The Future Of Primary Care

@robertvarnam #GPforwardview#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Practice manager
development conference
Network: etcvenues
Password: wifi5038

@robertvarnam #GPforwardview@robertvarnam #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
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# gpfv

@robertvarnam #GPforwardview#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Dr Robert Varnam
Director of General Practice Development
@robertvarnam
england.gpdevelopment@nhs.net
The future of primary care

@robertvarnam #GPforwardview
UK general practice is one of the world’s most complete embodiments of the values of primary care
Accessible Personal care built on
a relationship from cradle to grave
Community focussed Responsible for
a registered population, improving wellbeing
Holistic Dealing with the patient as a
person not a disease or part of the body
Comprehensive Handling wide range
of problems, managing clinical uncertainty
STRENGTHS OF PRIMARY CARE
“Primary” …
first, foremost,
central, key
Central Coordinating and connecting
other teams, referring where appropriate
Personal and population-orientated primary care is central …
if general practice fails, the whole NHS fails. Simon Stevens, General Practice Forward View

Accessible
Community focussed
Holistic
Comprehensive
STRENGTHS OF PRIMARY CARE
Central
Current constraints:
Demand >> workforce + funding
Practices are set up to provide mostly
medical care
Hard to coordinate other inputs and ‘pull
in’ specialist support
Too small and isolated to have significant
impact on population or system
Primary care doesn’t need reinventing, but liberating to deliver its potential

Specialists
Community
services
1948 CARE

Self
Care
Broader skillmix
Self
management /
social
prescribing
Emergency
care
Collaboration
with specialists
At scale
FUTURE CARE

GENERAL PRACTICE
FORWARD VIEW
Working at scale

What size should we be?
✓ Personal focus
✓ Clarity
✓ Commitment
✓ Agility
✓ Population focus
✓ Alignment
✓ Priorities
✓ Partnerships
20 100
Don’t accept
either / or
solutions

STP: 0.5-3m
Workforce & infrastructure planning
Large scale service reconfiguration
Major partnerships & shifts in
priority
Network: 100-900k
Finance, HR, governance, IT
Employment & career development
Specialist staff & services
Strategic partnerships
Population: wider determinants
Hub/home: 30-60k
Place of ‘belonging’
Acute care
Shared MDT
Population: proactive & preventive
care
Microteam: 3-4k
Continuity for complex
needs
Doing the right thing at the right scale

Working at scale: Opportunities for practices

 Staff pooling
• nurses, reception & clerical staff, sessional GPs …
internal ‘bank’
 Overflow support
• phone consultations
• access hub (phone +/- face-to-face)
• home visiting

 Purchasing
• Indemnity bulk purchasing
• Supplies & utilities
 Shared functions
• Single CQC registration
• Single accounting system
• Policies & procedures
• Procurement
• Correspondence management
• IM&T (eg support & maintenance, intranet, web, social media)
 Specialist functions
• HR
• Finance
• Clinical governance
• Business intelligence

 Planning
• Workforce
• Infrastructure development
• Service reconfiguration
• Public health
 Provision
• Acute care
• Community pharmacy
• Dentistry
• Optometry
• Social care
• Housing
• Welfare
• Voluntary sector

 Traditional healthcare roles
• Pharmacists
• Specialist nurses
• Physiotherapists
• MH therapists
• Paramedics
 Wellbeing workers
• Social workers
• Care navigators
• Health trainers & coaches
• Welfare advisors

 Sharing ideas
 Testing new ideas
 QI expertise
 Patient engagement
 Analytics
• Population health analytics
• Priority setting
• Benchmarking
• Realtime measurement
 Project management

 Recruitment
 HR
 CPD
 Career development
• New options
• In-house portfolio career
• eg
• Leadership
• Mentoring
• Service improvement
• Research

#GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Online consultation systems
bit.ly/gpfvonlineconsultations

#GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Better service for patients
Connects to the most
appropriate help
Gives patients more
control

#GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Information about
symptoms and treatments
Find local services
Ask a query, send a
clinical consultation

#GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
£45 million over three years
Available for every practice
Part of wider digital
transformation

#GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Support for planning and
procurement
Advice for practices to
maximise benefits
Materials and support to
engage patients

GENERAL PRACTICE
FORWARD VIEW
About Benefits Process SupportAbout
eg recent study - “unlikely to deliver hoped-for benefits”
• practices had no ‘clear rationale’
• no plan re likely costs and benefits
• insufficient training of non-clinical staff
• insufficient communication with patients
Look beyond the headlines …
Yes
“access improved … better
consultations … happier staff and
patients … GP workload
manageable”
Not many
“No problems as such, but very
few patients used it and we didn’t
notice an impact on workload”
Wide range of answers from different practices
Br J Gen Pract. 2018 Jan 30;bjgp18X694853
Is it beneficial?

GENERAL PRACTICE
FORWARD VIEW
Yes
“access improved … better
consultations … happier staff and
patients … GP workload
manageable”
Not many
“No problems as such, but very
few patients used it and we didn’t
notice an impact on workload”
Wide range of answers from different practices
But you knew that already …
Having it confers no benefit
Switching it on is a start
Using it to full effect could change your life
Is it beneficial?

