Archive for September, 2013


Michael Porter and Thomas Lee have published an article in the October 2013 edition of the Harvard Business review, entitled ‘The Strategy that will Fix Health Care’.  You can find it here.  Or alternatively you can read this relatively short post and I will tell you what it says!

It starts with the premise that there needs to be a ‘transformation to value-based health care’.  This is essentially a shift in the focus of health care delivery from value and profitability of services provided to the patient outcomes that are achieved.  This transformation, it claims, is on its way,

There is no longer any doubt about how to increase the value of health care.  The question is, which organisations will lead the way and how quickly can others follow.

Some in the NHS understand this.  The development of the Outcomes Framework is a good example of a simplistic attempt to shift the system with one golden bullet.  Many, however, do not, hence the reason the Outcomes Framework has been largely ignored despite its stated importance.  What is clear is that achieving this shift is far easier to say than to do in practice.

So how will this be achieved?  Step one, according to Porter and Lee is to define a proper goal for the health care system.  To improve outcomes for patients.  Not increase volumes or improve margins, just to improve outcomes for patients.  We say we have set this goal in the NHS but of course we have not.  We understand it is breaking even, achieving the 4 hour and 18 week targets, and becoming Foundation Trusts that is really important.

The strategic agenda for moving to a high value health care delivery system has 6 components, which are interdependent and mutually enforcing.

The first is to organise into what the authors describe as Integrated Practice Units.  These units are responsible for the full care pathway of a patient’s condition, not just the individual pieces of it.  These are clinicians and managers working together to provide every aspect of care for a given disease, such as diabetes.

The second is to measure outcomes and costs for every patient.  The outcomes must be those that actually matter to the patient, and be by condition such as diabetes, not by specialty such as podiatry or intervention (eye examination).

The third is to move to bundled payments for care cycles.  Specifically this is neither global capitation not fee for service (the mechanisms generally used in the NHS) as neither reward improvements in outcomes for patients.  This would mean a full care cycle for an acute condition; a year of care for a long term condition; or primary and preventive care for a specific population e.g. children.

The fourth is to integrate care delivery systems.  I like the authors’ description of integrated care, as it has a substance commonly lacking in NHS expositions of the topic.  They comment that most multi-site organisations are not true integrated delivery systems but loose confederations of largely stand-alone services that often duplicate each other.  True integration, they say requires 4 choices:

I.            Define the scope of the services, i.e. only deliver those services where you can genuinely deliver high value for patients

II.            Concentrate volume in fewer locations, because volumes matter for outcomes

III.            Choose the right location for each service line, i.e. deliver the routine and less complex out of hospital

IV.            Integrate care for patients across locations.  The integrated practice units should operate across locations if necessary.

Even the authors note that the politics of this is daunting, as many of us in the NHS have already discovered!

The fifth is to expand geographic reach.  The time has come to end the delivery of health care as a local model only, and allow superior providers for particular conditions to be able to serve a wider population.  This would either be a hub and spoke model, where a provider creates satellite facilities for the relevant integrated practice unit and fully employs, trains and rotates staff through the parent organisation.  The alternative is a clinical affiliation where the integrated practice unit provider partners with community or local providers and uses their facilities and staff, but applies its own successful approach.

The sixth and final component is to build an enabling IT platform (these keep getting easier…).  This IT platform would be centred on patients, use common data definitions, make medical records accessible to all, have templates and systems for each condition, and information would be easy to extract.  Simples.

There is a lot in the article and I am sure I have not done it justice, so I would encourage you to read it for yourself.  While much of what is suggested is both complex and daunting, there is nothing that I would obviously disagree with.  Equally there is very little that could be easily done tomorrow.

As leaders in and of the NHS the starting point has to be an acceptance of the basic premise of the article, that the focus of health care delivery must become solely about improving outcomes for patients.  We need to be less protective of the NHS that we have today, and engage our patients, our public and our staff in a conversation about the need for change so that we can serve them better, and so that some of the changes suggested can move from the theoretical and aspirational, to being realistic and implementable.

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There is a big gap.  This gap exists between how general practice understands its need to change, and how the wider health system needs it to change.  And at present there is very little that is constructively being done to resolve it.

General practice understands its need to change based on two things: income and workload.  Drawings are down and workload is up.

The two are not entirely unrelated.  As the drawings for each GP partner are calculated based on a split of the total ‘profit’ of the business, as income falls practices tend to go one of two ways.  They either reduce the number of partners or number of staff to keep drawings at the same level, or they accept a reduction in earnings and maintain staffing levels.

