Developing General Practice:
Surviving transformation
Dr Chaand Nagpaul
Chairman, BMA General Practitioners
Committee
Where we are today - increasing
demographic demands on GPs
• Rising demand from ageing population
• 29% population have a long-term condition
• Between 2008-2018 no. of people with 3 or more
LTCs predicted to rise from 1.9 to 2.9 million
• Patients with LTCs make up 50% of appointments
• LONDON- ethnically diverse, non-English speaking,
mobile population, additional deprivation indices
Where we are today: progressive
transfer of care out of hospitals
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Chronic disease management
Earlier inpatient discharge
Expansion of day care surgery
Reduced post op follow up
Reduced OP follow up
Increased investigations in the community
“Out of Hospital Care” – explicit policy direction
LONDON effect- hospital closure programme
Where we are today understaffed
Where we are today understaffed
Centre for Workforce Intelligence
“Our analysis on the available evidence on the demand
for GP services points to a workforce under
considerable strain and with insufficient capacity to
meet expected patient needs. There is a clear need to
substantially lift workforce numbers to more
sustainable levels.”
Where we are today : underresourced
• Between 06/07 – 10/11
– Spending increased on GP services by 10.2%
– Spending increased on hospital services by 41.9%
• In 2012/13
– £7.8bn spent on general practice
– Over £70bn spent on secondary care
• No national investment or strategy for GP premises
since 2004
Where we are today : under-resourced
Year
% total investment
% excluding dispensed
drugs
2004/5
10%
N/A
2005/6
10.41%
N/A
2006/7
9.83%
N/A
2007/8
9.17%
N/A
2008/9
8.74%
8.04%
2009/10
8.45%
7.81%
2010/11
8.31%
7.68%
2011/12
8.16%
7.56%
2012/13
8.04%
7.47%
Where we are today – overworked and
demoralised
• DH commissioned 7th worklife survey GPs (Aug 2013)
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lowest levels of job satisfaction since 2004 contract
highest levels of stress since start of the survey series
substantial increase in GPs intending retiring next 5 yrs
• BMA GPC GP contract imposition survey (Sep 2013)
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9 out of 10 increased workload past year, 100% incr bureaucracy
9 out of 10 say reducing appts and time for patients
Nearly 9 out of 10 reduced morale
1 in 2 GPs less engaged with CCG due to workload
Today’s political context
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NO NEW MONEY-austerity - £30b savings by 2020
GP contract changes 2014-15
Workload demands on GP practices continually rising
“Equitable funding” - LOSERS & GAINERS
Standardisation of care & quality in primary care
Increased scrutiny and performance management; NHS
England, CQC and CCGs
• Prime Ministers Challenge Fund: 7/7 opening
• Urgent care- Keogh review
• Competition; Monitor
Competing in a market
• AQP – a reality; APMS, ES, LA commissioning
• Competing with commercial providers: advantage of
size, business accumen, able to take risk, loss leading
contracts
• Competing with Foundation trusts (“vertical integration”)
• Competing with access and convenience (vs quality)8 a.m-8 p.m/7 days a week
• Opportunity costs in competing and tendering
• Abolishing practice boundaries; patient choice
• Increasing value of global sum £/patient
• Challenges of competition greater the smaller the
unit
Planning for the future
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No practice immune from external pressures and threat
Vulnerability increases the smaller the unit
Vulnerability for MPIG and PMS losers
Implications for all GPs-partners and sessional doctors
London effect: Higher prevalence of:
 single-handed/small practices, inadequate premises
 BME GPs, salaried and freelance GPs
 Greater ethnic diversity; London specific demographic needs
Securing our future: GP practices
working together
• Survival of the fittest: economies of scale, ability to
compete, sharing opportunity costs, managing financial
risk, security in numbers
• New opportunities: new/expanded services, new income
streams, professional development and new roles, peer
support and education, managing workload and risk
• Looking after our own, supporting the
disadvantaged; supporting small practices;
maximising the potential of inadequate GP workforce
The weak or disadvantaged
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Poor, inadequate premises (locked in); CQC vulnerable
Small & isolated
Challenging population demographics
Low GMS funded
Poor historic Health Authority/PCT support, development
and investment
Poor staffing levels
Poor management support
Not policy savvy
Quality and potential of individual GPs obscured
Tiers of collaboration
• Primary medical services (G/PMS) and
enhanced services
• New provider models for expanded
services in the community; out of hospital
care
• Avoiding “tears” of collaboration
Primary Medical Services (GMS/PMS)
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GMS/PMS – flexibilities for informal & formal alliances
