GENERAL PRACTICE - THE FUTURE

Over the past 10 years my business has grown by 300% in terms of patient capacity and staff numbers alone whilst multiplying its turnover by a factor of 10.  Throughout we have maintained a clear mission and a vision that allows diversification but remains firmly rooted in general practice, its ethics and its principles.

At heart we a close partnership that operates a range of primary care contracts and a corporate serving the Cities of York and Hull with around 64000 reg patients.  We are part of, and I sit on the Board of, two large collaborations serving 140,000 and 75,000 patients in York and Hull respectively; both of whom have tackled the PCN DES in slightly different ways. Sitting outside, but alongside our core business and only incorporated in the past couple of years, our training team are the largest Primary Care Workforce and Training Hub in our STP whilst also offering a range of training services to other practices. And we also operate a small chain of 7 Pharmacies, which is the largest supplier of pharmacy services in York dealing with 55000 items a month. This creates a network of organisations, contracts, relationships and agreements that resembles the road map of Spain, so I think I have some understanding of managing complexity and the primary care industry.  I do of course acknowledge that there are bigger organisations in the game in both GP and Pharmacy services.

But the ask for your presentation is General Practice and its Future. I’m no Mystic Meg and I don’t possess a crystal ball. So I think we have to fall back on the quotes of the great and good, to look at what has already occurred, examine what is happening now and the things we know will affect us in our near future, to guess. Because, call it what you will, to predict the future is only ever an educated guess.

Formed just over 70 years ago to tackle Beveridge’s “five giants” of want, disease, squalor, ignorance, idleness, the NHS has by many measures been an outrageous success, however many of the challenges we face today were there in not dissimilar forms from its start, poor premises, availability of skilled staff, high demand, funding.  At is start GPs, despite choosing to remain independent, took on responsibility for the entire population, controlling access to specialist care; a major expansion in their role. Within one month 90% of the population had registered with a GP. By 1950 the Collings report, the first of its kind on quality in primary care, found poor standards, bad working conditions, and GPs isolated and under great pressure with limited support. The 1948 plan intended that GPs would be rehoused in health centres, but this proved untenable and in less than 10 years GPs complained that funding promises had been broken, funding for service improvements was inadequate and younger GPs were leaving for Australia.  

 In fact all this was foreseen by its architects, such as Bevan speaking in June 1948 at the RCN conference where he stated;

  “we shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing, improving – it must always appear inadequate”. 

 Personally I subscribe to that, inertia is our enemy. Development, improvement and change must be our constants.   It is probably why our health system is ranked as one of the best, if not the best in the World by many measures. Its pressures are, to a degree, from its success.   The population has increased from 50M in 1948 to 67.6M in 2019 whilst our proportion of under 65s fell from 88% to 80% as the numbers living longer increased with life expectancy in 1951 being 68 years, rising to 81 years in 2018. Our cancer survival has doubled, and death by chronic heart disease fallen by over 100k per year. However older people suffer more illness e.g. dementia and there are more people with multiple LTCs; average 3 per relevant patient. Plus we have the growth of “lifestyle” illness such as Obesity and Diabetes type 2. No wonder demand is high and our work is altering.  However, worryingly, inequalities remain.  For example in provision of GP care. Pre NHS, In the 1940’s in wealthy Kensington, London, there would be only a few hundred patients, or less, per GP; whereas in the slums of the East End, it was more likely to be 10,000.  Sadly inequalities exist still, as recently revealed by the Nuffield trust report showing decreased access to a GP, higher emergency admission rates and longer waiting times for the poorest areas of England. Perhaps our more recent contracts also drive us to inequality by focusing on QoF and other targets, almost overriding the “free at the point of need” principle and the “treat those who are ill or believe themselves to be ill” and the flexibility at the heart of our core contract? Funding geared to age and rurality possibly undermining health prevention and innovation?

Time for another quote from another great man; perhaps one of the greatest. The point being we know our past, and we know our present, as I will discuss further on. Plus we understand and can foresee the factors affecting us. Action is what is required.

