Can practice managers save the NHS (CHEC practice manager masterclass)
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The document discusses the future of general practice in the UK National Health Service (NHS). It argues that general practice is currently constrained and unable to deliver its full potential due to lack of funding, workforce shortages, and outdated premises. However, it also notes positive changes underway, like new models of care and types of organizations. Going forward, it envisions patient-centered care enabled by multiprofessional teams, new skills and roles, and organizations collaborating across practices to deliver services at scale. The key is pursuing purpose over form and focusing on leadership, service redesign, and freeing up capacity through reducing bureaucracy and demand.
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Can practice managers save the NHS (CHEC practice manager masterclass)
- 1. www.england.nhs.uk @robertvarnam Can practice managers save the NHS? Dr Robert Varnam Head of general practice development robert.varnam@nhs.net @robertvarnam CHEC 25 June 2015 bit.ly/20150625chec
- 3. www.england.nhs.uk @robertvarnam 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. What future for general practice?
- 4. www.england.nhs.uk @robertvarnam What future for general practice? workforce premises
- 5. 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. What future for general practice?
- 6. www.england.nhs.uk @robertvarnam But something else has been happening in general practice, too. People are working on some quite new approaches to care and the very organisations we work in. This too was a big theme in the Call to Action. We asked what practices were working on, and what would need to be done for improvements in care to be sustained. And we heard a very big set of messages about the future bit.ly/c2aGP bit.ly/nhs5yfv How are things? Where are you heading? How could ‘the system’ help?
- 7. www.england.nhs.uk @robertvarnam Actions to strengthen primary care • Stabilising core funding for general practice nationally • Co-commissioning to shift care from acute to community • Improving access to services and supporting new ways of working • Expanding number of GPs: recruitment, return to work schemes and retention & investing in other new primary care roles • Expanding funding to upgrade primary care infrastructure and scope of services offered to patients • New initiatives to provide care in under-doctored areas • Building the public’s understanding that pharmacies and online resources can help them with minor ailments • Identifying practical solutions to reduce bureaucracy and reshape appointment demand. Taking existing primary care strengths, we will build a firm foundation for the future and deliver a new deal for primary care by:
- 9. 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
- 10. www.england.nhs.uk @robertvarnam It is very clear that everyone is talking about change. In many parts of the country, change is already underway in a wide range of areas. This actually makes it even more important to ensure we’re clear about why. What is the case for change? Where are we heading with it? If you’re currently engaged in a programme of change in your practices, are these two things really clear?
- 11. www.england.nhs.uk @robertvarnam Why change? Scottish School of Primary Care
- 12. 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
- 13. Health & wellbeing-promoting care ‘Right access’ Consistently high quality Holistic, personalised, proactive, coordinated care
- 15. Phone first. Community diagnostics. Practice based paramedics. Pharmacy first. Web consultations. Primary care led urgent care centre. Minor injury service. Physio first
- 16. Direct specialist advice. Condition management training. Shared records. Care coordination. Hospital in-reach. Care home ward rounds. Virtual ward. Primary care-employed specialists.
- 17. Social prescribing. Travelling health pods. Peer-led walking groups Health coaching. Befrienders. Schools outreach. Community development.
- 18. www.england.nhs.uk @robertvarnam What may the future look like?
- 19. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
- 20. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
- 21. www.england.nhs.uk @robertvarnam 1. What kind of care? • Holistic, comprehensive, cradle-to-grave family care • Health & wellbeing-promoting care • ‘Right access’
- 22. www.england.nhs.uk @robertvarnam 1. What kind of care? • Holistic, comprehensive, cradle-to-grave family care • Health & wellbeing-promoting care • ‘Right access’ (time, place, person, care) • Personalised, proactive, coordinated care • Consistently high quality
- 23. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
- 24. www.england.nhs.uk @robertvarnam 2. What kind of work? • Segmented (one size does not fit all) • Multiprofessional teamworking • bring new skills • work to the top of our skills • Partnership with patients & community • Longer consultations with fewer patients • GP not always 1st port of call • Direct access diagnostics • ‘Pull-in’ specialist advice
- 25. www.england.nhs.uk @robertvarnam Wider primary care at scale Redirecting demand (self care, pharmacy) Intelligent front-end (signposting, self care, coordination) Consultation channel (online, phone, video, face) Match capacity & demand (scheduling, broader workforce) Care model (continuity, proactive & coordinated care) Release capacity Extended hours (evenings & weekends) Capabilities for service redesign PM GP Access Fund Wave one Wave two 57 schemes 2500 practices 18m patients
- 26. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?
