Dr Paul Driscoll, Chair and Medical Director, Suffolk GP Federation, discusses how federations can support practices to improve quality and address capacity issues, and how patients can benefit from the federation.
This presentation was filmed at our conference, Emerging models of primary care, on 18 October 2016.
So I am Paul Driscoll, Chair of the Suffolk GP Fed and I’m a GP in Felixstowe with a list of 7,500 and when I joined my three partners, eight years ago, there were four of us, four partners, now I find myself the senior partner, not due to any personal qualities but due to the fact that everyone has left and there’s myself and 7,500 patients and two other salaried doctors. So, some of the pressures we were talking about earlier, are well known to me, but I am here to talk about the federation.
The federation started in 2007, there were some loose groups of practices working around in Suffolk with three main aims – working at scale and collaboration between practices, supporting primary care, and delivering services in the community close to patients. It has grown organically over that period of time, initially our market town is Ipswich and it was a practice around Ipswich that started first, and people said you would never be able to work with the practice in Ipswich, they’re completely different. So, then the practice from Ipswich joined and then they said “Good God, you’ll never work with the practices out in the west, you know it’s cowboy country out there" – and then they joined as well, partly because, I think, they bought into what the federation could do in terms of us working closer together in a way that the other structures couldn’t. So, over that period of time we’ve developed various services and now have a turnover of about 5,000,000 with contracts and 120 staff.
So, just splitting up what we do with scan and collaboration, one of our biggest contracts is two million a year, which is community diabetes, just over the county in northeast Essex and this was commissioned by the CCG who wanted community diabetes and the diabetologists were keen to move into the community. So, all the diabetes care that used to be in the hospital out-patients is now seen in the community apart from three specialist clinics which is renal, maternity and foot. And we have done that by upskilling our GP colleagues, insulin initiation and all the diabetic specialist nurses are now based in the community supporting the practice nurses and the GPs in doing the more advanced diabetes care. We have also taken on in-patient diabetes as an initial contract with Colchester hospital, so now there’s a seamless service for diabetes, whether you’re in-patient or out-patient and often it is the same team of nurses that are looking through you of that whole journey. During that time, the numbers of patients with eight care processors, which is a sort of hallmark of diabetes care, has increased from less than 40 per cent to 60 per cent at the end of the first year and nearly 68 per cent in the second year with other KPIs for cholesterol, HbAlc etc. also being met, at a time of increasing numbers of diabetics. And to just give you an idea that’s an extra 4,000 patients in the first year and 6,000 in the second year. So, that’s been very significant and it’s moved Colchester from being in the bottom quartile of diabetes care in the diabetes UK audit, to the top quartile and we’re just outside the top decile at the moment.
We work closely in setting up the service with patient groups, with diabetes UK and we’re using the Betchley model of the year of care, where the patient comes in and sees a health care assistant for their blood monitoring, is then given the results with a booklet explaining about them, and asked to consider what they would like to be their priority for the following year. So, the meeting, then, with a clinician is actually focused on what the patient thinks their main aims should be in the following year, rather than traditionally what we think their aims should be in the following year. A lot of work was done in London and it has been a very positive effect in terms of the outcome measures. It has also given us the opportunity to look at diabetes as a whole system, so we’re also working closely with a diabetic foot provider at changing that to a much more responsive service for higher risk diabetic feet.
We did a small care homes nursing project, covering care homes in Felixstowe, in my neck of the woods, where we worked together with a nurse practitioner and provided routine home visiting in care homes, filling in paperwork for DNA CPR and special patient notes of the out of hours, which had an impact on supporting nurses in care homes, decreasing the number of home visits that were needed by GPs and hospitalisations. And then we have also spent a lot of time looking at how we can work as GPs collaboratively working. And again, as groups of practices, looking at how we can develop models where not every practice is on call every day of the week, if there’s a clusters, how that can work and doing joint visiting between us. And picking up on the other themes of bringing more health professionals into primary care – how we could work with other health professionals across practices and often there’s a role for the federation in that, because small practices probably can’t afford to employ a pharmacist the whole time, but across a group of practices it is possible to do that.
