Making general practice fit for the future

General practice represents a paradox. On the one hand, it is widely and rightly viewed around the world as a model of primary care to be studied and emulated. On the other hand, it is based on small, independently minded units, unable to operate on the scale needed to meet changing population needs.

GPs in some areas recognise that practices have to change to rise to the challenges of an ageing population and shifting disease burden. We have studied four of these areas in our new report, Commissioning and funding general practice: making the case for family care networks, which describes how federations and networks of practices are working to deliver extended services and raise standards of care. These innovations in care are valuable, but much more is needed to ensure general practice really is fit for the future.

In our report, we make the case for the development of family care networks led by GPs and integrated with a range of other services such as those provided by community nurses, physiotherapists, mental health professionals, pharmacists, social care staff, and some services currently provided in hospitals. Family care networks would have responsibility for out-of-hours primary care and would be tasked with providing a rapid and joined-up response to patients at times of crisis. They would deliver care that is preventive and proactive with the aim of supporting people to remain independent for as long as possible.

Practices would have to collaborate through federations and work at sufficient scale to be able to lead the development of family care networks. This is likely to mean serving populations in the range of 25,000 to 100,000 and possibly even larger over time. The opportunity this offers is to strengthen the role of GPs primarily as providers of care, co-ordinating the delivery of services on behalf of their patients and working in collaboration with others to provide joined-up services in the community. Hospital specialists such as geriatricians and paediatricians would work alongside GPs in these networks to make a reality of care closer to home.

Our vision will not be realised unless there are fundamental changes to the commissioning and funding of general practice. We therefore propose that federations of practices should be able to take on a population-based, capitated contract that includes funding for the extended services to be provided in family care networks. The new contract would be optional, enabling GPs to retain their existing contracts where they wish.

Funding in the new contract would include the costs of care delivered by practices and there would be flexibility for federations to use savings in other areas of care to increase spending in practices. One of the potential benefits would be to reverse the decline in the share of the NHS budget allocated to primary care highlighted by the Royal College of General Practitioners and others. Key features of the approach we propose include:

  • the contract focuses on outcomes and not inputs
  • providers demonstrate they have the capabilities to manage the contract
  • commissioners collaborate to support implementation
  • federations provide services direct or commission them from others
  • conflicts of interest are managed effectively
  • market regulators support rather than inhibit testing of the contract.

The registered list of patients means that practices are uniquely well positioned to take the lead in developing innovative models of care under the proposed approach. But if they are unable or unwilling to do so, then NHS trusts providing community services and acute services should be offered the opportunity of taking the lead, preferably in partnership with practices. At a time when the need for innovation in the NHS has never been greater, encouraging a variety of approaches to be tested and evaluated has obvious attractions, not least in unfreezing ways of working that appear increasingly anachronistic.

The British Medical Association’s opposition to our proposals suggests that innovation is unlikely to come from this source. Much therefore hinges on GP leaders at a local level to show the way, building on the examples described in our report and going much further to develop the new models of care needed in the future.

This blog is also featured on the British Medical Journal website

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Comments

#41702 Tom Black
Chairman N Ireland GP committee
NIGPC/ BMA N Ireland

GPs in N Ireland lead by the BMA's N Ireland GP committee have started the rollout of federations of practices. A single organisational model has been agreed- a not for profit social enterprise model and the first 3 federations are up and running in Derry, Belfast and Downe. NIGPC plans to extend this model to all areas of N Ireland.

#41703 charlotte jones
Chair GPC Wales
GPC Wales

I think the BMA / GPC view has been distorted in this blog - GPC UK does support networks / federations of practices working together to improve services for patients but not with removal of core contract as this provides core stability for individual practices. Additional monies would enable GPs to lead this agenda across the network working together with other health and social care professionals which will be good for patients as well as the professionals involved. GPC UK is not being obstructive it is just, as always, putting a practical point of view of how these ideas can be implemented on the ground thus getting the best for patients - all too often we have undeliverable "ideas" put forward. Am disappointed to see how the BMA / GPC UK has been portrayed in this blog. For info, GPC Wales is taking forward GP clusters working together across Wales as we believe this is the way forward for getting more resources into primary and community care to develop services for patients in the community and closer to the patents home which aligns with WG strategic priorities.

