Scaling up general practice: are we up to the challenge?

Transcription

1 Scaling up general practice: are we up to the challenge? Dr Rebecca Rosen GP, South East London Senior Fellow, The Nuffield Trust 1 st February 2015

2 Multiple drivers of demand Lack of access to social care Rising patient expectations New providers/ supply induced demand Primary care Aging populations Rising prevalence of chronic disease New medical technologies

3 David Cameron World s first 24/7 service reiterated at party conference last weekend Access GPs evening and weekends 7/7 Increased use of technology New skill mix and shift patterns

4 Jeremy Hunt 5,000 more GPs / 50% of med school graduates Look at the terms & conditions of general practice. Reduce burn out They need to feel they are valued... that they are part of the future, Skill mix:...blood tests, could be offered by nurses instead of doctors Safety and a caring NHS Data and transparency

5 Simon Stevens, Speaking at Vitality Partnership with the PM Five Year Forward View Prevention blitz on smoking, drinking, junk food. Fundamental redesign of services New models; integrated physical & mental health; choice and personalisation Financial sustainability iron out variations in efficiency. But with an aging population we are going to need more money Empowered, engaged, resilient communities New models of care Enablers of change:

6 Underlying NHS Context: Financial and workforce pressures Workforce: Recruitment and retention Numbers planning early retirement Reduced working hours Community nursing shortage 30bn funding gap 2.4bn predicted deficit 15/16 New Models/ transformation remain the key idea for 22bn efficiencies Emerging solutions Workforce devel.strategy (HEE) Competency based, role flexibility, adaptive to context NHS England 10pt GP plan Community education networks and new roles

7 Hostile policy context, no clear view of role of primary care in national health system

8 Organisational and functional transformation General practice is transforming fast: Larger scale organisations Organisational redesign bringing practices toegether New professional roles Growing population focus Growing use of technology Increasing scope of work

9 Super partnership model Main characteristics: Keeping what s good about small and local Built on local general practice with local GPs Delivery at scale: 80k+ patients: practice mergers Expanded general practice teams Clinically and quality focused, managerially smart Integrated planning and delivery of generalist, specialist and community services Provider-led population health care management Foundation for large education provider

10 Networks and Federations Tower Hamlets London Borough of Tower Hamlets has established eight GP networks Main characteristics: 36 practices were formed into 8 networks 2006/7. Geographically aligned. 4 5 practices per network. Initially formed to improve diabetes care, then extended to address other conditions Substantial PCT investment ( 8m over 3 years) in admin staff to support networks, IT, care planning and incentives for quality improvement Focus for peer led change and improvement with a linked education and training programme Care coordination enabled by care planning, shared electronic record and monthly MDT mtgs Peer led performance review against KPIs for incentive payments

11 Networks and Federations Suffolk Federation Formed between Suffolk GP practices, April 2013 Main characteristics: 40 original practices invested a fixed payment (30p per patient) to join the federation now 60. Membership organisation governed by a board of 9 GPs, 3 practice managers and the CEO Each practice has 1 vote for strategic decisions Covers a population of 539,000 patients Formed to win contracts for extended services. Portfolio of services now covers: Diabetes, Ultrasound, lymphoedema, cardiology and urology Diversifying roles into practice support including running a locum bank, HP and procurement

12 Multi-practice models Main characteristics Partnership and PLC versions Run multiple practices and services through multiple contracts Variety of services offered: standard general practice; urgent care centres; walk-in centres Geographically scattered Variable governance arrangements Examples: The Hurley Group, The Practice PLC

13 Proactive, population focused health care Bromley by Bow Healthy Living Centre Health GPs, community nurses, health networkers, artists, gardeners, community care workers and a youth team to explore and create new ways of thinking about health in a holistic way. Enterprise Enterprise Hub - eight social businesses helping people return to work Skills development and return to work ESOL, sewing and art groups, plus opportunities for NVQ, HNC, HND qualifications (eg working in the centre café) Environment a high quality environments to raise aspirations and boost self-esteem. Creche supporting opportunities for working parents to return to work Links with third sector organisations community groups supporting health promoting activities

14 RCGP Nuffield Trust survey July Nov 2015 survey of 94 CCGs and almost 1000 GPs Survey through direct s and RCGP chair updates CCG responses: 126 responses (incl incomplete/duplicates) 94 analysed > 75% from chairs or accountable officers 25% from vanguard sites GP responses: 1017 responses, 982 analysed 55% from GP partners, 11% managers, 10% salaried GPs, 24% others.

