developing general practice: surviving transformation
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Developing General Practice: Surviving transformation. Dr Chaand Nagpaul Chairman, BMA General Practitioners Committee. Where we are today - increasing demographic demands on GPs. Rising demand from ageing population 29% population have a long-term condition - PowerPoint PPT PresentationTRANSCRIPT
Developing General Practice:Surviving transformation
Dr Chaand NagpaulChairman, BMA General Practitioners Committee
Where we are today - increasing demographic demands on GPs
• Rising demand from ageing population • 29% population have a long-term condition• Between 2008-2018 no. of people with 3 or more
LTCs predicted to rise from 1.9 to 2.9 million• Patients with LTCs make up 50% of appointments• LONDON- ethnically diverse, non-English speaking,
mobile population, additional deprivation indices
Where we are today: progressive transfer of care out of hospitals
• Chronic disease management• Earlier inpatient discharge• Expansion of day care surgery• Reduced post op follow up• Reduced OP follow up• Increased investigations in the community• “Out of Hospital Care” – explicit policy
direction• LONDON effect- hospital closure
programme
Where we are today - understaffed
Where we are today - understaffed
Centre for Workforce Intelligence
“Our analysis on the available evidence on the demand for GP services points to a workforce under
considerable strain and with insufficient capacity to meet expected patient needs. There is a clear need to
substantially lift workforce numbers to more sustainable levels.”
Where we are today : under-resourced
• Between 06/07 – 10/11– Spending increased on GP services by 10.2%– Spending increased on hospital services by 41.9%
• In 2012/13– £7.8bn spent on general practice– Over £70bn spent on secondary care
• No national investment or strategy for GP premises since 2004
Where we are today : under-resourced
Year % total investment % excluding dispensed drugs
2004/5 10% N/A2005/6 10.41% N/A2006/7 9.83% N/A2007/8 9.17% N/A2008/9 8.74% 8.04%2009/10 8.45% 7.81%2010/11 8.31% 7.68%2011/12 8.16% 7.56%2012/13 8.04% 7.47%
Where we are today – overworked and demoralised
• DH commissioned 7th worklife survey GPs (Aug 2013)
lowest levels of job satisfaction since 2004 contract highest levels of stress since start of the survey series substantial increase in GPs intending retiring next 5 yrs
• BMA GPC GP contract imposition survey (Sep 2013)
9 out of 10 increased workload past year, 100% incr bureaucracy
9 out of 10 say reducing appts and time for patients Nearly 9 out of 10 reduced morale• 1 in 2 GPs less engaged with CCG due to workload
Today’s political context• NO NEW MONEY-austerity - £30b savings by 2020• GP contract changes 2014-15• Workload demands on GP practices continually
rising• “Equitable funding” - LOSERS & GAINERS• Standardisation of care & quality in primary care• Increased scrutiny and performance
management; NHS England, CQC and CCGs• Prime Ministers Challenge Fund: 7/7 opening• Urgent care- Keogh review • Competition; Monitor
Competing in a market• AQP – a reality; APMS, ES, LA commissioning• Competing with commercial providers: advantage
of size, business accumen, able to take risk, loss leading contracts
• Competing with Foundation trusts (“vertical integration”)
• Competing with access and convenience (vs quality)- 8 a.m-8 p.m/7 days a week
• Opportunity costs in competing and tendering• Abolishing practice boundaries; patient choice• Increasing value of global sum £/patient• Challenges of competition greater the
smaller the unit
Planning for the future• No practice immune from external pressures and
threat• Vulnerability increases the smaller the unit• Vulnerability for MPIG and PMS losers• Implications for all GPs-partners and sessional
doctors• London effect: Higher prevalence of: single-handed/small practices, inadequate premises BME GPs, salaried and freelance GPs Greater ethnic diversity; London specific demographic
needs
Securing our future: GP practices working together
• Survival of the fittest: economies of scale, ability to compete, sharing opportunity costs, managing financial risk, security in numbers
• New opportunities: new/expanded services, new income streams, professional development and new roles, peer support and education, managing workload and risk
• Looking after our own, supporting the disadvantaged; supporting small practices; maximising the potential of inadequate GP workforce
The weak or disadvantaged• Poor, inadequate premises (locked in); CQC
vulnerable• Small & isolated• Challenging population demographics• Low GMS funded• Poor historic Health Authority/PCT support,
development and investment• Poor staffing levels• Poor management support• Not policy savvy• Quality and potential of individual GPs obscured
Tiers of collaboration• Primary medical services (G/PMS)
and enhanced services• New provider models for expanded
services in the community; out of hospital care