#41705 Michael Woodhead
Editor
China Medical News

Australia recently set up GP networks known as 'Medicare Locals'. They have only been operating for a couple of years but the new conservative health minister (backed by the Australian Medical Association) has described them as an added layer of bureaucracy and is making noises about abolishing them.

#41707 Harry Longman
Chief Executive
Patient Access Ltd

Read and absorb - this is a thought provoking piece. Rather than remodelling general practice, to me it calls for something more and different in the space between traditional GP contracts and secondary care, a level that cannot be delivered by existing structures. The call is clearly for capitated and outcomes based contracts. Secondary care is activity based, primary care largely capitation based which does work well but is (I would argue) poorly measured and highly variable. To date we have seen in that space a mixture of block community contracts with weak measures, community hospitals trying to take activity from acute trusts, and myriad LES/DES delivered at individual practice level on an activity basis. This is bound to add up to a highly variable service for patients, and high variation in costs.

What I would like to see is detail on the nature and volume of demand in this space. How well can it be measured now? Without this starting point, commissioning is a shot in the dark. The design motto "Form follows function" works here too - structures to deliver this new kind of contract should be grounded in what they need to deliver.

Extending the successful capitation model beyond primary care into this new level is promising, but it means taking a risk, in a similar way to that borne by GP partnerships. It is unrealistic to expect a good match first time round, but someone is going to have to do it - or find a flexible commissioner prepared to share risk. The detail of design for outcomes and the way they are measured is therefore crucial. Let's not expect perfection, but try things.

I wonder whether the PM's Challenge Fund might throw up some useful models and outcomes during 2014-15?

#41708 Dr John M Ribchester
GP, and executive partner
Whitstable Medical Practice

I welcome this well thought out report. In Whitstable we have developed a model of community integrated healthcare which has delivered a better patient experience, and better outcomes at less cost. Unfortunately the current commissioning environment is not designed to enable this type of initiative. The King's Fund report makes a compelling case for the improvement of community health and social care, with General Practices having a key and enhanced role. I hope and trust that legislative change will follow in order to allow Family Care networks to thrive.

#41712 Peter Gibson
Pharmacist

Re engineer the separate GP/CommunityPharmacy/Community Nursing/Optom etc contracts into one all-encompassing Primary Care Contract which forces and provides a seamless link between the professions. It would have GP’s firmly at the centre. Efficiency savings, avoidance of duplicated effort and better quality care must be result from it.
Access to patient records is an aspiration for pharmacy. What could add value is the fact that pharmacy is in a prime position routinely seeing people who are well and therefore can monitor and advise on wellness, before health issues and illness arises. What is currently missing is any recording of the progression from health to illness ie self medication, advice given etc, by community pharmacy which can then be seen ‘upstream’ by the GP on a shared heath record when the need ultimately arises – a more complete picture of patient care with the pathway working comprehensively both ways.
Finally focus on needs of people/patients health needs not professional tribalism and there has to be public, political and professional alignment to ensure success and that I suspect is a big ask!

#41715 Dr Chaand Nagpaul
Chair, BMA GPs committee
BMA GPs committee

A press release cannot capture the BMA's fuller response. We thank the King Fund for this important and valuable report and we in the BMA agree and support much of it, which chimes with out own views. It rightly highlights that the NHS is built upon a solid foundation of general practice, which requires greater resources and infrastructure to deliver its true potential. The BMA’s view is that GP practice networks, integrated with community teams and in collaboration with other community, secondary care providers and social care, is essential for the future sustainability of general practice and the wider NHS - this is spelt out in our own vision document http://bma.org.uk/gpvision. Further we are currently conducting a national survey of GPs views on networks, to support practices working together. We have also produced guidance on how GP practices can set up networks, and also how they can share staff under current arrangements http://bma.org.uk/practical-support-at-work/gp-practices/collaborative-g....