As result GPs are either paid less or overworked.  And in many cases it is both.  GPs feel that the current situation cannot continue in the direction that it is currently going.  Some just want to retire and be done with it.  Others are too young and want things to change.

But very few have signed up anywhere in this to evolving the business of general practice.  They want to continue doing the work they do now.  The notion of specialisation is something that most GPs turned their back on when they chose to become a GP in the first place.  But the reimbursement for core general practice is what is being eroded, and is what will continue to be eroded.  The government want more and more for less and less from the core GMS/PMS contract, and that is not going to change any time soon.

At the same time district general hospitals are coming to the realisation that growth is not the answer, that total income is not king, and that a shift of services out of hospital is required if the health system is going to be able to live within its means in years to come.

I was talking recently to an acute trust Chief Executive about this.  He understood the problem really well.  He talked eloquently about how he was working with community services and social care to shift services out of the hospital setting and into local communities.  He gave some great examples of how care was now being delivered in different ways, such as the hospital funding healthcare at home services.

I asked him where general practice was in this in new way of working, and what role it was playing. He looked at me blankly.  I explained the key role that general practice could be playing, with different practices building areas of expertise in different specialties, driving down variation and linking with hospital specialists to enable much more care to be delivered at the first point of contact the NHS has with each patient.  He said no-one in his organisation really understood general practice so they had to get on with making the change happen regardless.

This is the reality.  Those outside of general practice look upon it with bewilderment.  It feels like a magical world of impenetrable acronyms, like GMS, PMS, DES, LES, and (worse) MPIG.  There is no mechanism for engaging general practice as a provider in the conversation about system change.  As a result change is happening regardless of general practice, not because of it.

So this is the gap.  GPs want change for their own survival, but are not particularly interested in models beyond core general practice.  The wider system wants to change but is clear neither on the role of general practice within this change, nor on how to even engage it in the conversation.  There is a very real danger that general practice and the wider system will change in isolation from each other, and not in a way that solves each other’s problems.

CCGs are uniquely placed as organisations that understand the need for system change and understand general practice.  We must step up as organisations and provide the direction the system needs.  General practice in this country, the envy of the rest of the world, presents a huge opportunity to become the platform on which the health and social care system is developed, so that it can tackle the issues of ever increasing demand, a rising, aging population, and an explosion in long term conditions.   And it is up to CCGs to ensure this opportunity is taken.



While the talk nationally is all about changing the GP contract, what do we really need to do to support the transformation of general practice?  Is making funding harder and harder to access, or changing the rules around the incentive structure really going to drive the change required?

Little or no thought seems to be being given as to what is needed to support the development of general practice.  If the Secretary of State wants to genuinely support real change, then this is where significant funding should be targeted.

The NHS has invested huge sums of money in recent years in developing NHS organisations.  Hospitals have been supported to become foundation trusts, and for those that have not yet made it there is even now a Trust Development Authority.  Clinical Commissioning Groups have been supported through the authorisation process, and have their own dedicated development team within NHS England.  But virtually nothing has been invested in the development of general practice.

Practices across the country are under pressure.  Workload is going up and earnings are going down.  Many now recognise that they need to change, and the RCGP themselves have made it clear in their document ‘The 2022 GP’.

The problem most practices face is that either they do not know how to change or they do not have the capacity to change.  The busier the practice becomes, the harder it is to release GP partners or indeed anyone to understand and drive the process of change.

We are currently relying on a small number of exceptional individuals who are making change happen in pockets around the country.  But they are doing this despite the system not because of it.  The NHS needs to be making it easy for practices to change, and be actively providing support.

So where should organisational development support for general practice come from?  The Area Teams of NHS England certainly do not have the capacity to do it.  CCGs in some areas are starting to take this on, but are risking all sorts of accusations of conflicts of interest in doing so.  And is it really sensible to replicate the development of support 212 times?

The best way for support to be delivered would be through a national General Practice Development Agency.  The role of such a body would be to support large numbers of practices to change, so that both the practices have financially sustainable futures and that practices are able to play their role in enabling local health economies to become financially sustainable.

This agency would need to have the funding to support practices to change.  It would develop and make available the tools for change, and more importantly create a visibility of the change.  It would accelerate learning, share best practice, and provide tangible support to those that need it.

The big objection to this comes from the fact that GP practices are independent businesses.  So essentially there are two problems: first why should the NHS support non-statutory bodies; and second what jurisdiction could any such agency have over independent practices?

GP practices are funded by NHS money, provide NHS services, and are a recognised cornerstone of the NHS.  Using public money to provide development support to GP practices would pass the Daily Mail test.  So the first objection is theoretical rather than real.

