Right access - and some myth busting about general practice

www.england.nhs.uk @robertvarnam #PMChallengeFund
Delivering
right access
Dr Robert Varnam
Head of general practice development
robert.varnam@nhs.net
@robertvarnam
Sheffield PMCF
25 June 2015
bit.ly/20150625access

One of the things motivating me as I first looked outside the walls of our practice, to lead
some local service redesign for diabetes, was fear. A fear that general practice, despite
being a service depended on by the country, had a very uncertain future.
In fact, I was afraid that general practice was being run into the ground. Although NHS
spending was rising, with growing amounts of staff and money, the majority was going
elsewhere in the system. Even though we were talking increasingly about the importance
of providing more care outside hospital, the investment was going inside hospital.

How’s it feeling?
Figure 1 Proportion of patients reporting positive experiences
of primary care services, England 2011-12 to 2013-14
11% of requests for an appointment are unmet
10% of those divert to A&E/WIC, 3% see a pharmacist instead, 12% get no care
An estimated 2-5% of A&E attenders have not tried to obtain GP care

The founding principles of UK primary care are admired the world over, and rightly so.
General practice is a jewel in the crown of this country.
Right now, general practice feels in a bad place. Constrained, hemmed-in and, to some,
marginalised.
Whatever the state of things in your part of the country, in general, I think it’s fair to say
that, at the very least, general practice is currently constrained from delivering its full
potential.
We need to see increases in funding, a growth in the workforce, and improvements to
premises. Without those, existing services may not be sustainable.
How’s it feeling?
We DO care …
but it’s too hard to right now
to deliver our potential

In my work over the past few years, I’ve encountered some persistent
myths about general practice and change. They run quite deep and
hold back a lot of potential. They don’t just affect policymakers or
politicians, either – they’re often things primary care leaders believe
themselves.
The Challenge Fund is a great opportunity to achieve lasting
transformational change in your area. But, to make the most of that,
you’re going to have to be confident in challenging five key myths.
@robertvarnam #PMChallengeFund
Myth-busting

Myth One

Myth 1: general practice is finished. Or, at least, not far off.
There are some who talk as though general practice is finished, or as
near as makes no difference. Sometimes, these are people within the
profession, sometimes outside.
When morale is low, it’s understandable for negative emotions to
influence our assessment. But just look what happened when the
government invited practices to apply for this innovation programme
– nearly two thirds of the country responded! And, with very
exceptions, every proposal was for worthwhile change. The team
here were nearly drowned by the work of processing it all.
That’s not a part of the NHS that’s dead, lacking in energy or in ideas.
We just need to give general practice the headroom for it to fulfil the
enormous potential it has. The creativity, plans and energy are
already there.
General practice is
finished
PM Challenge Fund
57 schemes
2500 practices
18m patients

Myth Two

Myth 2: Access is simple
We’ve been here before, launching a national programme to improve access in general
practice. But I’m struck by how simplistic much of the thinking has been on previous
occasions. We’ve treated access as though it stands alone as a feature of general
practice. As though it’s meaningful to improve speed of making an appointment without
asking who it’s with, or what kind of care they’re able to provide.
That’s clearly nonsense, and we risk providing very poor value to individual patients and
taxpayers if we don’t acknowledge that access is one facet of a complex system of care.
We similarly risk thinking that every patient needs the same kind of access. Just saying it
like that, it’s clearly untrue. Yet how many times have we – even you or I – been involved
in a change which was about moving from one monolithic, one-size-fits-all appointment
system to another?
In the first year of the Challenge Fund I was delighted to see that many schemes were
actually aiming to deliver what I’ve dubbed ‘right access’ – connecting the right patient
with the right person, able to give the right care in the right place at the right time. And
acknowledging that it’s right for some patients not to ‘see the doctor’, just as it is for
some to have much greater confidence that they will, soon.
Access is simple
Right
Access

