4. www.england.nhs.uk @robertvarnam
An example of this in practice at the
moment is the Prime Minister’s GP Access
Fund. Now covering a significant
proportion of the country, practices in this
are implementing quite wide-ranging
redesign of their services, acknowledging
that extended hours are only one part of
good access. The practices participating in
this programme are already beginning to
implement many of the transformational
changes envisaged by the Five Year
Forward View. This is generating valuable
learning about the specific changes
required, including the ways in which the
system can make progress easier and
more sustainable.
Wave one Wave two
57 schemes
2500 practices
18m patients
The Prime Minister’s Challenge Fund
5. www.england.nhs.uk @robertvarnam
What are PMCF schemes doing?
Wider primary care at scale
Reshape
demand
Active
front-end
Contact
modes
Match
capacity &
demand
Rapid
access
model
Extended
hours
Release capacity Service redesign team
Broaden
skillmix
Complex
care model
Premises I.T. Workforce
ServicecomponentsSystemenablers
bit.ly/PMCFresources1
8. www.england.nhs.uk @robertvarnam
At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and
they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill.
When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person
would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they
would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get
better, return to work, and, in a year or two, they might become ill again.
That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s
needed.
However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact
underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age.
As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third
of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases.
Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase.
And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or
two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues
which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more
simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising
in one part of the body. These people need treating as people, not diseases.
So the population of people who need what only primary care can offer has grown, the amount of time they need has grown –
and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs.
This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every
developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis
where the population’s need is.
Scottish School of Primary Care
Why change?
9. www.england.nhs.uk @robertvarnam
Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form
Top lessons so far
12. www.england.nhs.uk @robertvarnam
• Monthly colloquium
• Quarterly colloquium
• Committee
• Executive team
• The Boss
Decision making
Face-to-face visits
Bulletin
Online forum
Surveys
13. www.england.nhs.uk @robertvarnam
Outsourced management
Spare time
New managers
Distributed leadership
Leadership & infrastructure
Vision-casting
Data gathering
Programme
management I.T.
Procurement
Workforce
Mobilisation
Governance
Practice engagement Patient engagement
Stakeholder
partnerships
Analysis
15. www.england.nhs.uk @robertvarnam
Purpose > function > formPurpose > function > formPurpose > function > form
1. Stop obsessing about form
Purpose > function > form
Pick something to improve for patients
Improve it together
Build infrastructure to support & sustain
16. www.england.nhs.uk @robertvarnam
2. Create shared purpose
• A sense of shared identity sufficiently
strong to allow collaboration that
crosses boundaries of organisational
sovereignty.
• We share ideas, data, resources
• We will adopt a standard approach
• We can call on each other
• A purpose beyond ourselves,
orienting us around the needs of our
patients.
• Commitment to us and our purpose
sufficiently strong to make compliance
unnecessary
18. www.england.nhs.uk @robertvarnam
Leadership
Creating shared
purpose
Strategic planning
& partnerships
Leading through
change
Being a leader
Improvement
Patients as
partners
Processes and
systems
Using data for
improvement
Rapid cycle
change
Business
Governance
Operations
management
HR
Business
intelligence
Capabilities
Enablers
Innovation spread
Policies &
permissions
Contracts &
incentives
Infrastructure
Productive
federation
Transparent
measurement
3. Invest in development
What do teams
and individuals
need?
These are
interdependent
How can the
system catalyse
& accelerate
change?
19. www.england.nhs.uk @robertvarnam
At an organisational level, what will wider primary care at scale look like? Again, the precise details
should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to
patients and staff, not just creating a new organisation because it makes us feel safer. Our new
networks, federations or mergers should have enhanced capabilities, for leadership, management,
services and improvement. We also need to ensure that, as we operate at large scale, we maintain the
personal care which is so hugely important for many patients (and staff). That will take deliberate design:
it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the
same sense of belonging, ownership and commitment as in the best practices now. Regardless of the
actual business model. That, too, will take planning and skill.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
** ADD NARRATIVE TO EVERY SLIDE **
NB Each slide has white text in the background, to provide narrative notes for SlideShare
An example of this in practice at the moment is the Prime Minister’s GP Access Fund. Now covering a significant proportion of the country, practices in this are implementing quite wide-ranging redesign of their services, acknowledging that extended hours are only one part of good access. The practices participating in this programme are already beginning to implement many of the transformational changes envisaged by the Five Year Forward View. This is generating valuable learning about the specific changes required, including the ways in which the system can make progress easier and more sustainable.
At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again.
That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s needed.
However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase.
And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases.
So the population of people who need what only primary care can offer has grown, the amount of time they need has grown – and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs.
This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis where the population’s need is.
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.
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.
At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.