Reflections on the ways in which general practices are changing in order to meet the current pressures and opportunities.

1. The future of
general practice
Dr Robert Varnam
Head of general practice development
@robertvarnam
Worcester
14 Oct 15
bit.ly/151209future

2. www.england.nhs.uk @robertvarnam
So why are people talking about change?
It’s partly about the pressure we’re under
right now, and partly about the huge
opportunity to do something better. And,
for once, the same changes that would
help with one are also necessary for the
other.
Pressure Opportunity

3. www.england.nhs.uk @robertvarnam
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.
Why change?

4. 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?

5. 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

6. www.england.nhs.uk @robertvarnam
So why are people talking about change?
It’s partly about the pressure we’re under
right now, and partly about the huge
opportunity to do something better. And,
for once, the same changes that would
help with one are also necessary for the
other.
Pressure Opportunity

7. What kind of care?
What kind of organisation?

8. What kind of care?
What kind of organisation?

9. Health & wellbeing-promoting care
‘Right access’ Consistently high quality
Holistic, personalised, proactive, coordinated care
Comprehensive, joined-up care for a registered population,
shaped around them in the community
bit.ly/nhs5yfv
‘Wider primary care, at scale’

12. Phone first.
Community diagnostics.
Practice based paramedics.
Pharmacy first.
Web consultations.
Primary care led urgent care centre.
Minor injury service.
Physio first

13. Direct specialist advice.
Condition management training.
Shared records.
Care coordination.
Hospital in-reach.
Care home ward rounds.
Virtual ward.
Primary care-employed specialists.

14. Social prescribing.
Travelling health pods.
Peer-led walking groups
Health coaching.
Befrienders.
Schools outreach.
Community development.

15. www.england.nhs.uk @robertvarnam
Wave one Wave two
57 schemes
2500 practices
18m patients

16. www.england.nhs.uk @robertvarnam
PM Challenge Fund
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

17. What kind of care?
What kind of organisation?

18. What kind of care?
What kind of organisation?

19. www.england.nhs.uk @robertvarnam
No blueprint

20. 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.
Design principles
Bigger
Personal
Capable
Connected

21. www.england.nhs.uk @robertvarnam
e.g. Slough

22. www.england.nhs.uk @robertvarnam
eg Whitstable medical practice

23. www.england.nhs.uk @robertvarnam
e.g. AT Medics

24. www.england.nhs.uk @robertvarnam
e.g. Wakefield, Bristol, Richmond
• staff pooling
• shared training
• common policies &
procedures
• new specialist input

25. www.england.nhs.uk @robertvarnam
Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form
1. Pick something to improve for patients
2. Improve it together
3. Build infrastructure to sustain it
bit.ly/151209future
Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form