So, supporting primary care, the Fed 1, the Prime Minister’s Challenge Fund for extended hours GPs service booked via GP. So, extending to the evening from 6.30 to 9.30 and weekends initially 8 am – 8 pm Saturday and Sunday but now limited on Sunday because the demand wasn’t there. That’s given significant benefit to, particularly practices in Ipswich, who are hard pressed and we know that the practices that are hardest pressed, are the ones that are mostly using this service. So, it is one of the few initiatives I have come across, that has actually delivered support to the practices that are actually struggling in real times and we have got the contract for that going forward and will be extending that into our rural parishes as well, working with the CCG.
One of the surgeries, again in Felixstowe, single-handed, 4,500 patients, the GP wanted to retire, was unable to recruit. No other practice locally was interested in taking it on or merging, so the federation has joined with the incumbent as a joint contract and he will leave at the end of twelve months and we will run that as a GP federation practice, using our management structures to run that.
I will talk about leadership training. We trained a series of GPs. Leadership training, leading the way in the first five years or ten years or so of their qualification and then we run a future leaders course for GPs further down the line, who were looking at taking other positions and it was inspirational. I had a particularly inspiring day at Bromley-by-Bow and they came back full of questions including one of my colleagues who works with me, who asked me all sorts of difficult questions when she came back. But, I think, touching on what we are talking about – leadership and training – one of the GPs on the future leaders course says this is the first time anybody has spent any time on me as a doctor to help me develop my skills. And I think we have realised, looking across the practices, that as a profession, we are really bad at developing our workforce, because often it is too hard to do it in the small little units we are working in. There is very little management structure, very little oversight and that includes practice nurses, receptionists, admin – the whole practice team. So, we have also run training for practice managers and we are looking at our practice nurses next.
We’ve supported different ways of working. Suffolk Primary care, which is a single partnership, super partnership is the other word for it, which is just formed of 13 practices. The Fed were supported by some management support for that. But there are other ways of working with Suffolk and I’ll talk about that in a minute. We represent practices, or we represent General Practices on the STP. We have some accountable care organisations as well, working with the hospitals and we have been putting forward a view of how we should be developing General Practices as a part of the STP, which Maureen Baker was talking about earlier. It’s really important that GP is represented at those conversations, otherwise you might find you get secondary care deciding what general practice looks like, and we are aware of the risks of being involved with that, and we are there with the LMC and the CCG are there as well.
In terms of working at scale, we negotiated medical cover, a discount rate, if 100 doctors change, which actually provided significant benefits for primary care. In terms of delivering services in a community, and our philosophy is delivering services closer to the patients, more convenient to the patients and with patient in-put into the design of the services. So, lymphedema service would provide to patients with a very active lymphedema support group. Cardiology in collaboration with the hospital in the community. Diabetes I have talked about, a community ENT clinic, community ultrasound service, 1200 ultrasounds a month at 17 locations in the community and a community pain service in west Suffolk, which is run by a consultant, a nurse consultant and a physiotherapist. And first approach to pain is a holistic approach and physical therapies, exercise, rather than medication, opiates and injections – they’re only if the simple things fail.
So, what else have we done. As part of our working in that way, we’ve developed collaborative working with other parts of the provider environment. So, with our Prime Minister’s Challenge Fund, we have actually extended that to taking referrals back from emergency department, where they are not appropriate, direct transfer from the ambulance service and also 111, where we have had spare capacity to offer to them. With the STP, we are looking at working as a community alliance with other community providers - community nursing, mental health nursing and social services. So, that’s an opportunity for us to actually stop the solo working and work together. Diabetes I have talked about and the primary care change I have talked about.
