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Archive for the ‘CCGs and Primary Care’ Category

Feb
09

Remember independent bookstores?  There was a time when they were the sole provider of must-read bestsellers.  Each sold at full price and carried a 40% profit margin.  Business boomed.  But then along came book megastores like Borders Books and Waterstones.  They had more inventory but needed traffic, so sold bestsellers at hugely discounted prices.  End of independent bookstore profits.

They regrouped and focused instead on niche markets with targeted discounts in these areas.  Then came Amazon, with its selection and discounts across the board, and this sealed their fate.  Books are more available (and cheaper) than ever, but independent bookstores are, sadly, now a dying breed.

What did it feel like when the owner of one of these stores heard that Borders Books was opening across the road?  How did they then feel when they heard that Amazon was setting up an online bookstore? 

By now you might be wondering why I am writing about books!  Is the story of independent bookstores relevant to primary care?  The Royal Pharmaceutical Society certainly thinks so.  In its new document, ‘Now or never: shaping pharmacy for the future’.  (find it here), point 1 is ‘The traditional model of community pharmacy will be challenged as economic austerity in the NHS , a crowded market of local pharmacies, increasing use of technicians and automated technology to undertake dispensing, and the use of online and e-prescribing bear down on community pharmacies’ income and drive change.

It goes on to say, ‘In a market which has become increasingly crowded, a recent report by AT Kearney estimated that these challenges would reduce the profits of the average community pharmacy by 33%, resulting in the closure of 7.5% of all England’s community pharmacies by 2016.

These pressures will continue and intensify past this date, and community pharmacy will face significant challenges where it does not (change).

But what about general practice itself?  The advent of PMS and APMS contracts signaled a desire to broaden the range of general medical service providers, and it was almost in response to this that some practices started the uncomfortable conversations with their neighbours about mergers.  But a much more fundamental shift is happening: the advent of integrated care.

The system is no longer prepared to accept general practice operating in isolation, with the inherent variation that multiple small businesses present.  Some Foundation Trusts are looking at general practice and exploring how it fits within their model of integrated care.  My view is that it is only the general ignorance that resides within secondary care about the operation of general practice that has prevented this happening further and faster. 

But a more real and present danger are community trusts.  If I ran a community trust the first line of my strategy would be to become the lead provider of primary and community care for specific locality areas.  For community trusts to secure the investment that has historically gone into hospitals they need to reduce demand, and the only way they can do this is to partner effectively with (take over) general practice. 

General practice’s ‘amazon moment’ is actually the Better Care Fund.  Millions of pounds are being invested into community health and social care with clear markers of success predicated on managing emergency demand.  Whatever plans are made, they will only be successful with general practice at the core.  This cannot be as a collection of disparate providers; someone is going to need to bring practices together.

So the race is on for general practice.  The runners are Foundation Trusts, community trusts and general practice itself.  My worry is that the majority of general practice is looking out of the window with an ‘on-line bookstores will never catch on’ mentality.  If it is, I fear the fate of the small businesses that make up today’s general practice will mirror that of independent bookstores.

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Feb
02

It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (http://ccginformation.com/a-3-step-guide-for-developing-general-practice/).  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.

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Dec
16

Much has been written about maggots this week, but those involved in the maggot business are so concerned with the lack of balance in the reporting that some are thinking about getting out altogether.  So is it time to get out?

At their most basic level, maggots are the larvae of flies, but as you and I know, they are so much more than that.  For a start nearly all fish love maggots, and for them they are a great source of food as well as being effective bait.  Fishermen are even prepared to pay for them: at WillysWorms.co.uk they go for £2.48 a pint.

Live maggots have been applied as a medical treatment since antiquity, as an effective means of wound treatment.  The late Princess Margaret is possibly the most famous patient to receive ‘larval therapy’ which involves using sterile maggots to clean an infected wound.

And forensic scientists use the presence and development of maggots on a corpse as a way of estimating time elapsed since death.   So called ‘entomological evidence’ was first used to convict a murderer in 1935 when Dr Buck Ruxton was found guilty of the murder of his wife and maid based on maggots dated at 12-14 days old.

But despite their really positive contribution, the business of maggots is getting increasingly bad press.  They are, it seems, becoming something of a problem. 

In August a Worthing woman discovered a maggot in a burger that she bought from McDonalds.  Apparently she wasn’t loving it.

