The future of general practice

The future of general practiceDr Robert VarnamHead of general practice development

@robertvarnamWorcester14 Oct 15www.england.nhs.uk@robertvarnam** RECORDING **1The future of general practiceDr Robert VarnamHead of general practice development

@robertvarnamWorcester14 Oct 15bit.ly/1501014future

www.england.nhs.uk@robertvarnamAbout me2

www.england.nhs.uk@robertvarnam** Whos having a tough week?** What are the challenges? [5min]3Outsourced managementSpare timeNew managersDistributed leadershipLeadership & infrastructureVision-castingData gatheringProgramme managementI.T.ProcurementWorkforceMobilisationGovernancePractice engagementPatient engagementStakeholder partnershipsAnalysis

www.england.nhs.uk@robertvarnam1. Stop obsessing about form2. Create shared purpose3. Invest in development3. What kind of organisation?Top tipswww.england.nhs.uk@robertvarnam

@robertvarnamwww.england.nhs.uk@robertvarnamMonthly colloquiumQuarterly colloquiumCommitteeExecutive teamThe BossDecision makingFace-to-face visitsBulletinOnline forumSurveys

www.england.nhs.uk@robertvarnamThe 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. What future for general practice?

www.england.nhs.uk@robertvarnamThe 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. 8But 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/nhs5yfvHow are things?

Where are you heading?What are you working on?

How can we promote, support & sustain improvements?www.england.nhs.uk@robertvarnamBut 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 future9So 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.

PressureOpportunitywww.england.nhs.uk@robertvarnamSo 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. 10At 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, thats still the kind of care thats 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 populations need is.

Scottish School of Primary CareWhy change?www.england.nhs.uk@robertvarnamAt 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, thats still the kind of care thats 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 populations need is. 11Its 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.

Not just more of the samewww.england.nhs.uk@robertvarnamIts 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. 12So 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.

PressureOpportunitywww.england.nhs.uk@robertvarnamSo 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. 13

www.england.nhs.uk@robertvarnam

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam15

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam16

Health & wellbeing-promoting careRight accessConsistently high qualityHolistic, personalised, proactive, coordinated careComprehensive, joined-up care for a registered population,shaped around them in the communitybit.ly/nhs5yfvWider primary care, at scalewww.england.nhs.uk@robertvarnamC2A findings WHAT KIND OF CARE?

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www.england.nhs.uk@robertvarnam18

Phone first.Community diagnostics.Practice based paramedics.Pharmacy first.Web consultations.Primary care led urgent care centre.Minor injury service.Physio firstwww.england.nhs.uk@robertvarnam19

Direct specialist advice.Condition management training.Shared records.Care coordination.Hospital in-reach.Care home ward rounds.Virtual ward.Primary care-employed specialists.www.england.nhs.uk@robertvarnam

Social prescribing.Travelling health pods.Peer-led walking groupsHealth coaching.Befrienders.Schools outreach.Community development.www.england.nhs.uk@robertvarnam

Wave one Wave two57 schemes2500 practices18m patientswww.england.nhs.uk@robertvarnamAn 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 extended hours are only one part of good access. The practices participating in this programme are already beginning to implement many of the transformational changes envisaged by the Five Year Forward View. This is generating valuable learning about the specific changes required, including the ways in which the system can make progress easier and more sustainable. 22

Right Accesswww.england.nhs.uk@robertvarnamRight access in the Challenge FundWider primary care at scaleReshapedemandActivefront-endContact modesMatch capacity & demandRapid access modelExtended hoursRelease capacityService redesign teamBroaden skillmixComplex care modelPremisesI.T.WorkforceService componentsSystem enablersbit.ly/PMCFresources1 www.england.nhs.uk@robertvarnam1. What kind of care?

Great access to high quality services including proactive, person-centred coordinated carewww.england.nhs.uk@robertvarnamThis is the kind of care we want patients to receive from primary care. The GP Access Fund has shown that great access involves patients obtaining the right care from the right person, in the right place at the right time and that different patients have different needs (in particular, it is necessary to meet the differing needs of people who require continuity of care from their usual GP and those who do not). NHS England is supporting 37 groups of practices 17.5m patients to introduce improved access.

