www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development [email protected]@robertvarnam Tameside CCG 18 June 2015 bit.ly/ 20150618future
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1. www.england.nhs.uk @robertvarnam The future of general
practice Dr Robert Varnam Head of general practice development
[email protected] @robertvarnam Tameside CCG 18 June 2015
bit.ly/20150618future
2. www.england.nhs.uk @robertvarnam The future of general
practice Dr Robert Varnam Head of general practice development
[email protected] @robertvarnam Tameside CCG 18 June 2015
bit.ly/20150618future
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. Does
general practice have a future?
4. 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 its 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. Does general practice
have a future?
5. www.england.nhs.uk @robertvarnam Does general practice have
a future?
6. www.england.nhs.uk @robertvarnam I joined NHS England back
in the summer of 2013 to help with the newly announced Call to
Action on General Practice. Among other things, this was an
opportunity to take stock of the challenges facing general practice
and the ways in which NHS England could play a part in supporting
sustainable and improved care. Very much building on what people
told us then, the NHS Five Year Forward View outlines ways in which
we are committed to being part of the solution to the present
challenges. bit.ly/c2aGP bit.ly/nhs5yfv How are things? Where are
you heading?
7. www.england.nhs.uk @robertvarnam For that reason, Im 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. Well feel
the benefit of some of those things sooner than others, but theyre
all welcome, and Im proud to have played a part in creating this
momentum. The new deal for general practice 7 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 publics understanding that pharmacies and online
resources can help them with minor ailments without need for GP or
A&E 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:
8. www.england.nhs.uk @robertvarnam So, for the first time in a
while, there seem to be several reasons for optimism about the
future of general practice. BUT I dont believe that simply carrying
on is going to cut it. ?
9. Its 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 its a
big but just doing more of the same is simply not going to cut it
any longer.
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 were clear about why. What
is the case for change? Where are we heading with it? If youre
currently engaged in a programme of change in your practices, are
these two things really clear?
11. www.england.nhs.uk @robertvarnam This seminal data, which
youve probably already seen, illustrates the reason why just doing
more of the same isnt appropriate either clinically for our
patients or at a system level for the country. We are now spending
at least half our time dealing with people who have multiple
longterm problems. And that proportion is just going to rise as we
all get older. Yet these are not problems the NHS was originally
structured to deal with. In 1948 it was generally assumed that
someone gets ill and they consult their GP. If its a simple, quick
and straightforward thing, the GP will give a prescription and the
person will be cured. If not, a referral will be made to a clever
doctor who will give a prescription, perform an operation and the
person will be cured. And, perhaps, in a year or two, they might
fall ill again, and theyll return for a cure. LTCs are problems
that cant be cured. And most people have several. So seeing a
specialist in one condition with the expectation theyll cure you is
no longer appropriate for the people we spend most of our time
with. Why change? Scottish School of Primary Care
12. www.england.nhs.uk @robertvarnam We need a qualitative
change in the model of care for these people. Just turning the
handle faster, or adding more staff to do the same things would
actually be wrong. We need also to change tack quite considerably.
Not just more of the same New GPs will take TIME to train The world
has changed more than general practice demography technology
economics Many patients need a different kind of care less medical
less dependent New care models present big opportunities, now
13. You may be feeling rather uncomfortable by now, about all
this change. Personally, Ive been through many periods of deep
discomfort over recent months as Ive grappled with all this and met
with colleagues around the country and the world who are doing
likewise. However, I believe that much of whats being described at
the moment is about releasing the potential already in our model of
primary care. Its about returning to the values which attracted me
to general practice in the first place. The things that are most
admired about the NHS when you speak to people from other
countries. These are descriptions of what people told us they were
working towards in the Call to Action. And theyre embedded in the
vision of the future presented by the Five Year Forward View.
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
14. Here are some of the innovations being implemented right
now by practices around England. For years, much of this has been
theoretical or a matter of wishful thinking. But its happening now,
and many of these are, I think, set to become mainstream in the
foreseeable future.
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 So why are people talking
about change? Its partly about the pressure were 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
19. www.england.nhs.uk @robertvarnam New organisational forms
for integrated care
20. www.england.nhs.uk @robertvarnam The NHS Five Year Forward
View outlined a number of new organisational forms which we believe
will help make these changes more attractive, simpler and more
sustainable. The two with the biggest interest for general practice
are the multispeciality community provider and the primary and
acute care system. bit.ly/nhs5yfv New types of organisation
Multispecialty Community Providers Primary and Acute Care
Systems
21. 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
22. 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
23. www.england.nhs.uk @robertvarnam
24. www.england.nhs.uk @robertvarnam What could the future look
like?
25. 1. What kind of care? 2. What kind of work? 3. What kind of
organisation?
26. www.england.nhs.uk @robertvarnam This is the kind of care I
think patients should expect from us 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
27. www.england.nhs.uk @robertvarnam A small aside about access
we need to do much better at defining and improving it so as to
deliver real improvements in value for patients. Its not a
one-dimensional thing. This is the kind of care I think patients
should expect from us 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
28. www.england.nhs.uk @robertvarnam These are key design
principles well need as we build for the future. I dont think there
are any silver bullets here well need to include all of them. How
that looks in practice will need to be different in different parts
of the country, depending on the needs of your population and the
opportunities presented by your current arrangements. 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
29. www.england.nhs.uk @robertvarnam An example of this in
practice at the moment is the Prime Ministers 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 just extending opening hours isnt enough, and
that other things need to happen in order for that to happen
anyway. 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
30. 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
wont just happen. Finally, it should like its 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. 3.
What kind of organisation? Bigger Personal Capable Yours
31. www.england.nhs.uk @robertvarnam One example is the
Whitstable medical practice. Here, through practice mergers, they
are now a single organisation serving 34000 patients. They have
great facilities which enable them to provide a wider range of
care, and more holistic, less medical approaches to long term
conditions eg Whitstable medical practice
32. www.england.nhs.uk @robertvarnam On the other hand, the
same design principles are being applied by the GP Care federation
in the Bristol area. Here, practices have remained entirely
independent as businesses, but theyre working in increasingly close
collaboration, developing new services and sharing back office
infrastructure. eg GP Care federation, Bristol
33. www.england.nhs.uk @robertvarnam Where to start?
34. www.england.nhs.uk @robertvarnam Here are my 4Ps for where
you could start bit.ly/GP4Ps Purpose Partnerships Proactivity
Possibility 4 Ps for transforming primary care
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