In November cousins Ella Grix and Chloe Appleford were about to take a spoonful of Weetabix, when they were, according to the Worthing Herald, ‘horrified’ to look down on their chocolate-laden biscuits to see maggots crawling in and around them. The girls’ grandmother, Yvonne Read, 45, had bought the box in Gravesend, Kent.  ‘I will never buy or eat Weetabix again. It was disgusting,’ a dismayed Ms Read told the Herald.

Stories like this are just the surface of it.  There are a number of horror stories also doing the rounds.  In July the Independent reported this story, one that the more squeamish amongst you might want to skip.

Derbyshire resident Rochelle Harris had just returned from a holiday in Peru when she began developing shooting pains in her face.

The 27-year-old initially thought little of it, and assumed the problem would quickly disappear, but the following day she  woke to find a strange liquid covering her pillow and began hearing scratching sounds coming from inside her head.

Increasingly concerned by the discomfort, Ms Harris decided to visit the Accident and Emergency department at the Royal Derby Hospital, but was told the problem was likely to be a simple ear infection or mosquito bite.

It was only after she was referred to the local Ear, Nose and Throat clinic for an hour-long examination that was intended to confirm the infection, that the sickening truth of the problem became clear…the doctor said ‘You’ve got maggots in your ear’. I burst into tears instantly… I was very scared – I wondered if they were in my brain. I thought to myself ‘This could be very, very serious’”.

The doctors immediately tried to remove the maggots from Ms Harris’ ear canal, but the deeper they probed the further the maggots went inside her head, eventually disappearing from sight.

A brain scan was swiftly ordered to work out where the maggots were hiding and exactly how many of them there were, as concerns grew that or more of them could reach the brain. …The brain scan revealed the maggots burrowing inside Ms Harris’ head had left much of the area untouched, only chewing a 12mm hole in the ear canal.

Doctors decided the best course of treatment to remove the maggots was to flood the ear with olive oil.

Ms Harris said: “It was longest few hours of my life… I had to wait overnight to see if the treatment worked… I just wanted them out of me and now I knew what was causing the sensations and sounds it made it all the worse.”

Unfortunately the tactic failed, but the following day doctors were able to remove two living maggots that been flushed closer to the entrance of the ear.

Concerned that there may be another maggot they might have missed, doctors sedated Ms Harris and conducted a full re-examination of her ear. 

They were shocked to discover a further eight large larvae – what they dubbed a “writhing mass of maggots” – but with the patient sedated and the creatures easier to reach following the olive oil experiment, the doctors were able to remove them.’

With maggots getting such a hard time in the press, it is doubtless hard sometimes for those in the business to find the motivation to carry on.  It does feel like there is always going to be another story around the corner.  Despite the countless happy fish, one rogue maggot can ruin it for everyone. 

It is probably no consolation, but I think maggots are a force for good, and I hope everyone in the maggot business sticks with it and decides that, at the end of the day, despite the scaremongers, the good that the vast majority of maggots do every day all over the country make it worth carrying on.

 

Oct
27

The development of general practice as a provider of an extended range of services is welcomed by some and resisted by others.  The main barrier is the concern that some GPs have that any change will mean a requirement for them to specialise in some way. 

So it is helpful to consider the development of general practice into new service delivery areas separately to the development of general practice as the provider of core GMS/PMS services.  It is helpful because the development needs of each are different, because delivering new services is an optional not a necessary development, but primarily because it reduces resistance by clarifying the freedom that any GP has to continue to concentrate on the delivery of core general practice.

CCGs that are serious about whole system transformation require general practice to develop  in ways that enable provision outside of hospitals to be radically changed. 

So how might this development take place?  What stages might this consist of?  A route map at this point for those who are keen but don’t know how would be very helpful.  So here is an attempt to outline three key steps for the development of general practice provision. 

1. Practices form provider organisations.  The first step is the development of the basic infrastructure.  The current unit of general practice is too small to deliver an extended range of services at any sort of scale.  Practices need to find partners that they can work with.  This will primarily be other practices, but it could be a whole range of partners including other NHS organisations or even private providers.

Part of what is needed at this stage is investment.  This is required to set up governance structures, invest in any necessary capital, and to develop expertise in areas such as business case development.  This investment can come from the practices themselves, or can be part of any new partnership that the practices enter into. 

Initially these new provider organisations can hold a standard NHS contract for out of hospital services.  CCGs can help by consolidating the various LES’s into a single contract, which practices can then choose to deliver collectively through the new provider organisation.

