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LMC Email update February 2015

Date sent: Monday 16 February 2015

Email sent by Wessex LMCs, on Sunday, 15 Feb 2015

Over the last couple of years I seem to start my emails by telling you what you already know (times are difficult) then I tell you things will get better (some think I am deluded) and then describe how I see that change coming about (now total disbelief!).

Despite the coverage of the problems facing Accident and Emergency Departments over the last few weeks, the greater problems and workload difficulties have been experience by general practice.

Between 200/10 and 2013/4 the spend on general practice has fallen on average by 1.3% per year and despite the rhetoric about moving resources from hospital over the same period the spend on hospital based care has increase by an average of 2% and community services by closer to 5%.

Click here for more information.

It therefore no surprise that general practice is facing the current difficulties.

Public Health England has reported a significant rise in winter deaths this year, reported as 10,000 more than would be normally expected.  Who did they think would be have been looking after these patients?  Who would have experienced the greatest increase in workload?

When we look back at 2015 I believe it will viewed as a significant point in time in the evolution of general practice.

General practice will continue, this is not the end of traditional general practice. 

The importance of the holistic care provide by a GP, who is known and trusted by the patient  remains important, as does the registered list of patients held at practice level, the life long medical record, continuity of care and acting as the patient’s advocate.

The LMC is all too aware of the difficulties faced by GPs, Practice Managers and Practices.  We need to find solutions and fast.

Change is coming and we must decide whether to embrace the change and make the most of it where we can and ensure that we end up in a better position that we currently find ourselves in or resist change.

Contents

The future of general practice

 

So what is being talked about?

General practice working at scale
Out of hospital care
Place based commissioning
Integrated care
New models for delivery
Urgent care

General practice working at scale

For some this is being delivered by merging practices into bigger units – we now have practice that have over 30,000 registered patients.  This is a good model for some but does not work for everyone.

Other alternative, are working together as a loose group of practices – called a federation.

Some practices have established a provider company that cover a population of 50-200,000.

We have got enough work to do, why do we need to work at scale?

Our local population is usually services by one or two hospital, a single community provider, one ambulance service and anything from 50 – 150 individual GP practices, all working independently.  This is often referred to as a health economy. 

The reality is that when providers are developing models of care working across the health economy, working with the commissioners, general practice barely gets a look in and certainly has less power and influence than the large single providers. 

Currently general practice can deliver services as individual small unit but frequently is not able to deliver a single service across a large geographical population.

Take winter pressure funding – it may come as a great surprise but comes around every year.  Discussions take place about service that could keep patients out of hospital or focus on providing more hospital based care so the funding is then given to acute trusts, community providers and the ambulance service – general practice does not usually get a look in, yet we experience winter pressures, every year!

We need a system that will provide help and support to our patients that also helps us to cope with the winter demands, and while we are at it what about the every day demand that we see is increasing almost by the day!

This is why we need to general practice to work at scale – without being too dramatic, the survival of general practice may depend on this transformation.

 

Out of hospital care

So we all agree we cannot continue to increase year on year  spend on hospital based care or we will bankrupt the NHS without a significant increase in funding. 

The evidence all points towards needing to develop a model of care outside hospital, but not one as we have now but a single service that might include aspects of general practice, community care, mental health and social care.

This would enable the health issues of a population to be addressed in a more effective way.

The current way we work in silos with significant barriers between each organisation is one of the major reasons for inefficiencies, issues with quality of care and one of  the reason general practice is under so much pressure.

So if we need to develop a model of out of hospital care who should lead this?  Community Trusts, Hospitals, the Private Sector, the Voluntary Sector or General Practice?

In my view what would be best for patients and also general practice would be if general practice leads this but ensures services are truly wrapped around the patient and supports the work of individual practices.

For example take urgent care – more later – but defined as care needs to be provided that day as defined by the clinician or the patient – for some patients this is best delivered by a clinician that knows the patient, but for many especially the 45m patients who do not have a long term condition, does that care need to be provided by a GP, or even by a practice. 

Could you manage the demand if 10 – 20% of your daily workload ewas taken care of by someone else?

If we worked at scale could we bid for winter pressures funding and deliver a services that covers a larger population, meets the demands, help general practice with their workload and critically keeps patients out of hospital? 

The critical issue here is not that practices need to divert half their workforce to the organisation that is delivering primary care at scale but I would argue should be part of that organisation and benefit and contribute in different ways.

This could be through a provider company, a network of general practices or one of the new emerging organisations called an Accountable Care organisation, a Community Interest Company etc.

 

Place based commissioning

This is essentially saying that you should look at the needs of a community.

That may be 50 – 100,000 people or more and would therefore include more than one general practice.  