Our difference of opinion is the report’s assertion that this requires replacing the national GP contract and to subsume this into a local capitated provider contract, and we believe this is a red herring. We believe this will dilute and undermine the core level and national standards of general practice care that patients currently receive. We believe the report’s aims can be achieved more productively by federating practices and creating community provider networks (that could have capitated outcome based contracts) that sit alongside practice contracts providing care under national core GP standards. We believe this will preserve and protect the essence of the success of UK general practice, while achieving the wider aims of moving care (and resources) into the community. Indeed this is already an emerging reality in GP-led federations in England, Northern Ireland (Tom Black' post above), and in Wales (Charlotte Jones post). We also believe the report has not addressed the perverse funding and payment systems that operate in England that has created unnecessary division between primary and secondary care, and which is inhibiting investment in primary care as part of an integrated approach to healthcare delivery

This is precisely the debate we should be having at this juncture in the NHS, an we would welcome the opportunity for a productive dialogue with the Kings Fund on how to achieve our joint aims

#41719 Chris Ham
Chief Executive
The King's Fund

I am pleased our report has attracted so much interest and debate. it might help to clarify a few points.
First, the new contract we propose is optional. Only willing GPs would take it up. Others could retain the exisiting contract (s).
Second, some BMA reps have opposed our proposal on the grounds it would involve further NHS restructuring. Nothing could be further from the truth. The option of a new contract is designed to encourage innovation by GPs in how services are delivered and not in how organisations are arranged. Family care networks would vary around the country in how they provide care - we are not prescribing a particular model.
Third, our report draws on experience in 4 areas of England to show the complexity and limits of current contracts. We are not convinced that GP led integrated services in the community on the scale/scope needed can be delivered through these contracts.
Fourth, primary care's share of NHS funding has fallen. The budget for the NHS is unlikely to increase any time soon. Using the budget more flexibly as we propose holds out the prospect of more money going into primary care if savings in other areas of care can be realised.
The King's Fund does not have all the answers but we will keep on asking the difficult and important questions and look forward to engaging in an open debate on how primary care can be in the vanguard of the new models of care required.

#41732 Simon Bradley
GP + Medical Director
Quality Practice Ltd

There is lots of useful information in here but also some fundamental disconnects.

The home-grown examples of collaborative associations are as far from the concept of large organisations managing population based capitated budgets as to be almost irrelevant to making the arguments contained in this paper.

Secondly belief has become evidence. In 2010 Ham said “Definitive *data* on how large groups need to be *does not exist*, but some experts estimate that the organization should have at least 100,000 patients if it is going to take global capitation. Others believe that lower numbers – perhaps 25,000 patients – could be adequate.” This has become “Evidence” in this paper that a “range of between 25 and 100,000 patients”, is the ideal number for a network or federation. This is description of evidence is inaccurate and I believe requires correction by the authors.

It would seem to me that IPAs that failed, who typically had 100s of physicians as members, already much larger than the sizes described above, lacked the capacity to be successful with capitated budgets at least in part because they lacked the resources to do so effectively which was in turn often because of lack of scale.

#41734 Chris Ham
Chief Executive
The King's Fund

Simon's comment on size omits to mention our argument that federations need to be big enough to manage budgets and services but not too big to be distant from practices. We also argue that size will depend on the range of services take on by federations and extent of risk sharing. For these reasons the popn range we indicate is reasonable