- 27. www.england.nhs.uk @robertvarnam bit.ly/nhs5yfv New types of organisation Multispecialty Community Providers Primary and Acute Care Systems
- 28. www.england.nhs.uk @robertvarnam Multispeciality Community Providers GP practice GP practice GP practice GP practice GP practice GP practice GP practice GP practice Specialists Pharmacists Community provider SC provider VCS VCS VCS MH Trust VCS VCS VCS
- 29. www.england.nhs.uk @robertvarnam Primary and Acute Care Systems Community provider SC provider VCSMH Trust Acute provider GP practice GP practice GP practice GP practice GP practice GP practice GP practice GP practice
- 30. www.england.nhs.uk @robertvarnam Purpose > function > formPurpose > function > formPurpose > function > form 3. Design rules for organisations Purpose > function > form a) Pick something to improve for patients b) Improve it together c) Build infrastructure to enable, accelerate & sustain
- 31. www.england.nhs.uk @robertvarnam 3. Design rules for organisations
- 32. www.england.nhs.uk @robertvarnam eg Whitstable medical practice
- 33. www.england.nhs.uk @robertvarnam eg GP Care federation, Bristol
- 34. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Bigger Personal Capable Yours
- 35. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Big enough for: • resilience • collaboration • broader workforce • minor illness nurses, pharmacist, MH practitioner, welfare rights, OT, physio, LTC nurses, HCA, physician’s assistants • pull-in power • economies of scale • meaningful accountability eg collaboration covering 30,000+ patients
- 36. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Capable: • leadership • strategic, transformational, team • partnership with patients and the public • contribution to & from community, accountability, patients as partners in improvement • workforce • building & running effective multiprofessional teams, inc CPD • an attractive place to work • service redesign & improvement • high end QI capabilities • business • operations management, finance, procurement, facilities, business intelligence • facilities: comprehensive services in the community • governance • clinical, financial, organisational
- 37. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Personal: • culture that values people • valuing • deliberately designed systems, teamwork & processes to promote continuity
- 39. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Personal: • deliberately designed systems, teamwork & processes to promote continuity • proactive coordinated care • connecting patients with non-medical support • using tech to promote wellbeing, self-care and management • known in the community
- 40. www.england.nhs.uk @robertvarnam 3. Design rules for organisations Yours: • well-designed • well-led • every GP matters • systems to ensure you flourish
- 42. www.england.nhs.uk @robertvarnam Strong network / federation facilitates service development Not all networks/federations/superpractices are equal GPs don’t always like being led, but leadership is key Evidence from PM Challenge Fund Huge variety in legal forms, structure, etc … no evidence about superiority for delivering change programme / improved care (but ?other factors, eg economies of scale) Size may matter
- 43. www.england.nhs.uk Size may matter Category Average time for full mobilisation % of practices offering weekday extended hours provision as a result of PMCF (at ‘full mobilisation’) % of practices offering weekend extended hours provision as a result of PMCF (at ‘full mobilisation’) Scope Leadership Small (<10 practices) N = 5 6 months 81% 81% More likely focused on general practice change High practice commitment Medium (11-50) N = 11 7 months 98% 95% Greater focus on partnerships outside general practice More likely high practice commitment Large (>50) N = 4 8 months 55% 66% More likely integrated with system- wide transformation Change slower & harder
- 44. www.england.nhs.uk @robertvarnam Strong network / federation facilitates service development Not all networks/federations/superpractices are equal GPs don’t always like being led, but leadership is key Evidence from PM Challenge Fund Huge variety in legal forms, structure, etc … no evidence about superiority for delivering change programme / improved care (but ?other factors, eg economies of scale) Size may matter Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form
- 45. www.england.nhs.uk @robertvarnam Purpose is pivotal – but … • Not always as clear as people thought • Not always as shared as people thought • Often self-centred • Most effective when commitment to reach across boundaries to collaborate in the interests of patients & population Evidence from PM Challenge Fund
- 46. www.england.nhs.uk @robertvarnam Deliberate design of: Purpose Leadership Decision making Service redesign capabilities Business infrastructure Governance Successful collaborations These appear important regardless of the ‘form’ (network / federation / single organisation)
- 47. www.england.nhs.uk @robertvarnam How? Where to start?