You look at the health and social care needs of that population, and start to address the unmet  needs of the population as a whole. This may be about a better and more efficient use of existing resources but may also be about making a better use of other resources available and ultimately may result in geographical localities holding budgets.

Take diabetic care as an example – currently most care takes place in general practice, but also you have the Pharmacists, Community Staff, Specialist Nurses and hospital based services.  If you were to look at a better and more efficient way of looking after this group of patients would you deliver care in the same fragmented way that we do now or would you change the delivery model?

How could we make better use of social care and the voluntary sector?

Place based commissioning will lead to delegated health and social care budget for populations to allow much more effective service provision.

 

Integrated care

This is a term that has been around for some time.  There is good evidence when a wider range of services than a single organisation work together as a single team the outcomes are better than when those organisations work independently.

We seem to have spent a lifetime talking about integrating with community services yet in many areas they are less and less involved at a practice level.

Out of hospital care will only be effective if we wrap services around patients and work in a far more integrated way. 

The new models that are described in the NHS Five Year Forward view such as the Multi-Speciality Community Provider or the Primary and Acute Care System, are examples of far greater integration.

For the Five Year forward Plan click here.

 

New Models of delivery

When I have talked to GPs and Practice Managers about these models, I have been told that there is little interest locally for these and they only apply to other parts of the country. 

Well before you accept that, there are currently 8 submissions of expressions of Interest, that I am aware,  of in our area to establish these types of organisations.

Also when you look at the published level of funding at practice or CCG level compare how badly we are funded compared to other parts of the country.   These models may possibly be a way to attract additional funds to meet the needs of our population.

 

Urgent care

Urgent care is defined as clinical care that is deemed to be necessary within the next 24 hours and this could be defined by the clinician or the patient. It is estimated that anything up to 40% of the GP workload is urgent care. We are rightly fiercely protective of the benefits of providing care to a registered population by a GP who is known to the patient and trusted. This associated with access to the life long medical record have significant benefits to patient care and improved outcomes. 

But .. urgent care is delivered by Pharmacists, minor injury units, walk in centres, the ambulance services, NHS 111, GPs and Accident and Emergency Departments.

We need to develop more effective ways of dealing with urgent care, for those that are known to GPs they may be the best person to manage the patient but for many they could be equally well managed by a healthcare professional, preferably with access to their comprehensive medical records.

 

General Practice debated in Parliament

On the 5th February 2015 there was a debate in the House of Commons entitled “Building sustainable GP services”.

The debate was generally positive, one or two statements were incorrect.

If you would like to read a transcript of the debate please follow the link. This will also allow you to see a recording of the debate.

Follow this link for the full transcript.

 

 The BMA provided a briefing for MPs and this can be found following this link

 

Building the workforce – a better deal for practices

This 10 point plan was recently published by NHS England, Health Education England and supported by the GPC and RCGP.

The aim to promote solutions to recruit and retain GPs and also assist returners.

Recruit

Promoting general practice
Improving the breath of training
Training Hubs
Targeted support

Retain

Investment in retailer schemes
Improving the training capacity in general practice
Incentives to remain in practice
New ways of working

Return

Easy return to practice
Targeted investment in returners

 

So what does all this mean?

 

Promoting general practice

The four organisations are going to launch a marketing campaign about the positive aspects of general practice and choosing this as a career option.

LMC Comment: We have to move from the negative comments to more positive ones but this has to be associated with creating a better and more sustainable environment for GPs to work in.

 

Improving the breadth of training

This is looking to provide a further year of training for GPs after they have completed their training. These roles would be available in areas where it is hard to recruit.

The training could include developing other skills such as paediatrics, dermatology, Public Health, Psychiatry, leadership, academic studies etc.

LMC Comment: Areas where it is difficult to recruit would now probably cover most of the UK!

We have worked with the Deanery and CCGs to create GP Fellows who undertake similar role and this has proved to be very popular.

 

Training hubs

This is where groups of practices work together to offer inter-professional training to primary care staff.

LMC Comment: This again is about general practice working at scale and able to embrace the opportunities that exist and are being created.

 

Targeted support

NHS England is going to  work with the BMA GP Committee and the RCGP to explore a time-limited incentive scheme to offer additional financial support to GP trainees committed to working in specific areas for 3 years.

LMC Comment: This seems like a sensible idea.

 

Retain

Investment in retailer schemes

The current retainer schemes will be reviewed and there will be a new national scheme with additional investment, making sure it meets the needs of both GPs and practices.

LMC Comment: This is a good idea to help retain GPs especially in the middle of their career.

 

Improving the training capacity in general practice

The recent £1bn announcement about investment in premises is expected to deliver additional capacity and better infrastructure to create new and additional training places.

LMC Comment: This £1bn is being announced multiple times at the moment and it is hard to see how it will deliver all that is expected from it!

