GP re-imagined
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Presentation at the RCGP NorthEast Faculty annual conference
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GP re-imagined
- 1. #GPforwardview#GPforwardview GENERAL PRACTICE FORWARD VIEW Dr Robert Varnam Director of General Practice Development @robertvarnam The future of general practice Re-imagining care, our practice, ourselves? bit.ly/170511gp
- 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 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
- 6. #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.
- 7. #GPforwardview What are people doing? Access Working at scale Releasing time for care
- 8. #GPforwardview What are people doing? Access Working at scale Releasing time for care
- 9. #GPforwardview#GPforwardview What is good access?
- 15. #GPforwardview#GPforwardview Collaborative working Whole system approach Self-care Broader workforce Tech bit.ly/GPFVaccess
- 16. #GPforwardview What are people doing? Access Working at scale Releasing time for care
- 17. #GPforwardview Personal focus Clarity Commitment Agility Population focus Alignment Priorities Partnerships 4 400 Not an either / or solution
- 18. #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
- 19. #GPforwardview Working at scale: Opportunities for practices bit.ly/MCPinfopage
- 20. #GPforwardview What are people doing? Access Working at scale Releasing time for care
- 21. #GPforwardview 10 High Impact Actions to release time for care Innovations from around England that release time for GPs to do more of what only they can do. bit.ly/gpcapacityforum
- 22. #GPforwardview Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum 10 High Impact Actions to release time for care
- 23. #GPforwardview Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum 10 High Impact Actions to release time for care bit.ly/gpcapacityforum
- 24. #GPforwardview 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 First port of call and central point of care for all, for life
- 25. #GPforwardview 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 The organisation of our practices and our work constrains us from delivering some of the promise of primary care
- 26. #GPforwardview The future GP: more of the same (promise) Personal expert generalist Tamer of uncertainty Diagnostician Complex care planner Expert coach of expert patients Consultant, coordinator & connector Improvement leader Population manager Leader in the local system Social shaper
- 27. #GPforwardview#GPforwardview GENERAL PRACTICE FORWARD VIEW @robertvarnam The future of general practice Re-imagining care, our practice, ourselves? bit.ly/170511gp
Editor's Notes
- THUMBS – how optimistic do you feel? Managing workload?
- 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.
- Good access is at the heart of good general practice. Yet too many efforts to improve access have been rather one dimensional, focusing on speed often at the cost of other aspects of quality such as continuity. The Prime Minister’s GP Access Fund (originally called the “Challenge Fund”) involved 2,500 practices collaborating in 57 schemes across England to improve access and care. Their approach was very different. Patients and professionals have always recognised the central importance of access in providing good care. Yet getting the right model for access is more complex than is often acknowledged. Access is a multifaceted aspect of value, but initiatives to improve it have often been rather one dimensional, focusing for example on speed alone or promoting a one-size-fits-all solution. Schemes in the GP Access Fund can be seen to have worked on introducing ‘right access’, ensuring patients get access to the right care from the right person at the right time and through the right channel. This is more holistic than just focusing on providing rapid appointments, and it acknowledges that there is no “one size fits all” approach – in particular, some patients place high value on speedy access to an appointment, whereas others prefer to wait to see their own GP. A ‘right access’ appointment system allows for both. GPAF schemes often made wide-ranging improvements to the model of care for patients. They considered the whole patient journey, starting before someone becomes ill. Innovations were introduced to help prevent ill-health and educate people about how to use health services wisely. When patients contacted their practices, new systems and staff training helped to actively signpost them to the most appropriate source of advice or help. Consultations themselves were undertaken in innovative ways including online and on the phone, and using text messages and group consultations to help people manage their longterm conditions better. Access was also improved by broadening skillmix, incorporating pharmacists, advanced nurses, physiotherapists, paramedics and care navigators into the practice team.
- Access is a key part of the overall commitment of the practice to look after the lifelong wellbeing of the patient and their community. As such, access to appointments cannot be considered in isolation from other work to promote wellbeing. The practice will also want to collaborate closely with others in the community who can support people to stay well and to look after themselves, such as community pharmacies and other providers of care and support. These are often highly accessible, and focus on meeting needs without resort to a medical approach. They therefore offer benefits for patients and the community, as well as reducing pressure on GP practices.
- When patients contact services, it is important to ensure they are connected with the most appropriate source of advice or help, and that the opportunity is taken to build their own efficacy for self management. Active signposting provides patients with a first point of contact which directs them to the most appropriate source of help. Web and app-based portals can provide self-help and self-management resources as well as signposting to the most appropriate professional. Receptionists acting as care navigators can ensure the patient is booked with the right person first time.
- When people do require a consultation with a clinician, a much more diverse range of approaches is being taken, to improve the convenience of care for the patient and, in some cases, make more efficient use of the clinician’s time. Phone Use of the telephone for consultations is growing rapidly in general practice. Some practices have been offering this kind of consultation for ten years or more, but interest has grown significantly since about 2012. From a starting point of treating phone contacts as brief triage encounters, practices are increasingly recognising the feasibility and value of fully addressing the patient’s need in a single phone contact where appropriate. Experienced consulters generally find phone consultations are half the length of face-to-face ones, and that approximately 75% of consultations can be fully concluded on the phone. This releases GP time, reducing waiting times for patients, and making it easier to offer better continuity and longer face-to-face appointments for patients who need it. Most practices implement phone consultations as part of other changes, for example the introduction of active signposting and redesign of systems to create more productive workflows, particularly with a focus on matching capacity with patterns of demand through the week. E-consultations Using a mobile app or online portal, patients can contact the GP. This may be a follow-up or a new consultation. The e-consultation system may be largely passive, providing a means to pass on unstructured input from the patient, or include specific prompts in response to symptoms described. It may offer advice about self care and other sources of help, as well as the option to send information to the GP for a response. Text message In addition to sending reminders, text messaging can be used for more interactive two-way communication between patients and their practice. Systems exist to help automate this, allowing for quite sophisticated packages of education, reminders and support self-care. Group consultations For patients with longterm conditions, group consultations provide an efficient approach to building knowledge and confidence in managing the condition, which includes a peer-led approach as well as expert input from professionals. Access hub Run by a group of local GP practices, these allow patients to obtain care outside traditional surgery hours. Face to face consultations In many cases, practices are seeking to change the experience of face to face consultations, particularly through using longer appointments for people with complex needs. This is enabled by the fact that phone and online consultations generally require less clinician time.
- A growing number of practices is broadening their skill mix, to reduce demand for GP time and connect the patient more directly with the most appropriate professional. This may include training a senior nurse to provide a minor illness service, employing a community pharmacist or providing direct access to physiotherapy, counselling or welfare rights advice.
- Underpinning much of the service redesign work undertaken by innovators in the GPAF is a recognition that not all patients have the same needs, and that improvements to access should deliberately include specific measures to meet differing needs. The most relevant difference is often between the needs of people with an isolated acute problem and those with ongoing or complex needs. The former group of patients is primarily interested in receiving care promptly, and continuity of care is less important as long as the clinician they consult has access to their GP record. The latter group is generally more concerned with seeing their usual clinician, and it will often be better for them to wait longer to see them. Achieving this difference requires a nuanced design, and does not occur by default.
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- False polarities
- Resilience Economies of scale System partnerships Skillmix Innovation and improvement Staff development
- A growing collection – submit your own examples and questions.