- 48. www.england.nhs.uk @robertvarnam How? Where to start? Release capacity. Now.
- 50. www.england.nhs.uk @robertvarnam Reduce bureaucracy • payment & reconciliation • contracts management • information flows Reduce demand • increase self help & self management • reliable hospital appointment systems • standard local approach to sick notes, etc Work differently • active front end • online/phone consultations • proactive, coordinated care + continuity + longer appts • enhanced clerical roles • physician associate • care navigator Wider primary care at scale • pharmacists • physio • minor illness nurses • social prescribing • welfare rights
- 51. www.england.nhs.uk @robertvarnam Reduce bureaucracy • payment & reconciliation • contracts management • information flows Reduce demand • increase self help & self management • reliable hospital appointment systems • standard local approach to sick notes, etc Work differently • active front end • online/phone consultations • proactive, coordinated care + continuity + longer appts • enhanced clerical roles • physician associate • care navigator Wider primary care at scale • pharmacists • physio • minor illness nurses • social prescribing • welfare rights
- 52. www.england.nhs.uk @robertvarnam Reduce bureaucracy • payment & reconciliation • contracts management • information flows Reduce demand • increase self help & self management • reliable hospital appointment systems • standard local approach to sick notes, etc Work differently • active front end • online/phone consultations • proactive, coordinated care + continuity + longer appts • enhanced clerical roles • physician associate • care navigator Wider primary care at scale • pharmacists • physio • minor illness nurses • social prescribing • welfare rights
- 53. www.england.nhs.uk @robertvarnam Reduce bureaucracy • payment & reconciliation • contracts management • information flows Reduce demand • increase self help & self management • reliable hospital appointment systems • standard local approach to sick notes, etc Work differently • active front end • online/phone consultations • proactive, coordinated care + continuity + longer appts • enhanced clerical roles • physician associate • care navigator Wider primary care at scale • pharmacists • physio • minor illness nurses • social prescribing • welfare rights
- 54. www.england.nhs.uk @robertvarnam Reduce bureaucracy • payment & reconciliation • contracts management • information flows Reduce demand • increase self help & self management • reliable hospital appointment systems • standard local approach to sick notes, etc Work differently • active front end • online/phone consultations • proactive, coordinated care + continuity + longer appts • enhanced clerical roles • physician associate • care navigator Wider primary care at scale • pharmacists • physio • minor illness nurses • social prescribing • welfare rights
Editor's Notes
- 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.
- 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.
- But something else has been happening in general practice, too. People are working on some quite new approaches to care and the very organisations we work in. This too was a big theme in the Call to Action. We asked what practices were working on, and what would need to be done for improvements in care to be sustained. And we heard a very big set of messages about the future
- For that reason, I’m very pleased at the progress being made nationally on driving change here – to improve the amount and the fairness of funding, giving greater power to local CCGs, training extra GPs, making the profession more attractive, improving premises and IT. We’ll feel the benefit of some of those things sooner than others, but they’re all welcome, and I’m proud to have played a part in creating this momentum.
- 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.
- It is very clear that everyone is talking about change. In many parts of the country, change is already underway in a wide range of areas. This actually makes it even more important to ensure we’re clear about why. What is the case for change? Where are we heading with it? If you’re currently engaged in a programme of change in your practices, are these two things really clear?
- BUT: underfunding greater focus on hospital heroics workforce crisis ALSO: OPPORTUNITIES FOR BETTER CARE
- 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.
- C2A findings … WHAT KIND OF CARE?
- But something else has been happening in general practice, too. People are working on some quite new approaches to care and the very organisations we work in. This too was a big theme in the Call to Action. We asked what practices were working on, and what would need to be done for improvements in care to be sustained. And we heard a very big set of messages about the future
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