The second is equally easily overcome.  The problem a national agency with funds and resources for practices will have is complaints about the speed and ease with which practices can access these resources, not whether they will want to in the first place.  I am not suggesting we set up a GP equivalent of the TDA, with a directive and imposing style.  What I am proposing is a dedicated agency whose role is to support and accelerate the changes that many practices already want to make.

We need a General Practice Development Agency.  We need support for practices to change that is effective, coordinated and resourced.  And we need it now.


The CCG Development Team at NHS England is working on a directory of development support for CCGs.  The idea is to connect up those who can provide support with CCGs to accelerate their development.

But what have we learnt as CCGs in our first 6 months about support?  What have we found even at this early stage about what works and what is less successful? 

I am sure it will be different for each CCG, but for me there are 3 lessons that I would say are already starting to emerge:

1. Start by understanding my problems.  CCGs are very different from any predecessor NHS organisation.  They are membership organisations with elected GPs and they all operate very differently.  As a result the development needs of each CCG are very different, and care needs to be taken to make sure they are understood properly.

I have found that the unique nature of the CCG means that support has only been successful when it has taken time to really understand the problems that are being tackled.  At its best, partners work with the CCG to carry out some form of diagnostic.  The results of the diagnostic are then used to design the intervention.  Which brings me to the second lesson…

2. Avoid ‘one size fits all’ solutions.  There have already been a number of examples where organisations have designed a service or a product or a course, which they are then keen to impose on CCGs.  Often these are available only on a specific day (and as a side note there is no point arranging sessions for Mondays or Fridays if you want GPs from CCGs to attend).  Worse is when CCGs are required to carry out certain actions, or free up so many people for so many days, in order to be able to access it. 

CCGs are not time rich organisations.  GPs, who are often new into leadership roles and the ones for whom development support is best initially targeted, work for only two or three sessions per week for the CCG.  So any investment in support needs to be built on an understanding of how the CCGs works, and be highly tailored to the specific needs of the organisation. 

3. Treat me as a partner, not as a customer.  As support organisations get used to the new world there has been a lot of talk of CCGs as the ‘customer’.  What this is resulting in is a focus on things like customer service and relationship managers, who seem to spend their time making sure that the CCGs are happy.

My view is that this has all gone too far.  Ultimately what is important is that whatever the CCG and their support provider are working on is successful.  If the CCG is not playing its part, then the support provider needs to let the CCG know. 

I think ‘partner’ is a better description than ‘customer’ in terms of what CCGs need at this stage.  CCGs have much to learn, and employ support to provide the necessary skills, expertise and challenge.  The relationship needs to be two way, with support providers being robust in their challenge to the CCG where it is required to ensure that agreed outcomes are delivered.

So in summary I would say that the learning so far is that great support is rooted in my world, is tailored to my needs, and is where the provider works with me in as challenging a way as is necessary to make sure that whatever we are trying to achieve is successful.


I recently received a letter from a local man with Parkinson’s Disease.  Hearing from patients, and gaining just a small insight into their lives, is one of the privileges that working in a CCG brings.  I want to share with you the story that he shared with me, and that he is happy that I share with you, directly, and in his words.

‘Whenever I have been asked, ‘How do you feel today?’ there is a simple 3 word answer: ‘Abandoned’, because we have been.  ‘Angry’, not at the condition (that is pointless). I am angry at the way we are treated.  How much use in reality is one 15 minute consultation with your neurologist every 12 months?

The last word is ‘frightened’, not just for me but for my wife, my children and grandchildren. I am in the middle of a ‘bad patch’.  It’s not nice when Parkinson’s Disease rears up and bites. This morning my wife wasn’t speaking to me and to make matters worse I was having a really bad “off” start to the morning. We still were not speaking at lunch time. Paranoid as men are in these circumstances, I pushed to find out what I had done wrong – it flared up for the first time in 4 years of marriage that we had really gone off at each other. 

I got in the car and drove off for 1/2 an hour.  Walking was out.  If I could have managed 100m today it would have been a miracle. When I got back we sat at the dining table, held hands, and I asked, ‘come on, what’s up?’.  ‘I’m scared. I’m scared for you and I’m scared for me’ was her answer, and the only thing I could say was, ‘That makes two of us then’.

There’s nothing I can add to this.  It brings home the responsibility we have to the communities and to the individuals that we serve.  Sometimes commissioning can get reduced to QIPP plans and financial reports.  But really the point is how are we, how am I, making a difference to the lives of the individuals who need us.