Sharing human resources, cross-cover, training
Subcontracting & sharing services across practices
Back office functions e.g. PAYE, bulk purchasing
Improved access: extended hours DES; Xmas closing
Supporting statutory functions/HR/information
governance, CQC registration etc
• Quality assurance and professional development:
clinical governance, peer review, education
• Succession planning for potential vacancies
Structural options for new provider
models
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Form to follow function; depends on purpose
Simple alliances; sharing premises and staff
Formal mergers as partnerships
GP co-operatives
Private companies limited by shares
Community interest companies (CICs), social enterprises
Charity or charitable incorporated organisation (CIO)
Limited Liability Partnership
Companies limited by guarantee
NEED EXPERT LEGAL ADVICE
Principles of working together
• What is purpose? Shared vision, equity of opportunity
and ownership, avoid “corralling” practices
• Preserving the essence & success of general practice
• Benefits to patients
• Supporting the weakest and disadvantaged GPs and
practices
• Creating synergy vs “takeovers”
• Providing true contractual and career development
opportunities
Challenges and risks to collaborative
working
• Loss of autonomy, loss of “essence” of general practice
(patients like small practices)
• Differences in opinions and philosophies
• Different starting points
• Sharing unequal historic resources
• Developing trust and collective ethos
• Legal & liability implications
• Setting up costs
• TIME to plan
It can happen and work
• Derbyshire Health United: Not for profit social
enterprise, 300 GPs covering 1m patients, provides 4
walk-in centre services, OOH triage and call handling
• Midlands Medical Partnership: 33 GP partners, 4 GMS
contracts, 60000 patients
• AT Medics: Private company limited by shares, across 8
CCGs in London, corporate structutr providing core and
enhanced services, and support for career development
• Suffolk GP Federation: not for profit community interest
company, 40 practices, 360,000 patinets
• Sessional Drs: www.pallantmedical.co.uk – a chambers
of freelance locum GPs
Making it happen
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Can’t afford ostrich approach
Start talking within your practices and between practices
Premises constraints – estate strategy with hubs
IT infrastructure to support networks
LMC role
CCG role supporting practices and resource shifts from
secondary care
• AT role - supporting collaboration, resources
• Learn from others - look at what’s working elsewhere
GPC guidance
• “Collaborative GP alliances and federations”
October 2013
• “Guidance for practices on how to employ
shared staff” October 2013
• GPC survey of GPs on collaboration (Feb
2014)
http://bma.org.uk/working-for-change/negotiating-forthe-profession/bma-general-practitionerscommittee/priorities/gpc-vision
Integrated care,
built around the practice
“Community health care teams built around GP practices.
Collaborative working across localities with practices either
singly or collectively employing or directly managing
community nurses who, working together with practice
nurses, will provide a seamless and more flexible nursing
service for patients in the community.”
“Greater collaboration between community pharmacists
and practices with a practice- aligned pharmacist
undertaking medicines management and other elements of
chronic disease management”.
Integrated care,
built around the practice
“Secondary care clinicians and GPs working
collaboratively to design and provide care pathways for
local areas, bringing more diagnostics and specialist
care out of hospital and into community settings,
including hospital-based specialists visiting nursing and
residential homes and working alongside GPs in
practices when appropriate.”
Turning solutions in to reality
FUNDING:
“Government should set a target for NHS England to
invest in a year on year increase in the proportion of
funding in to general practice”
Ending PbR and perverse funding systems – money to
follow changing patterns for care
WORKFORCE:
National strategy for recruitment & retention now
Support returners back to work
Turning solutions in to reality:
PREMISES: Fit for the future
- 10 year programme of premises development
- Create a GP premises development fund
- Practices working together to make maximum use of
premises
- Guaranteeing reimbursement of running costs
EMPOWERING PATIENTS AS PARTNERS
- Self care, demand management
Changing external mind-sets
• 4 hour+ A&E waits due to demand exceeding
supply, pressures, need more resources, more
A&E Drs…
• Waits for GP appointments due to fault of GPs
not working hard enough, not open long enough,
practice creating obstacles…
Changing mind-sets
• Investing in hospitals is about investing in care
and services
• Investing in general practice is about paying
GPs more
• Is there a way of investing in general practice
without necessarily being linked to perceptions
of GP pay?