• Avoiding “tears” of collaboration
Primary Medical Services (GMS/PMS)• GMS/PMS – flexibilities for informal & formal
alliances• Sharing human resources, cross-cover, training• Subcontracting & sharing services across
practices • Back office functions e.g. PAYE, bulk purchasing• Improved access: extended hours DES; Xmas
closing • Supporting statutory functions/HR/information
governance, CQC registration etc• Quality assurance and professional development:
clinical governance, peer review, education• Succession planning for potential vacancies
Structural options for new provider models• Form to follow function; depends on purpose• Simple alliances; sharing premises and staff• Formal mergers as partnerships• GP co-operatives• Private companies limited by shares• Community interest companies (CICs), social
enterprises • Charity or charitable incorporated organisation
(CIO) • Limited Liability Partnership • Companies limited by guarantee• NEED EXPERT LEGAL ADVICE
Principles of working together• What is purpose? Shared vision, equity of
opportunity and ownership, avoid “corralling” practices
• Preserving the essence & success of general practice
• Benefits to patients• Supporting the weakest and disadvantaged GPs
and practices• Creating synergy vs “takeovers”• Providing true contractual and career
development opportunities
Challenges and risks to collaborative working
• Loss of autonomy, loss of “essence” of general practice (patients like small practices)
• Differences in opinions and philosophies• Different starting points• Sharing unequal historic resources• Developing trust and collective ethos• Legal & liability implications• Setting up costs• TIME to plan
It can happen and work• Derbyshire Health United: Not for profit social
enterprise, 300 GPs covering 1m patients, provides 4 walk-in centre services, OOH triage and call handling
• Midlands Medical Partnership: 33 GP partners, 4 GMS contracts, 60000 patients
• AT Medics: Private company limited by shares, across 8 CCGs in London, corporate structutr providing core and enhanced services, and support for career development
• Suffolk GP Federation: not for profit community interest company, 40 practices, 360,000 patinets
• Sessional Drs: www.pallantmedical.co.uk – a chambers of freelance locum GPs
Making it happen• Can’t afford ostrich approach• Start talking within your practices and between
practices• Premises constraints – estate strategy with hubs• IT infrastructure to support networks• LMC role• CCG role supporting practices and resource shifts
from secondary care• AT role - supporting collaboration, resources• Learn from others - look at what’s working
elsewhere
GPC guidance• “Collaborative GP alliances and
federations” October 2013
• “Guidance for practices on how to employ shared staff” October 2013
• GPC survey of GPs on collaboration (Feb 2014)
http://bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/priorities/gpc-vision
Integrated care, built around the practice“Community health care teams built around GP practices. Collaborative working across localities with practices either singly or collectively employing or directly managing community nurses who, working together with practice nurses, will provide a seamless and more flexible nursing service for patients in the community.”
“Greater collaboration between community pharmacists and practices with a practice- aligned pharmacist undertaking medicines management and other elements of chronic disease management”.
Integrated care, built around the practice
“Secondary care clinicians and GPs working collaboratively to design and provide care pathways for local areas, bringing more diagnostics and specialist care out of hospital and into community settings, including hospital-based specialists visiting nursing and residential homes and working alongside GPs in practices when appropriate.”
Turning solutions in to reality
FUNDING: “Government should set a target for NHS England to invest in a year on year increase in the proportion of funding in to general practice”Ending PbR and perverse funding systems – money to follow changing patterns for careWORKFORCE:National strategy for recruitment & retention nowSupport returners back to work
Turning solutions in to reality:
PREMISES: Fit for the future- 10 year programme of premises development- Create a GP premises development fund- Practices working together to make maximum use of premises- Guaranteeing reimbursement of running costsEMPOWERING PATIENTS AS PARTNERS- Self care, demand management
Changing external mind-sets
• 4 hour+ A&E waits due to demand exceeding supply, pressures, need more resources, more A&E Drs…
• Waits for GP appointments due to fault of GPs not working hard enough, not open long enough, practice creating obstacles…
Changing mind-sets• Investing in hospitals is about investing in
care and services
• Investing in general practice is about paying GPs more
• Is there a way of investing in general practice without necessarily being linked to perceptions of GP pay?