 General Practices are, mostly, businesses, mainly partnerships. With a culture of independence it is not surprising that the NHS are constantly bemused that we have different views amongst ourselves, are a bit competitive and understand the difference between collaboration and control.  We enjoy a high level of public support, despite the tabloid press, and GPs are ranked very highly on independent benchmarks of trust.

There are roughly 6900 GP Practices in England with an average patient list size of 8500 patients, but there are seven practices in England with 50,000 or more patients; probably more as this benchmark is taken from contract size not organisational structure. Plus there are many more are in collaborations and PCNs, Primary Care Home systems and other ventures. Almost whole population of UK is registered with a practice and, as we have discussed, at a National level it is aging with comorbidity on the increase.  Practices deal with more than 1 million contacts per day, driven when you examine the data, as much by contract than perhaps by immediate need and we produce over 1.5 million prescriptions per day.  We are great value, primary care accounts for only 8.3 % of total NHS budget (reduced from 11% 6 years ago). We offered roughly 307M GP appointments in 2018 alone and our workload increased 16% 2009 to 2018 (The Lancet and the Kings Fund).  We do this against significant core workforce challenges, such as a decrease of 1088 FTE GPs since September 2015 with GP Partners decreasing by 5% over the period 2018 – 2019.  

General Practice is fairly good at reacting to its environment so perhaps moving towards scale naturally and largely as a business choice is to be as expected as have been the changes in our workforce. Even prior to the “Investment and evolution” contract variation we have seen the rise of the non-GP clinician, admittedly often supported by schemes such as the one for clinical pharmacists, but often without.  And whilst most of us are not over on the full toblerone side of the diagram we are certainly more trapezoid in shape than inverted triangle.  In many areas we have thriving Workforce and Training Hubs and whilst it is evolving there certainly seems to be funding and other support from this system. These new clinicians bring a new perspective to primary care, new specialist skills and opportunities. They will need new roles, different grades and rewards, new careers and some career progression. Soon, like practice nurses before them, people will be bemused that they didn’t exist before. This alteration must have an impact on GPs.  The basic split of GPs into partner, salaried, trainer, locum will and is altering.  Some are already calling themselves consultants and there are moves for them to become recognised as specialists. New roles will include leadership of MDTs, Directors of Boards – CD and otherwise, system leaders , mentors as well as trainers and perhaps those who work best on-line, video or in an acute triage setting working differently to others with long term illness in specialist clinical skills.  We will have to become adept at appointing and developing the right GP for the right role more than has been the case in the past. Portfolio careers are more likely for most, especially as both the NHS and the professions become live to well-being as an important element in sustainability.

 Like many we at Haxby are feeling the impact and benefit of the new clinicians and non-clinicians, reinforcing GP teams and making an impact in the workload of urgent care, visits and prescription and medicines management. It isn’t easy, takes time and support, but can be done.

No Government could ignore the realities of the costs and demographic challenges faced. Before the recent election every flavour of Political party stated commitment to the NHS with various promises. The NHS 10 year LTP targets prevention and improvement aka Bevan earlier, and promises £4.5bn for primary AND community care, it introduces new systems, ICS, and PCNs, focuses on digital and has a big theme of leadership “Great quality care needs great leadership at all levels”.   This last is hugely as a result of Don Berwick’s report into Mid-Staffs in 2013 where he stated:

“All NHS leaders and managers should actively address poor teamwork and poor practices of individuals, using approaches founded on learning, support, listening and continual improvement…

If you haven’t read it I recommend that you do.

The resulting “Investment and evolution” and the NHS Interim People plan, reinforce workforce and system change and promise funding.

However you have to be live to the fact that not all things stated in the closing 5 year forward view and unrealistic promises around GP numbers were never really delivered; if at all.  In the military we had a saying that “no plan survives contact with the enemy” and so it will prove to be with this one, as has already proven to be the case with PCNs.  General practice should not be afraid of its own powers of veto and the impact of its voice as patient advocates.  Plus we, and the centre, must also recognise the realities of market forces and social change or movements that might resist or divert any plan. Ten years is a long time.  This notwithstanding the themes in NHS plan and Investment and Evolution make sense, and probably reflect what many were moving towards anyway. But it’s the application that is troubling. Nothing seems to start with the patient, or with data. Guidance, direction and policy should not be dogma and diktat.

