on General Practice. Among other things, this was an opportunity to take stock of the challenges facing general practice and the ways in which NHS England could play a part in supporting sustainable and improved care. Very much building on what people told us then, the NHS Five Year Forward View outlines ways in which we are committed to being part of the solution to the present challenges. bit.ly/c2aGP bit.ly/nhs5yfv How are things? Where are you heading?
7. 7. www.england.nhs.uk @robertvarnam For that reason, Im very pleased at the progress being made nationally on driving change here to improve the amount and the fairness of funding, giving greater power to local CCGs, training extra GPs, making the profession more attractive, improving premises and IT. Well feel the benefit of some of those things sooner than others, but theyre all welcome, and Im proud to have played a part in creating this momentum. The new deal for general practice 7 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 without need for GP or A&E 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 So, for the first time in a while, there seem to be several reasons for optimism about the future of general practice. BUT I dont believe that simply carrying on is going to cut it. ?
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.
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 This seminal data, which youve probably already seen, illustrates the reason why just doing more of the same isnt appropriate either clinically for our patients or at a system level for the country. We are now spending at least half our time dealing with people who have multiple longterm problems. And that proportion is just going to rise as we all get older. Yet these are not problems the NHS was originally structured to deal with. In 1948 it was generally assumed that someone gets ill and they consult their GP. If its a simple, quick and straightforward thing, the GP will give a prescription and the person will be cured. If not, a referral will be made to a clever doctor who will give a prescription, perform an operation and the person will be cured. And, perhaps, in a year or two, they might fall ill again, and theyll return for a cure. LTCs are problems that cant be cured. And most people have several. So seeing a specialist in one condition with the expectation theyll cure you is no longer appropriate for the people we spend most of our time with. Why change? Scottish School of Primary Care
12. 12. www.england.nhs.uk @robertvarnam We need a qualitative change in the model of care for these people. Just turning the handle faster, or adding more staff to do the same things would actually be wrong. We need also to change tack quite considerably. Not just more of the same New GPs will take TIME to train The world has changed more than general practice demography technology economics Many patients need a different kind of care less medical less dependent New care models present big opportunities, now
13. 13. You may be feeling rather uncomfortable by now, about all this change. Personally, Ive been through many periods of deep discomfort over recent months as Ive grappled with all this and met with colleagues around the country and the world who are doing likewise. However, I believe that much of whats being described at the moment is about releasing the potential already in our model of primary care. Its about returning to the values which attracted me to general practice in the first place. The things that are most admired about the NHS when you speak to people from other countries. These are descriptions of what people told us they were working towards in the Call to Action. And theyre embedded in the vision of the future presented by the Five Year Forward View. Health & wellbeing-promoting care Right access Consistently high quality Holistic, personalised, proactive, coordinated care Comprehensive, joined-up care for a registered population, shaped around them in the community bit.ly/nhs5yfv
14. 14. Here are some of the innovations being implemented right now by practices around England. For years, much of this has been theoretical or a matter of wishful thinking. But its happening now, and many of these are, I think, set to become mainstream in the foreseeable future.
15. 15. Phone first. Community diagnostics. Practice based paramedics. Pharmacy first. Web consultations. Primary care led urgent care centre. Minor injury service. Physio first
16. 16. Direct specialist advice. Condition management training. Shared records. Care coordination. Hospital in-reach. Care home ward rounds. Virtual ward. Primary care-employed specialists.
17. 17. Social prescribing. Travelling health pods. Peer-led walking groups Health coaching. Befrienders. Schools outreach. Community development.
18. 18. 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
19. 19. www.england.nhs.uk @robertvarnam New organisational forms for integrated care
20. 20. www.england.nhs.uk @robertvarnam The NHS Five Year Forward View outlined a number of new organisational forms which we believe will help make these changes more attractive, simpler and more sustainable. The two with the biggest interest for general practice are the multispeciality community provider and the primary and acute care system. bit.ly/nhs5yfv New types of organisation Multispecialty Community Providers Primary and Acute Care Systems
21. 21. 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
22. 22. 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
23. 23. www.england.nhs.uk @robertvarnam
24. 24. www.england.nhs.uk @robertvarnam What could the future look like?
25. 25. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
26. 26. www.england.nhs.uk @robertvarnam This is the kind of care I think patients should expect from us 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
27. 27. www.england.nhs.uk @robertvarnam A small aside about access we need to do much better at defining and improving it so as to deliver real improvements in value for patients. Its not a one-dimensional thing. This is the kind of care I think patients should expect from us 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
28. 28. www.england.nhs.uk @robertvarnam These are key design principles well need as we build for the future. I dont think there are any silver bullets here well need to include all of them. How that looks in practice will need to be different in different parts of the country, depending on the needs of your population and the opportunities presented by your current arrangements. 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
29. 29. www.england.nhs.uk @robertvarnam An 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 just extending opening hours isnt enough, and that other things need to happen in order for that to happen anyway. 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
30. 30. www.england.nhs.uk @robertvarnam 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. 3. What kind of organisation? Bigger Personal Capable Yours
31. 31. www.england.nhs.uk @robertvarnam One example is the Whitstable medical practice. Here, through practice mergers, they are now a single organisation serving 34000 patients. They have great facilities which enable them to provide a wider range of care, and more holistic, less medical approaches to long term conditions eg Whitstable medical practice
32. 32. www.england.nhs.uk @robertvarnam On the other hand, the same design principles are being applied by the GP Care federation in the Bristol area. Here, practices have remained entirely independent as businesses, but theyre working in increasingly close collaboration, developing new services and sharing back office infrastructure. eg GP Care federation, Bristol
33. 33. www.england.nhs.uk @robertvarnam Where to start?
34. 34. www.england.nhs.uk @robertvarnam Here are my 4Ps for where you could start bit.ly/GP4Ps Purpose Partnerships Proactivity Possibility 4 Ps for transforming primary care robert.varnam@nhs.net