Myth Three

Myth 3: if we just did this one thing…
It’s probably human nature, but ‘silver bullet’ thinking abounds in
the NHS. Probably in your own team meetings. How many times,
often with a sigh of frustration, does someone (maybe you)
exclaim “If we just did x/y/z, it would solve this”?
Sometimes, a single change makes a massive difference. But
rarely. Every one of the innovations you’re proposing is very
sensible. Most have at least some evidence already. But none of
them has ever been found to achieve all the improvement we need.
You’re going to need several, combined.
At best, silver bullet thinking will lead you disappointed and tired.
At worst, it’ll discredit the ideas you’re trying out, simply because
someone allowed in the thought that just doing this one thing
would achieve all your goals. It’s almost never true.
If we just …

It’s too easy to approach challenges just by
thinking we need more.
The NHS has a well established habit of
this – new initiatives, new challenges or
opportunities are usually met by us talking
about more. More money, more staff – or
both. And, we know that, in general
practice, we do need both more money
and more staff.
BUT – and it’s a big but – just doing more
of the same is simply not going to cut it any
longer.
Not just
more of the same

Myth Four

Myth 4: Our good ideas are all we need
When you’ve been working on a set of ideas for what changes to make to
your service, it’s natural to become quite attached to them. You may have
had some feelings of resentment lately as people have asked you probing
questions about them, through the due diligence process.
The trouble is, the consistent experience of people leading large scale
change is that 70% of efforts fail. Not just in the NHS, or in healthcare, but
worldwide in every industry.
And one of the big factors causing that depressing experience is a belief
that good ideas are enough. They’re not. They’re obviously necessary, but
I’m afraid they’re not sufficient.
Along with the ‘WHAT’ of your change, you need the ‘HOW’. The strategies,
tactics and methodologies by which you turn the good idea into a
movement of people and a plan of action. If you don’t skilfully lead people,
if you don’t use an effective improvement methodology, if you don’t
measure right … the evidence shows you risk failing. We’ll do all we can
this year to support you with the HOW of change. I’d ask you to start by
commiting to have plans which combine the how and the what, and which
unleash your practices’ commitment by clearly articulating the WHY (we’ll
talk more about that later)
Good ideas are enough
WHAT HOWWHY

Myth Five

Myth 5: failure is not an option
In the NHS, one can be led by a culture of regulation or performance management to fear failure or
change. Even to be tempted to cover them up.
Is that appropriate for innovation leaders?
Do you know the significance of the number 5127? It’s the number of prototypes James Dyson had
to make before his first bagless vacuum cleaner worked fully. Is that 5127 failures? Of course not,
it’s 5127 steps on the way to getting a good idea to work in the real world. Eddison once said “I have
not failed, I have found 10,000 ways NOT to make a lightbulb.”
If, at the end of this year, you tell us that every part of your initial plans was a fantastic success, I
will conclude that you are either foolish, deluded or lying. Because they won’t be. Everyone who has
ever set out with an idea about making a service better has found that some aspects of the idea
work first time, and others need to be tweaked. And some of our ideas just don’t seem to work – at
least not in our context or with our implementation approach. Discovering that is not a failure, it is
necessary. The failure would be not to anticipate it or not to spot it.
If you encounter something that’s not working as you expected, change it. It would be an appalling
waste of public money and confidence if you didn’t. Just do it with your eyes open and your brain
engaged. Please don’t make decisions based solely on instinct or opinion. If you suspect
something’s not working right, measure it. Make a rational, evidence based assessment.
And when you start finding things that need tweaking or possibly even stopping, please tell us as
soon as possible. We really want to learn from your experience, including from failure. You should
expect we’re going to ask why you think it needs changing. If we can, we may connect you with
someone else who’s done something similar and had a different result, to see if that helps you or we
can learn more about the conditions for success.
But failing to get every idea to work without any tweaking is not failure, it’s innovation. In fact, it’s
life.
We must not fail
Learn from it!

@robertvarnam #PMChallengeFundbit.ly/20150625access

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