15 RCGP Nuffield Trust survey 73% of GPs in a formal (37%),informal (26%) or both (10%) collaboration 44% of collaborations had formed in the previous year Driven mainly by GGG encouragement and support <50% of CCGs had provided financial support most offered support in kind : convening meetings/expert advice/lending staff Over 2/3 cover a population over 50,000 Commonest governance form is a private ltd co. only 8% are CIC Most common focus: economies of scale and developing extended services Biggest reported challenge is building trust & engagement

16 RCGP Nuffield Trust survey Terminology is confusing: Networks and federations are broadly the same thing. Individual practices remain separate Agree to work together in specified areas May be formal where individual practice belong to an overarching organisation (LLP, private Ltd Co. CIC) Or informal no overarching governance structure may have an MOU

17 RCGP Nuffield Trust survey

18 RCGP Nuffield Trust survey

19 RCGP Nuffield Trust survey

20 RCGP Nuffield Trust survey

21 Recent HSJ headline...

22 RCGP Nuffield Trust survey July Nov 2015 survey of 94 CCGs and almost 1000 GPs Survey through direct s and RCGP chair updates CCG responses: 126 responses (incl incomplete/duplicates) 94 analysed > 75% from chairs or accountable officers 25% from vanguard sites GP responses: 1017 responses, 982 analysed 55% from GP partners, 11% managers, 10% salaried GPs, 24% others.

23 RCGP Nuffield Trust survey 63% of GPs part of a formal (37%) or informal (26%) collaboration 44% of collaborations had formed in the previous year Driven mainly by GGG encouragement and support (though <50% of CCGs had provided financial support most offered support in kind : convening meetings/expert advice) Over 2/3 cover a population over 50,000 Commonest governance form is a PLC. only 8% are CIC Most common focus is developing extended services Biggest reported challenge is building trust & engagement

24 RCGP Nuffield Trust survey

25 RCGP Nuffield Trust survey

26 RCGP Nuffield Trust survey

27 RCGP Nuffield Trust survey

28 RCGP Nuffield Trust survey

29 Recent HSJ headline...

30 So, what s the overall aim? 3 main paradigms High quality, efficient general practice Improve quality/reduce variation Improved access Improve business viability Overcome workforce challenges Good citizenship working well with other providers Adherence to CCG protocols / commissioning incentives schemes Appropriate referrals and use of A&E Coordination for complexity /working with MDTs Leading transformation Holding capitated budgets and redesigning care pathways Extended clinical services in the community Influencing the activities of other providers

31 Very early findings from Nuffield case studies Greatest progress has been made within general practice: improving the quality and efficiency of daily work Impressive initiatives to up-skill non-clinical staff, creating wider roles within practices Growing use of technology and electronic communications Some work to support practices with care coordination Three of the four sites delivering extended (specialist) services in the community Not yet leading whole pathway transformation

32 Lessons from US physician groups with budgets 1. Invest heavily in leadership, management and infrastructure Networks too loosely structured Lacked physician leadership Under-invested in management and infrastructure, 2. Balance quality, patient experience and cost incentives. Underpinning narrative for change must blend all three 3. Create moderate and meaningful incentives Organisations and individual clinicians should carry some financial risk, but these must relate to things they can control. Savings must be available to the group 4. Consequences of poor performance must be made clear in advance and applied consistently

33 Lessons from US physician groups with budgets 5. Minimise insurance risk as far as possible Larger populations Adequate risk adjustment Exclude very complex, high risk or rare conditions Use stop loss insurance 6. Create real or virtual budgets Supported by detailed, accurate data and Robust systems for performance monitoring 7. Encourage hospitals and specialists to cooperate with emerging organisations Through incentives? Shared employment? 8. Acknowledge that success takes time!

34 Making it happen: essential ingredients Strong clinical leadership and GP engagement Clear vision for the organisation(s) who are trusted by their peers Time and skills in leaders/belief it s work making the effort in followers Infrastructure IT systems for shared records and data analytics Telehealth and telemedicine Education and training Organisation and workforce development New models of governance Skilled managerial support and resources for OD Developing skill-mix and increase multi-disciplinary working

35 Making it happen: essential ingredients Relationships with wider health economy Ability to see GP/Primary care role as part of a whole health system Willingness to collaborate with local specialists and community services Capacity to contribute to evolving design and delivery of integrated services Strategic and operational management skills Ability to develop and implement a strategic plan for growth and diversification Operational management skills that can be applied across practices Ability to bid effectively for new contracts Financial logic

36 Common bear traps! Bidding for services at prices which are too low Bidding to win without enough attention to operating costs Underestimating set up and compliance costs Winning a contract, but not able to recruit staff to deliver the service Workforce shortages creating costs pressures due to agency staff Senior staff covering shortfalls - burnout Taking on a contract at risk but not being able to influence peers to stick to agreed protocols

37 Further challenges: competing priorities PMS review pushing GPs to deliver more for less. Will they have any capacity to devote to scaling up? Within practice challenges such as recruitment and retention Too many initiatives in progress at one time (KPIs, Commissioning incentives schemes, AQP services etc)

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