2. Provider organisations offer an extended range of services.  The second step is for these new organisations to develop their service offering by incorporating new areas and skills, such as extending into the delivery of community services and building Consultants into their service offering.  Again this could be in partnership with other NHS organisations or by offering these services directly. 

At this point these provider organisations can start to demonstrate the value they can add beyond that of existing providers, by offering services across a whole pathway, e.g. for diabetes whereby the GPs and the consultants provide care as part of the overall service offering of the new provider organisation.  This allows CCGs to be able to commission pathways of care more effectively, and enables person centred care built around the core general practice offering to become more of a realistic possibility.

3. Provider organisations become ‘accountable care’ providers.  The third step is for these new organisations to really exploit the link between the list based care of the core general practice contract alongside the provision of extended services.  What this creates is the opportunity to take on responsibility for a budget for a specific population.  Innovative service delivery models will enable these organisations to improve the outcomes for a population, and for the organisations as businesses to generate a return on a capitation based budget.

At present general practice is getting lost in the ‘to federate, or not to federate’ question, as a largely defensive manoeuvre.  But in many ways this is the wrong question.  The right question is what is the vision for how the practice as a business will operate 5 years in the future, and what is required now to make this happen.  For CCGs the work is to help practices think these issues through, as an enabler of delivery models that can meet the financial and quality challenges ahead.  Practices do not have to change, but CCGs should give all the help they can to those who are up for the challenge.

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Oct
12

As we approach the precipice of the cliff, the pressure is on.  We look at the relentless tide of rising acute activity and everyone is clear, ‘something must be done!’.  In order for our hospitals to be able to restructure and organise services differently, experts and management consultants tell anyone who will listen that what we need is an ‘out of hospital strategy’.

But the NHS is changing. Out of hospital (as opposed to ‘in hospital’) is no longer the distinction that is helpful in framing the changes that clinical commissioning groups (CCGs) are striving to achieve.

Most CCGs are organised around some form of locality structure.  This is where groups of practices from the same area come together and operate as the underpinning infrastructure of the CCG.  In larger CCGs there may be up to 10 localities, and smaller CCGs may be made up of as few as one locality.  The principle however holds that practices are grouped in a rational way that makes meeting and decision making sensible and practical for the relevant practices.

A key question that many CCGs are grappling with is what exactly is the role of the locality in this post-authorisation world?  Initially the importance of localities was based on the engagement of practices in the CCG (which we have discussed on this site, for example here). 

But with the ‘call to action’ and the future of general practice becoming a live issue, the priority that CCGs are giving to the transformation of general practice, the introduction of the integrated transformation fund, and the murmurings about contracting general practice and community services together (here), the importance of localities is growing, and the role of localities is changing. 

Localities are now the focal point of the transformation of community based services around general practice.  The role of the locality is to bring the practices together into some coherent form of general practice provision.  This means a move away from, say, 6 practices operating in splendid isolation, to the 6 practices operating as one unit, and acting actively bringing together community services, social services and the voluntary sector.  There is no piece of NHS infrastructure better placed to support this change than the CCG locality.

This means the locality is no longer an arbitrary grouping of practices with collective responsibility for managing a budget, but is now the practical mechanism by which care for the local community will be organised and, dare I say it, integrated around local needs.  The crude separation of general practice as commissioner and general practice as provider is removed; the advantage of general practice as both is harnessed.

CCGs are redefining ‘out of hospital care’ as ‘locality-based care’.  It starts with the redesign of general practice.  It blends in community services and social care.  It adds any existing community estate.  It is all done in partnership with the local population.  And it can move at the pace of the quickest not the slowest; not all localities have to develop at the same rate.

Herein lies the biggest challenge and opportunity for CCGs.  There is no question this is a hugely difficult task.  But as membership organisations of GP practices CCGs are uniquely placed to make this happen, and if successful have the chance to make more of an impact on the design and delivery of healthcare than any predecessor commissioning organisation in the history of the NHS.

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Sep
22

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.

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Sep
14

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.

Aug
11

Michael Dixon suggested in Pulse recently that CCGs should directly commission general practice.  So should we?

You can find the article here.  Unsurprisingly the main reaction has been a vigorous waving of the conflicts of interest banner.  This unfortunately distracts from the main question Dr Dixon is trying to address, which is how do we transform general practice.