#41741 Adrian Jacobs
Primary Care Development Consultant
PCMMS

As an ex GP and current contract negotiator for NHS Employers I have fair amount experience with the existing contractual framework.The existing contractual framework is undoubtedly in need of change but changing the framework is only part of the issue. I have worked with many practices all over England and I have been in the enviable position of seeing why some teams succeed and why others fail from within the practice. Successful practices:
• Are well led
• Have a clear vision of how they can develop and transform the way that they deliver care.
• Manage their workload effectively
• Have effective teams that share the vision and have a core value set and live to an agreed set of guiding principles.
• Proactive and customer focused
• Prepared to invest in developing their infrastructure
Unsuccessful practices:
• Are poorly led often with a very directive model of leadership that is based on “You do what I say”
• Do not invest
• Are not customer focused
• Are reactive and unable to take their “nose off the grindstone” to embrace new ways of working
• Have poorly developed infrastructure.
The message for me is that the contractual framework is a small (but very important) part of what needs to happen. The biggest issue is how do we provide the capacity to develop and to transform General Practice? The need to help practices develop, leadership, teamwork, and the ability to transform the way they work has never been greater yet the capacity to support them has arguably never been smaller. From my experience, NHS England does not yet seem to have the capacity or capability to do it and by and large most CCGs have yet to see the importance of it. There is no doubt in my mind that investment is needed but the investment should initially be focused on development. The current RCGP campaign for a greater share of the resource cake is too poorly focused, what is needed is a contractual framework and an investment plan to help to deliver the transformation agenda.

#41742 Simon Bradley
GP + Medical Director
Quality Practice Ltd

Hi Chris,

Thanks for the response.

The BNF (British National Formulary) is the respected and authoritative guide on use of medicines that sits on most doctors’ desks in the UK. I stray outside its recommended dose ranges at my own peril and that of my patients. The Kings Fund is similarly and rightly respected and authoritative. It both guides and helps shape the developing configuration of UK healthcare. When The Kings Fund defines a range for the best size of collaborative or family care network, leaders will listen and may constrain their thinking within authoritative recommendation: for they stray outside The Kings Fund recommended range at their peril and that of patients.

The report states: “Evidence indicates that population coverage in the range of 25,000 to 100,000 is needed to enable federations and networks to function effectively.” I.e Above range would be too many and below too few to be effective. And you give as reference http://www.birmingham.ac.uk/Documents/college-social-sciences/social-pol... which does not seem to contain evidence to support the contention in this paper that this is the correct range. Genuinely, please correct me if I am wrong.

You cite Kaiser as an example of a much larger organisation, 9 million patients, that has avoided attenuating practice/practitioner engagement. Intermountain Healthcare with its 1,100 physicians and 33,000 employees would be another. All of the home grown examples used to illustrate this paper are much, much larger, more than double the size, of the top of this recommended range. That my practice area, a 10 minute drive-time, would enclose around 400,000 patients and my experience in setting-up GP Care, the largest English GP owned provider, company covering 1,000,000 patients means that your range intuitively feels wrong to me.

I would be most grateful to see the evidence that supports the statement that 25,000 to 100,000 patients is the correct range, to settle my cognitive dissonance.

Simon

#41748 Chris Ham

Simon

If you check p. 5 of the HSMC paper then the wording is absolutely clear based on US experience

It is also caveated as I pointed out in my previous response i.e. the numbers are likely to vary depending on the scope of the services/budget (full or partial capitation) and of risk sharing. I also pointed out it would vary depending on use of stop loss insurance

Federations over 100,000 are possible but then run into the challenge of retaining proximity and ownership among practices

KP achieves this through an extraordinarily well developed culture in the medical group

I hope this is clear but please do go back to the originals to satisfy yourself

Chris

#428170 Peter Devlin
GP and Clinical Director
BICS, Brighton & Hove Integrated Care Service

A very prescient comment from Harry Longman. We have been using our EPIC Prime Minister's Challenge Fund Programme as a platform upon which to build a raft of new services and functions sitting within primary care. Our experience highlights that GP colleagues absolutely require a set of functions around the deleivery of which they can collaborate or federate; and they will not collaborate or federate in the abstract, or just because teh RCGP, or NHS England or anyone else wants them too.

#462954 Trevor
Trainee Carer

GP's are essential
but so are hospital staff.
each play a valuable part in the Structure of the NHS.
but because the government Have messed things up so badly
it is therefore not surprising that the Important NHS is on it's knees.
the government is the spanner in the works that turns things into chaos.

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