30
Health Spending per Capita, 2010
Adjusted for Differences in Cost of Living
Dollars
$9,000
$8,233
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$3,433
$3,670
$3,974
$4,338
$4,445
GER
(11.6%)
CAN
(11.4%)
$5,056
$5,270
NETH
(12.0%)
SWIZ
(11.4%)
$3,022
$2,000
$1,000
$0
% GDP
NZ
UK (9.6%) AUS
(10.1%)
(9.1%)*
* 2009.
Source: OECD Health Data 2012.
FR
(11.6%)
US
(17.6%)
Sicker Adults
Cost-Related Access Problems in the Past Year
31
Percent
AUS
CAN
FR
GER
NETH
NZ
SWIZ
UK
US
Did not fill
prescription or
skipped doses
16
15
11
14
8
12
9
4
30
Had a medical
problem but did
not visit doctor
17
7
10
12
7
18
11
7
29
Skipped test,
treatment, or
follow-up
19
7
9
13
8
15
11
4
31
Yes to at least one
of the above
30
20
19
22
15
26
18
11
42
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Sicker Adults
Access to Doctor or Nurse When Sick or Needed Care
Same or next-day
appointment
Percent
32
Waited six days or more
100
79
75
79
75
75
70
63
59
59
51
50
23
25
2
4
5
8
10
12
0
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
16
23
33
Sicker Adults and Primary Care Physicians
Access to After-Hours Care
Percent
Sicker Adults: Difficult getting
after-hours care without going
to the emergency room
Doctors: Have arrangements for
patients to get after-hours care
95
100
94
90
89
81
78
76
75
63
55
50
40
55
56
40
34
25
21
26
0
Source: 2011 and 2012 Commonwealth Fund International Health Policy Surveys.
45
34
34
Sicker Adults with a Chronic Condition
Patient Engagement in Care Management
Percent reported
professional in
past year has:
AUS
CAN
FR
GER
NETH
NZ
SWIZ
UK
US
Discussed your
main goals/
priorities
63
67
42
59
67
62
81
78
76
61
63
53
49
52
58
74
80
71
66
66
56
64
64
63
84
80
75
48
49
30
41
42
45
67
69
58
Helped make
treatment plan you
could carry out in
daily life
Given clear
instructions on
symptoms and
when to seek care
Yes to all three
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
35
Primary Care Physicians
Practice Routinely Receives and Reviews Data
on Patient Care
Percent routinely
receives and reviews
data on:
AUS
CAN
FR
GER
NETH
NZ
SWZ
UK
US
Clinical
outcomes
42
23
14
54
81
64
12
84
47
Patient
satisfaction
56
15
1
35
39
51
15
84
60
Hospital
admissions and
ED use
39
30
9
24
21
43
32
82
55
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
36
Primary Care Physicians
Doctors’ Clinical Performance is Reviewed Against Targets
at Least Annually
Percent
100
96
83
80
67
60
53
47
43
43
41
40
37
20
0
UK
NZ
US
AUS
NETH
FR
GER
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
CAN
SWIZ
Primary Care Physicians
Doctor Routinely Receives Data Comparing Practice’s Clinical
Performance to Other Practices
Percent
100
80
78
60
55
45
40
35
34
32
25
25
20
15
0
UK
NZ
FR
SWZ
US
NETH
AUS
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
GER
CAN
37
General practice as a solution
• Pride and confidence - UK GPs and general practice
provide world leading primary care
• Bedrock of NHS: 340m consultations/yr vs 21m in A&E
• The most cost-effective part of the NHS? - £130
patient/yr unlimited care vs £200 single OPD PbR appt
• Investing, expanding and enabling general practice
makes absolute sense- is key solution to wider NHS
pressure and future sustainability
• "Developing General Practice today - Providing
healthcare solutions for the future"