Dr Dixon’s view is essentially that it is already clear that NHS England, who have responsibility for commissioning general practice, are not going to be able to lead any form of change.  Worse, he says that there has been a hiatus in the development of primary care since NHS England took it over which means GPs are not able to provide the service they want to.

His conclusion is that responsibility for directly commissioning general practice needs to transfer to CCGs.  He says, ‘I now think there’s no longer any alternative, because NHS England are not able to perform on this.  They’re having a great deal of difficulty in covering primary care and there’s not sufficient local sensitivity.   We need much greater fluidity between primary care and CCG budgets. This is holding up a lot of good work that could be done by CCGs.’

So, conflicts of interest to one side, is it true that shifting responsibility for commissioning general practice to CCGs is the best way of accelerating the transformation of general practice?

I am not so sure.  As direct commissioners the majority of effort gets sucked into the minority of very poor performers and outliers, and leaves very little capacity for working with the majority who are under pressure and struggling but keeping below the radar.

On top of that, contractual disputes between practices and CCGs seem to me to be a fast track to a deterioration of relationships, and would stop any real change of general practice dead in its tracks.

The reality is that for these reasons, and probably many others, PCTs, or indeed any predecessor commissioning organisation, were not able to effect a successful transformation of general practice.

For me, a much better model is for CCGs to step up and take a lead role in transforming primary care.  NHS England is not going to stop CCGs, and indeed are enthusiastic to work with CCGs for this to happen.  NHS England fully recognises the capacity constraints it is operating under, and can use its direct commissioning role to provide cover for CCGs who want to lead this change.

Changing general practice will not happen overnight.  As with any change what is important is to get some movement, some traction.  CCGs can use the space of NOT directly commissioning general practice to work those who want to change rather than those who do not to show what is possible and to create some momentum.

There are many practices that want to change but don’t really know how to do it.  That is where we should be focussing our efforts.  We don’t need to directly commission these practices to help them to change.   We can build change programmes, provide leaders with support, and create communities of the willing.

General practice needs  support to change.  CCGs should let NHS England focus on the really poor performers, giving whatever help is needed, but should use the relationships, the understanding of general practice, and the fact that we are membership organisations to start to make change happen.

CCGs don’t need anything else to transform general practice.  We just need to get on with it.  In the words of Barack Obama,

Change will not come if we wait for some other person or some other time.  We are the ones we’ve been waiting for. We are the change that we seek.

Jul
19

After the shambles of the RCGP 2022 GP document, it is refreshing to find a great report on the future of general practice.  The Nuffield Trust and the Kings Fund have produced a document, ‘Securing the Future of General Practice: New Models of Primary Care’.

You can find the document here.  It promotes fundamental changes to the organisation and delivery of general practice, which include linking together practices in federations, networks or merged partnerships.  It builds the rationale for this on a clear understanding of the case for change, which it articulates really well.

I think there are some areas where the report overly complicates the required change process.  But before I get into that I just want to reinforce that I think this is a great report, and one that should immediately become required reading for all CCG and NHS England staff!

First the good.  The report is really keen not to dictate to practices what they need to change into.  Instead it is keen that we have clarity on the functions required of primary care.  It suggests 5: improving population health, particularly amongst those at highest risk of illness or injury; managing short term non urgent episodes of minor injury or illness; managing or coordinating care for those with long term conditions; managing urgent episodes of illness or injury; and managing and coordinating care for those nearing the end of their lives.

I would fully support this approach.  It sets a clear outcome and leaves the form required to develop organically rather than be imposed.  What it does say is that general practice will require skilled facilitation, business planning and professional support (e.g. legal, financial, estates) when developing plans for extending service provision.  The universal experience from elsewhere is that all underestimate the support that is required.

I guess where my view differs from that of the report is the lack of ambition the report demonstrates for the role of CCGs in the transformation process.  Indeed, the report suggests that the very existence of CCGs is detrimental to the development of general practice, because the, ‘capacity for strategic work available is taken up by clinical commissioning responsibilities’!

Let us be clear.  No one is, or has ever been, better placed to facilitate the transformation of the autonomous, independent business units that are general practice than the CCGs that are membership organisations of those very practices.  CCGs understand general practice in ways that it is not possible for other organisations to, simply because it is made up of practices!  Its leaders are GPs!  I know I am stating the obvious, but this point seems lost on many outside of CCGs.