So, patient benefits of the changes we have made. One is support for practices and thinking about some of the practical things we’ve done, as well as the leadership, because I think unless you look after your staff in general practice, there isn’t going to be a general practice and I think it has been neglected for a long time. So, it is really good to hear about the other projects that are involved, in kind of supporting, us. Extended GP access, it has had a practical effect on the practices, particularly in Ipswich, who make most use of it. Care has moved closer to home and the services that we provide have been very high quality, our Prime Minister’s Challenge Fund, family and friend’s feedback is 99.9 per cent, last time I checked. And Diabetes UK’s reported on our diabetes service after the first year and were very complementary about it and we have active patient’s groups in the diabetes service.
But what haven’t we done. We haven’t really addressed variation at practice level, between practices or particularly made practices or help practices work in any particularly different ways with genuine collaboration. Practices are a little bit less resilient, but I think our leadership course has helped, and we are working with the CCG, so they did manage to get some of this famed vulnerable practice fund money, over £250,000, which will be coming to Ipswich and we are going to be using that with the CCG. And the practice is looking at using other health professionals in primary care, perhaps doing home visiting with ECPs, pharmacists and physicians associates into those hard pressed practices. And also, we haven’t really still got a single voice of who represents primary care. The federation has one view, our local MC has a slightly different view to us, and obviously, the CCG, sometimes see themselves as commissioners, sometimes they’re there as providers, so I think it’s been quite hard for the other big players in these conversations between the STP, to really work out what general practice is thinking, because there isn’t one clear voice for us from that.
So, why have we done it. Well, it takes time – we’ve been around for a few years, but it’s only relatively recently we’ve taken on big contracts and grown and I think, of the different models in care, this is a great picture from Dr Atty, who shows the three different models and as I’ve mentioned in Suffolk, we’ve got a group of practices going for full integration which is a sort of super partnership on the right. About the same number of practices are thinking of working closely together in a less formal structure supported by the federation in a federation. And about half our practices are, either happy as they are, often rural dispensing, they don’t have recruitment issues at the moment, or they’re in difficult situation, they can’t really get their head up out of the water to actually take time to reflect. So, I think probably 50 per cent on the left, 25 per cent in the middle and 25 per cent on the right. I mean, general practice has changed over the last fifty years. Fifty years ago, you would have seen a middle-aged bloke in a white coat and I couldn’t get one with a pipe I’m afraid, but with a pipe, and now we’ve got a much broader range of people in general practice which has been fantastic for us. But some things haven’t changed and I think that one of the things we’re thinking may be hindering things slightly, is the independent contractor status of GPs. And at the moment the setup is very flat with every practice duplicating what happens in every other practice and then next step up is the CCG and the next step is NHS England. And, if you were to lump all primary care together, you’ve got a lot of people. And it would sometimes seem to be more sense to have more of a, sort of, corporates the wrong word, but an organised structure, so that not everybody is repeating what everybody else is doing. And you could have specialists in various areas with HR, payroll, whatever and down to clinical level as well. You could share expertise of clinicians who are good at one thing, spreading that across the whole patch, rather than just their little practices and it’s really difficult to do that at the moment because you’re not covered insurance-wise if you share, so that’s one of the drivers towards the single partnership in Suffolk. But there’s no reason why it couldn’t be done in other ways such as the federation but our experience has been, it’s difficult to make that change, unless people are linked closer together.
So, what needs to happen? And this is happening, I think there is more appetite for commissioning at scale, which will help GPs work together. There’s got to be support for change. We have talked about how difficult it is, it takes time and there needs to be energy invested into our staff, to help them with that. Consistent message, which I think is also coming across more, realistic time scales, everything in NHS terms always has to be done by April, when you find out in November. Another opportunity, though, is that moving community education of all these staff into primary care with a community education, primary networks, which I think is very positive and we are supported by our postgraduate dean with that. And also, attention to the workforce, and that’s more recruitment into these posts that we need.
So, federations are good for certain things, but they’re not good for everything and I think we have a management structure which helps support general practice but it can’t do everything that, I think, sometimes people think it should be able to, in our experience.