NZ (10.1%)
UK (9.6%)
AUS (9.1%)*
FR (11.6%)
GER (11.6%)
CAN (11.4%)
NETH (12.0%)
SWIZ (11.4%)
US (17.6%)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$3,022$3,433 $3,670
$3,974$4,338 $4,445
$5,056 $5,270
$8,233
Health Spending per Capita, 2010Adjusted for Differences in Cost of Living
30
* 2009.Source: OECD Health Data 2012.
% GDP
Dollars
Sicker AdultsCost-Related Access Problems in the Past Year
31
Percent AUS CAN FR GER NETH NZ SWIZ UK US
Did not fill prescription or skipped doses
16 15 11 14 8 12 9 4 30
Had a medical problem but did not visit doctor
17 7 10 12 7 18 11 7 29
Skipped test, treatment, or follow-up
19 7 9 13 8 15 11 4 31
Yes to at least one of the above 30 20 19 22 15 26 18 11 42
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Sicker AdultsAccess to Doctor or Nurse When Sick or Needed Care
SWIZ UK FR NZ
NETH AU
SGE
R US CAN
0
25
50
75
100
79 79 75 7570
63 59 5951
32
Percent
UKSW
IZ NZ FR AUS
NETH US CA
N
GER
2 4 5 8 10 12 1623 23
Same or next-day appointment
Waited six days or more
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Sicker Adults and Primary Care PhysiciansAccess to After-Hours Care
UKSW
IZNE
THGE
R NZ FR US AUS
CAN
0
25
50
75
100
2126
3440 40
55 55 5663
33
Percent
UKNE
TH NZ
GER
AUS
SWIZ FR
CAN US
95 94 90 8981 78 76
4534
Sicker Adults: Difficult getting after-hours care
without going to the emergency room
Doctors: Have arrangements for patients
to get after-hours care
Source: 2011 and 2012 Commonwealth Fund International Health Policy Surveys.
Sicker Adults with a Chronic ConditionPatient Engagement in Care Management
34
Percent reported professional in past year has:
AUS CAN FR GER NETH NZ SWIZ UK US
Discussed your main goals/ priorities
63 67 42 59 67 62 81 78 76
Helped make treatment plan you could carry out in daily life
61 63 53 49 52 58 74 80 71
Given clear instructions on symptoms and when to seek care
66 66 56 64 64 63 84 80 75
Yes to all three 48 49 30 41 42 45 67 69 58
Base: Has chronic condition.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Primary Care PhysiciansPractice Routinely Receives and Reviews Data on Patient Care
35
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percent routinely receives and reviews data on:
AUS CAN FR GER NETH NZ SWZ UK US
Clinical outcomes 42 23 14 54 81 64 12 84 47
Patient satisfaction 56 15 1 35 39 51 15 84 60
Hospital admissions and ED use
39 30 9 24 21 43 32 82 55
Primary Care PhysiciansDoctors’ Clinical Performance is Reviewed Against Targets at Least Annually
36
UK NZ US AUS NETH FR GER CAN SWIZ0
20
40
60
80
100 96
83
67
5347 43 43 41 37
Percent
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Primary Care PhysiciansDoctor Routinely Receives Data Comparing Practice’s Clinical Performance to Other Practices
37
UK NZ FR SWZ US NETH AUS GER CAN0
20
40
60
80
100
78
5545
35 34 3225 25
15
Percent
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
General practice as a solution• Pride and confidence - UK GPs and general
practice provide world leading primary care• Bedrock of NHS: 340m consultations/yr vs 21m in
A&E• The most cost-effective part of the NHS? - £130
patient/yr unlimited care vs £200 single OPD PbR appt
• Investing, expanding and enabling general practice makes absolute sense- is key solution to wider NHS pressure and future sustainability
• "Developing General Practice today - Providing healthcare solutions for the future"