Out at the coal face we are all getting on with it, moving, and with further moves in-bound to “at scale” integrated care. As we are learning to better collaborate with each other, and with other sectors, through service development such as access, we face challenges as we move to Eco and away from self-interest.  There is work to be done to grip the purpose, the governance, clinical and corporate, and the roles tasks within these new structures and systems.  As we chase pennies and exigencies in the new contract I feel we must also be looking up at what we can be, whilst looking in at our patients to examine what they need.

Alongside these changes the arrival of “digital” is becoming a tidal wave. Some NHS driven, some not, as entrepreneurial business reacts to perceived opportunity.  We, our teams and our patients can only benefit from the flexible models of care, self-care or shared care they offer or might bring.  We must navigate carefully through the miasma of shiny new toys and focus on those that make a difference and offer VFM. We must surely resist the centrally imposed quick fix or where they latch on to the fashionable e.g. video. At the moment a lot of it feels like bolting a plastic wing on an old Ford Escort and I sense that there will be a settling out of the valuable from the rubbish in time. This is a great space to share and collaborate. However, I worry that we forget some of the deeper structural issues such as our records systems as at the same time we develop a bigger need for connectivity with integrated services. Most of all I feel we must keep bringing it back to our patient services and avoid inequalities arising. But without biases, as Haxby have recently proved with a trial for an online system called Klinik, patients from even the most surprising demographics can and will use these systems.

Of course tech is also about data and information.  Our own clinical and business systems allow us an unprecedented ability to understand ourselves and our patients. NHS Digital, Local Government and the CCGs also have access to a huge amount of information that we must bring to bear on designing and monitoring our care, our workforce and achieving value. I am not convinced that we are all paying enough attention to this huge opportunity.

And tech has also brought the entry of the disruptors, the fire starters, such as Babylon.   Like them or not they must make us look at what they are doing and learn, both the bad and the good, and see how we can apply or not apply elements that fit our service needs. Whilst also examining how it affects us as an industry. The Wolverhampton Trust/Babylon deal is interesting and cannot be ignored. 

Tech can also be liberating and even environmentally friendly.  Another of my hero’s Machiavelli in “The Prince”, questions the need for fixed locations (castles); offering costs and other liabilities as reasons to perhaps avoid them. So might tech and or collaboration allow us to address the burden of expensive premises, requirements for more rooms or unnecessary home visits. Encouraged by a 100% HMRC tax allowance, perhaps home visits, deliveries or similar could be completed in an electric car?

All this change must require and is receiving the attention of the regulators and we will see changes as they adapt to dealing with non-site specific services, shared staff, new types of staff and services.  We must “mind the gap” in accountability, responsibility, delivery and liability.

Returning again to the great Machiavelli he also talks of preparing for the inevitable, for the known or highly possible in terms of damning a river and reinforcing banks.   In short take charge of our own destiny as far as we can. In in Churchill’s words earlier do not be passive.  In mine. Don’t wait to be told, don’t ask permission, do not be diverted by demands away from our purpose, look at the facts, the data, and our history and the need and take action.

But how to start ? My advice is with your teams and the teams you are a part of. There is a wealth of evidence – much that fed Berwick’s report - that high performing teams can cope with pretty much anything and have a significant impact on patient outcomes. In short……Lead.  Look to your patient needs, understand your contracts challenge them where required, focus on quality. At Haxby we are developing a system based on the 10 building blocks of high performing primary care (derived from research in the US).  I also think there is mounting evidence that the Carr-Hill formula, now a quarter of a century old, must and should be challenged; as must QoF. So what is my point and what are my predictions?

 GP is the same, but different, the pressures are the same only altering in size and context. The only constant is change. Bevan was right.  GP is good at dealing with this; it has been from the start. Our challenge as managers is to take action, to control the river, reinforce the banks. To do this we must learn from history, each other and other sectors. We must start with patients, their data, their needs. We should build on the strengths we have as an industry, our service achievements, our relationship with our communities and realise the opportunities we have, through scale, tech and NHS change as much as challenges.  Contracts are only paper, it is people that deliver services, and if the contracts don’t meet our requirements, challenge them. 

We must take control of your own fortune; create our own future.