 

Incentives to remain in practice

There will be a detailed review to identify the most effective measures to encourage experienced GPs to remain within practice.

Options may include a funded mentorship scheme, opportunities to develop a portfolio career towards the end of your working life, and a clearer range of career pathways.

 

LMC Comment: There is no need to do a review I can tell them what would help:

 

New ways of working

We are short of GPs and will not manage to train the additional numbers we need, so could others help to meet the demand for example:

It is suggested that a shared programme of key pilots at scale in primary care, to invest in and trial new ways of working for these roles, demonstrating how they work across community, hospitals and within GP surgeries to support safe and effective clinical services for patients. This will support current GPs in managing their workload, as well as piloting new ways of working for the future.

LMC Comment: Yes great fully support this but who will pay for them when they are ready?  We need additional resources to fund these posts.

 

Return

Easy return to practice

A new induction and returner scheme, recognising the different needs of those returning from work overseas or from a career break, and work with the RCGP will take place to agree safe, and proportionate standards.

LMC Comment: Good news long overdue

 

Targeted investment in returners

NHS England will make available additional investment to attract GPs back into practice, increasing over time. Targeted at the areas of greatest need, the scheme will offer resources to help with both the costs of returning and the cost of employing these staff.

A review of the performers list in its current state and its value will be undertaken.

LMC Comment: Not really sure how this is going to work need more details!

 

Publication of NHS Payments to General Practice

This year we will see the introduction of two new unrelated publication schemes relating to GP income. 

On 12 February 2015 the Health and Social Care Information Centre (HSCIC) will publish NHS payments to individual providers of general practice services (including practices, walk-in centres and health centres) in England for 2013/14.  This will start an annual publication process. 

Practices do not have to do anything in relation to this publication as data is taken from the HSCIC GP payments system.  The report will break down payments by category including Global Sum, MPIG, QOF, enhanced services etc.

If publication of these figures generates media interest the LMC or the GPC will help you with this.

 

Publication of mean GP net earnings

From April 2015 it will be a contractual requirement for GMS practices to publish on their practice websites by 31 March 2016 the mean net earnings of the partners, salaried GPs and any locum who has worked in the practice for over six months. 

This includes income from NHS England, CCGs and local authorities for the provision of GP services that relate to the contract or which have been nationally determined. 

All earnings to be reported are pre-tax, National Insurance and employee pension contributions. 

For contractors the figures are net of practice expenses incurred.

Income and costs related to premises will not be included in this figure. 

Alongside the mean figure, practices will be required to publish the number of full and part time GPs in the practice.  The information must be published on practice websites before the end of the financial year following the financial year to which that information relates. 

Practices must also make available the information in hard copy on request – recognising that not all patients will be able to access the website.

NHS England will publish guidance for GPs and their accountants on how mean net earnings should be calculated.  Practices, or their accountants, will have to generate the report themselves.  NHS England has acknowledged that it can be difficult to disaggregate income and expenditure lines precisely and will recommend that practices should work within the reporting guidelines as far as is reasonably practicable.

Earnings for General Dental Practitioners will be published to the same timetable.

Click here for full details

 

Two week cancer waits

We have received a number of letters from GPs who have expressed their concern about patients who are seen in hospital and cancer is suspected and are being sent back to the GP to re refer the patient under a 2 week wait with the excuse that the hospital is unable to undertake internal referrals for two week waits.

The LMC has raised this issue with the relevant local hospitals and CCGs as this is clearly unacceptable and results in a delay in the patient’s care and generated additional work.

Once again we are grateful for the help and support of the Wessex Cancer Network and attached to this email is a helpful letter from the Chair form the network.

 

 

How to deal with DNAs

This was the topic that was covered in the 2nd of our Bulletins aimed at helping practices.

Wessex LMC Campaign Launch: Helping YOU to re-write the S.C.R.I.P.T

Click here for more information:

General information

Campaign Bulletins

This has generated quite a lot of discussion.

A GP shared with me a very interesting paper produced by NHS Bedfordshire that looked at some positive interventions that could help reduce the DNA rate.

The study showed that the three positive interventions that had the greatest impact were:

These interventions reduce the DNA rate in the practices by 30% over a 12 month period.

Does this mean the LMC advice was wrong?

I believe we should always try the positive approach first.  But if that has not been effective then other interventions need to be considered.

 

Best wishes

Nigel

Dr Nigel Watson

Chief Executive

Wessex LMCs

Churchill House, 122-124 Hursley Rd

Chandler's Ford, Eastleigh

Hants. SO53 1JB (Registered Office)

Tel: 02380253874

Mobile: 07825173326

www.wessexlmcs.com

 

Attached file: 20150126_2WW-referrals.pdf

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