GENERAL PRACTICE
FORWARD VIEW
Improved access
More convenient access, connected to the most appropriate person first
time, signposted to self help ad community resources
• eg Unity Health, York: GP wait reduced from 2-3 weeks to 1 day, DNAs from 10% to 3 - 5%
• eg Larwood surgery, Workshop: named GP wait reduced from 1-5 weeks to a few hours
More efficient use of GP time
Clerical queries addressed by clerical staff, some problems resolved without
face to face appointment, tests done before appointment
• eg Docklands Medical Centre: 40% of contacts resolved without patient needing to come in, mean 2.9 minutes’
GP time
• eg Unity Health, York: 66% handled remotely, take <10 min for clinician
More effective consultations
GP can deal more effectively with the problem because details of the history and the
patient’s ideas, concerns and expectations known in advance
• one of the first things reported by many GPs
• it is hoped that future academic research will seek to quantify this
Benefits in practice

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I’ve got this headache, and it’s been coming and going for the past month or
so. I’ve never had it this often before. I’ve tried my usual painkillers, but
they’re hardly helping. Some weeks I’m needing them virtually every day.
GP call back
History of tension type headache,
no previous prolonged or
recurrent episodes. Prescription
for Co-Codamol 8/500. No other
significant history.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
My head’s killing me and I ache all over. It’s been going on for three day, and
I’m really bunged up. My throat’s red raw. Today I’ve got a cough as well and
I’m hot and cold.
Signpost to self help
information / minor ailments
service
Normally well young adult.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I tried that new tablet for the migraine and it helped SO much. I think I felt a
little tired after taking it, but nothing much. Is it OK to stick with this one?
Should I throw the Zomig away? I’ve still got a packet from earlier.
Message back to patient
“That’s good news. Yes, let’s put this on
your repeat medications now. Please let
us know if the headache changes or the
new Sumatriptan stops working.
Unopened packets of old tablets can be
returned to your pharmacy – thank you.”
Longstanding migraine. Analgesia
limited help. 4/12 ago Rx
Zolmitripan, no help. 1/12 ago Rx
Sumatriptan, asked to inform GP
of the result.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I tried increasing the Amitriptyline tablets but I’m just getting worse.
Headache every day and I’m just so tired. Even just standing up, I get dizzy
and nearly black out. Please do something to help me.
Book appointment with
nurse for blood tests
then follow-up with usual GP
Chronic tension type headache,
4/12 ago started Amitriptyline for
prophylaxis, titrated to max dose
1/12 ago, asked to inform GP of
results. Also menorrhagia and
previous anaemia.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
This headache is killing me and no one’s doing anything. I was meant to
have a scan from the hospital but I’ve not heard anything.
Secretary to chase hospital
appointment / provide patient
with hospital contact details
Anxiety, depression and
headache, possibly migrainous.
No help from any medication.
Neurology appointment 3/12 ago,
ref’d for MR brain. No
correspondence since.

GENERAL PRACTICE
FORWARD VIEW
Do patients use it?
Yes … if they know about it and are encouraged by staff
• Where patients are not engaged by the practice, the service is hard to find on
the website or staff are not confident in describing the benefits, patient uptake
can be very low.
• This is not surprising, but it is sometimes overlooked by practices. Recent
academic publications confirm this.
Potential shift to ‘click first’ for patients
• Rydal practice (suburban): 40% contacts online within 3 months
• Unity Health (suburban and student): 87% online
Potential shift to ‘click first’ for patients:
eg Rydal practice (N London): 40% contacts online within 3 months
eg Unity Health (York): 87%
Use crosses the generations:

GENERAL PRACTICE
FORWARD VIEW
Is it ‘approved’?
Safety standards
• Detailed standards published by NHS England, October 2017, covering
legislation / standards for clinical safety, cybersecurity and information
governance.
• National approved suppliers established, January 2018, giving additional
assurance regarding essential functionality and financial stability.
Indemnity providers’ view
• Inform provider. No additional cost.
• Follow GMC and CQC requirements for good care, see in person if clinically appropriate,
don’t break confidentiality, check patient agreement with management plan
• Contact provider if…
• non-GPs are consulting (?additional cost)
• consulting with private patients (?additional cost)
• consulting without the record (?additional cost)
• consulting online with under 16s (may not be covered)

GENERAL PRACTICE
FORWARD VIEW
Policy information:
Case studies:
bit.ly/GPcapacitynet2
england.onlineconsultations@nhs.net

10 High Impact Actions to release time for care
GENERAL PRACTICE
FORWARD VIEW
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum

Innovations from practices
throughout around England that
release time and improve care.
GENERAL PRACTICE
FORWARD VIEW

GENERAL PRACTICE
FORWARD VIEW
Online Consultations: Making it work
in practice. Dr Minal Bakhai
Main room
Document Management: Maximising
Immediate and longer term benefits.
Paul Deffley.
Outlook room
Clinical Pharmacists: Making the
most of having one. Evelyne Beech.
Survey room

GENERAL PRACTICE
FORWARD VIEW
Getting everyone on board. Creating a
shared purpose for change. Angie Parks.
View room
Setting up for successful change. Using
every driver in the Change Model. Jo Godman.
Survey room
Creating a plan that makes sense and
works. Using driver diagrams. Jayne Beasley.
Outlook
room
Implementing change in rapid cycles. The
benefits and the practicalities. Sue Collis.
Main room

The Future Of Primary Care

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The Future Of Primary Care