In considering the right care, we want patients to be assured that they will receive consistently high quality care, incorporating patient safety, clinical effectiveness and a good patient experience. NHS England intends to provide support for practices who are struggling to meet acceptable standards, through peer support and targeted development.

For people living with longterm conditions, we wish all practices to provide more proactive, person-centred and coordinated care, as described by the House of Care. 25

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam26

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam272. What kind of work?Deliberate design for segmented needs (one size does not fit all)Greater multiprofessional teamworkingbring new skillswork to the top of our skillsPartnership with patients & communityLonger consultations with fewer patientsGP not always 1st port of callDirect access diagnosticsPull-in specialist advicewww.england.nhs.uk@robertvarnamHow will staff and services need to be organised in order to deliver this kind of care?28

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam29

1. What kind of care?2. What kind of work?3. What kind of organisation?www.england.nhs.uk@robertvarnam30

3. What kind of organisation?www.england.nhs.uk@robertvarnamWhat do YOU think?31

No blueprintwww.england.nhs.uk@robertvarnamAt 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?BiggerPersonalCapableConnectedwww.england.nhs.uk@robertvarnamBUILDING on existing strengths . the MORE list33Delivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. 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?BiggerPersonalCapableConnectedStep change in partnership workingacute & specialistcommunity servicesvoluntary & community sectorpublic healthhousingeducationwww.england.nhs.uk@robertvarnamDelivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. 34The creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. 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?BiggerPersonalCapableConnectedHighly capable infrastructure & leadersTransformational system leadershipEngaging, inspiring & supporting the teamService redesign, innovation & improvementOps management, HR, etcBusiness intelligencewww.england.nhs.uk@robertvarnamThe creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. 35

CapabilitiesEnablersInnovation spreadPolicies & permissionsContracts & incentivesInfrastructureProductive federationTransparent measurementCapabilities needed by every federationWhat do teams and individuals need?These are interdependentHow can the system catalyse & accelerate change?www.england.nhs.uk@robertvarnamOne of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders.

The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable.

Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Ministers Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it.

NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently. 36Purpose > function > form Purpose > function > form Purpose > function > form 1. Stop obsessing about formPurpose > function > form Pick something to improve for patientsImprove it togetherBuild infrastructure to enable, accelerate & sustainwww.england.nhs.uk@robertvarnam2. Create shared purposeA sense of shared identity sufficiently strong to allow collaboration that crosses boundaries of organisational sovereignty. We share ideas, data, resourcesWe will adopt a standard approachWe can call on each otherA purpose beyond ourselves, orienting us around the needs of our patients.Commitment to us and our purpose sufficiently strong to make compliance unnecessary

www.england.nhs.uk@robertvarnam3. Invest in development

www.england.nhs.uk@robertvarnamOne of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders.

The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable.

Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Ministers Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it.

NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently. 49

CapabilitiesEnablersInnovation spreadPolicies & permissionsContracts & incentivesInfrastructureProductive federationTransparent measurement3. Invest in developmentWhat do teams and individuals need?These are interdependentHow can the system catalyse & accelerate change?www.england.nhs.uk@robertvarnamOne of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders.

The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable.

Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Ministers Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it.

NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently. 50At 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. 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?BiggerPersonalCapableConnectedwww.england.nhs.uk@robertvarnamAt 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. 513. What kind of organisation?Federation design principles

hold a contractregister w CQCmake decisionsshare ideas, systems, processes & staffemploy staffcreate infrastructure

The name is not importantwww.england.nhs.uk@robertvarnamPurpose > function > form Purpose > function > form Purpose > function > form Where to startPurpose > function > form Pick something to improve for patientsImprove it togetherBuild infrastructure to enable, accelerate & sustainPick something to improve for patientsImprove it togetherBuild infrastructure to enable, accelerate & sustainwww.england.nhs.uk@robertvarnamHigh Impact Actions to release capacityActive signpostingReduce DNAsNew contact modesDigital primary careBroaden the workforceProductive work flowsIncrease personal productivityPartner with other practicesCare & support planningSupport self careDevelop quality improvement expertisebit.ly/RCpress151004www.england.nhs.uk@robertvarnam