The report suggests that the required transformation cannot rely on the ‘heroic’ model of leadership where it falls to a small number of single individuals carrying those around them.  As such it suggests two things: a ‘national framework’ to guide strategic direction; and new contractual and funding options to sit alongside the existing contract. 

Here I think the report is wrong.  Yes practices need support.  But developing a framework feels like a process that will delay change starting and that in reality will not drive change.  In fact I am not sure who it will actually help.  It talks about a new contract that NHS England will offer practices covering end of life, mental health, long term conditions, older people, and children.  But these areas all fall within CCG budgets.  It does give an alternative that CCGs could commission additional services from general practice.  But we already can, so I am not clear what exactly we would be changing?

I agree the changes will not happen by themselves.  What I think we need is two things.  First we need a strong partnership between NHS England and CCGs to enable the commissioning of an extended range of services, in as innovative a way as possible.  We discussed what this might look like recently.  You can find it here http://ccginformation.com/how-commissioning-can-transform-general-practice/ .

The second is to demonstrate to practices that it is possible to make these changes, to support the willing, and to create a critical mass that will become a tipping point for wider change.  We need to spend our time not on frameworks or contracts but actively supporting the process of change, and it is CCGs ultimately who must use the unique position they are in and take the lead role in this.

The report is excellent, but it is 100% wrong to suggest CCGs are a barrier to this change.  On the contrary we are the solution, and the ones who must take on lead responsibility for the task of implementing the core suggestion of the report: the transformation of general practice.

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Jul
08

The Royal College of General Practitioners have produced a new document, ‘The 2022 GP – A Vision of or General Practice in the future NHS’.  It is a missed opportunity for the leaders of the profession to drive real change with their members.

There are undoubtedly some helpful elements within the document.  It supports the development of federated networks, it encourages generalist led integrated networks, and it seeks the organisational development of community based practices, teams and networks.

But it fails on three counts.  It fails to make the case for change now, it fails to build on the opportunity of commissioning, and it  fails to empower general practice to take action now.  We’ll explore each of these in more detail.

The very notion of the 2022 GP starts with a far away picture of where we are going.  But the reality is that everything that is described is required now.  If it takes us 9 years to get there it will have taken us 9 years too long!

We have discussed on this site how the opportunity is now for general practice.  But to take it requires urgent action to radically transform the way general practice operates.  Page 29 of the document, however, suggests a different pace of change, ‘The current model of general practice will inevitably evolve to meet patients’ needs.  This does not require destabilising change, rather a realignment of new priorities and a new strategic focus on general practice development within the context of community led care.’

Sometimes it is incumbent upon national organisations, even membership organisations, to give tough messages.  General practice urgently needs to change.  The RCGP had an opportunity with this document to make this point, but shied away for fearing of upsetting those members who don’t want to hear it.

Absent from the document is any mention of the impact of commissioning.  It is totally ignored.  Now you could argue this is a clinical commissioning website so I am bound to say that, but as a minimum you would expect the 2022 GP to at least reference the impact of clinical commissioning, particularly given it is a legal requirement for each practice to be a member of a CCG.

Candace Imison in her blog on the King’s Fund website asks whether clinical commissioning will stand in the way of developing GP federations?  She says, ‘It would be tragic if, by developing GPs as commissioners, we undermine their growth and development as providers’.

Nearly every CCG I know is prioritising the development of primary care.  Because CCG leaders understand primary care, and because CCGs understand that the development of primary care is critical to their own success, Candace’s fear is unfounded, and in fact the reverse is true – CCGs will accelerate the development of general practice as providers.  The RCGP could, and should, have at least acknowledged this.

The final failure of the 2022 GP is that it does not make it absolutely crystal clear that it is first and foremost down to general practice to change itself.  I know this is in part a function of a royal college’s duty to gain external support, but what it does is place general practice in the role of the victim, which is not a place it needs to be.

Richard Vautrey, deputy GPC Chairman, sums this up in his comment, ‘The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss historic what the 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.

But this doesn’t help general practice, or gain any support.  Roy Lilley’s summary of the 2022 GP was, ‘Guess what; they want more GPs.  Very dull and uninspiring’.  The document does come across a bit like ‘if you want a general practice like this it is going to cost you’, when what we needed was a document that empowered general practice to own the challenge and own the actions.

I am passionate about general practice, about its pivotal role in the health economy, and about how it sets the NHS apart from any other health system in the world.  But it desperately needs to change, and the RCGP have missed an opportunity to help it do so.

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