General practice development framework (emerging)

Editor's Notes

• #3: Starting point: what kind of care do we want to be delivered for patients? These are the features of care originally described by NHS England in the emerging findings from the Call to Action on General Practice in Jan 2014, and included in the vision presented by the NHS Five Year Forward View. It is essential to establish this vision as the starting point before considering issues of changes to structures or systems of care. In many respects, this vision is about helping primary care in England to deliver more of its potential. These are things which have always attracted people to general practice, and which are already a feature of care. However, we need to release more of this potential.
• #4: Encouragingly, a growing number of CCGs and practices are already working to implement innovations aimed at establishing this kind of care for patients. The Call to Action on General Practice asked people what innovations they were implementing. The following slides present a selection of these.
• #5: Many innovations are introducing much wider multiprofessional collaboration, often with direct access for patients to other members of the team, rather than the GP acting as the first port of call for every need.
• #6: Many are addressing interfaces between providers.
• #7: Finally, a significant group of innovations is helping to revitalise practices’ contribution to public health and wellbeing.
• #8: This diagram illustrates the areas within which work needs to occur in order to deliver the changes described in the vision.
• #9: One of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders. The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable. Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Minister’s Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it. NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently.
• #11: The experience of many previous initiatives to introduce change in primary care has confirmed there is a need to invest in building the capabilities described in the development framework.
• #12: Addressing these development needs will not be easy, simple or quick. There is currently a very large capability gap, resulting from historic underinvestment in development in this sector. There are also unique features of general practice which make capability building more difficult in some areas, and require a culturally aware approach to development. General practice is used to operating at small scale, making change in a largely organic and ad hoc way, rather than a systematic or data-driven way. The independence of these small organisations also means there is relatively little experience in undertaking collaborative change at scale across a geographical area. The mindset of many GPs, combined with their very limited capacity, means that traditional academically-focused approaches to leadership and other development are unappealing to many. Finally, although there are superb examples of innovative practice around the country, many have been achieved by individual leaders or teams who, while admired by others, are often regarded as being so different from the average practitioner that it following suite is regarded as problematic.
• #13: Experience from capability-building programmes of varying size gives rise to some key design principles for any programme seeking to achieve the widest possible engagement. The most consistent and important appear to the importance of investment in building intrinsic provider capabilities rather than repeatedly paying for external consultancy to plan and implement change; and the attraction for primary care staff of adopting a ‘learn while doing’ approach. This is where learners, ideally working in teams, lead a programme of actual change while receiving training, coaching and peer support relevant to their work.
• #15: At present, there is a good range of support offers for GP practices and federations to address some needs, such as legal and financial consultancy. However, there are very few sources of support to build capabilities in other areas of the development framework. Where support does exist, the capacity of the suppliers is currently very limited. This challenge is compounded by the tendency of most suppliers to operate within a framework limited by their own capabilities. So, for example, it is clear that federations using a legal consultancy as their development partner often do not receive challenge or support to build their leadership or service improvement capabilities. It may be that, in future, we need firstly to ensure that all suppliers of development and support to general practices operate consciously within the comprehensive framework described here, signposting to other sources of support where appropriate, and secondly that a new generalist case manager role is available, to help providers to undertake a comprehensive diagnosis of need and create a comprehensive development plan.