Primary care - strengths and future
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Presentation to practices in Lincolnshire, looking at the strengths of primary care, the ways in which it could deliver more of the promise and emerging lessons about successful at-scale primary care.
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Primary care - strengths and future
- 1. #GPforwardview#GPforwardview GENERAL PRACTICE FORWARD VIEW Dr Robert Varnam Director of General Practice Development @robertvarnam Primary care Our strengths and the future bit.ly/170525lincs1
- 2. #GPforwardview UK general practice is one of the world’s most comprehensive embodiments of the founding principles of primary care… Accessible, personal care built on a relationship from cradle to grave Community based responsible for prevention and care of a registered population Holistic perspective understanding the whole patient not just a disease Comprehensive care able to handle high degree of uncertainty Personal and population-orientated primary care is central … if general practice fails, the whole NHS fails. Simon Stevens, General Practice Forward View First port of call and central point of care for all, for life
- 3. #GPforwardview 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
- 4. #GPforwardview Pressures in general practice Workload > Workforce Rising volume Rising complexity Recruitment not rising fast enough Rising part-time working Return too difficult Rising early retirement The varied biopsychosocial needs presented to us are not adequately met by a largely biomechanical service
- 5. #GPforwardview 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. Based on: The Lancet doi: 10.1016/S0140-6736(12)60240-2
- 6. #GPforwardview Specialists Non-specialist / failed consultant Gatekeeper / door-holder King of my castle It’s all in me Community services
- 7. #GPforwardview Self Care Broader skillmix Self management / social prescribing Emergency care Collaboration with specialists At scale Delivering more of the potential within our model of expert generalist primary care. Population wellbeing management and holistic person-centred care provided by a multiprofessional team led by the GP, supported by at-scale collaboration and efficiencies.
- 8. #GPforwardview GENERAL PRACTICE FORWARD VIEW Why change? Releasing more of our potential… Population: big enough for partnerships and impact Comprehensiveness: care to match our biopsychosocial insight Empowerment: systematically enabling self-care Appropriateness: right person, right care, right time
- 9. #GPforwardview#GPforwardview GENERAL PRACTICE FORWARD VIEW Panacea, distraction or potential enabler? Collaborative at-scale working
- 11. #GPforwardview Personal focus Clarity Commitment Agility Population focus Alignment Priorities Partnerships 4 400 Not an either / or solution
- 12. #GPforwardview STP footprint: 300k-2m Workforce & infrastructure planning Large scale service reconfiguration Major partnerships & shifts in priority MCP: 100-350k Organisational infrastructure & governance Specialist staff & services Employment & career development Model design (population management, care models) Strategic partnerships Hub/Home: 30-60k Acute care Locality-tailored services Shared MDT Place of ‘belonging’ Core team: 3-4k Coordinated, complex multidisciplinary care Continuity
- 13. #GPforwardview Working at scale: Opportunities for practices
- 14. #GPforwardview Staff pooling • nurses, reception & clerical staff, sessional GPs … internal ‘bank’ Overflow support • phone consultations • access hub (phone +/- face-to-face) • home visiting
- 15. #GPforwardview 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
- 16. #GPforwardview Planning • Workforce • Infrastructure development • Service reconfiguration • Public health Provision • Acute care • Community pharmacy • Dentistry • Optometry • Social care • Housing • Welfare • Voluntary sector
- 17. #GPforwardview Traditional healthcare roles • Pharmacists • Specialist nurses • Physiotherapists • MH therapists • Paramedics Wellbeing workers • Social workers • Care navigators • Health trainers & coaches • Welfare advisors
- 18. #GPforwardview Sharing ideas Testing new ideas QI expertise Patient engagement Analytics • Population health analytics • Priority setting • Benchmarking • Realtime measurement Project management
- 19. #GPforwardview Recruitment HR CPD Career development • New options • In-house portfolio career • eg • Leadership • Mentoring • Service improvement • Research
Editor's Notes
- 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.
- 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.
- False polarities
- Resilience Economies of scale System partnerships Skillmix Innovation and improvement Staff development