New organisational models for general practice Dr Rebecca

New organisational models for general practice: Dr Rebecca Rosen Senior Fellow The Nuffield Trust General Practitioner South East London December 18 th 2013 © Nuffield Trust 13/11/2013

Overview 1. Why do we need to think about changing general practice? 2. New models of practice organisation 3. Strengths and weaknesses of different models © Nuffield Trust

Compelling case for change: (inter)national context • Primary care is having to balance financial constraints with rising demand • Widespread shift in services from hospital to community is adding to demand for GP services • Public expectation is rising • Unwarranted variation between practices in many areas of evidence based practice (Kings Fund, 2011) • Fragmentation: Practices operate in relative isolation, without formal links with other services • . © Nuffield Trust

Compelling case for change: practice perspectives • As small businesses GP practices are vulnerable to marginal reductions in income – need to diversify income streams • Typically have insufficient staff to accommodate new clinical, administrative & regulatory roles & requirements • Reduced income requiring more efficient business model • Potential to increase scope of business but need scale • GPs are becoming burnt out and open to wider variety in their working lives • Some are slightly bored of the status quo and looking for a fresh challenge © Nuffield Trust

Making it happen: New organisational models for general practice Super partnerships: Large practices on several geographically local sites. Formed through practice mergers. GP led. Single legal entity created. Networks and federations: Collaboration of local practices, which remain independent. The collaboration may be informal (a network) or formalised as a legal entity which can hold contracts. The aim is to increase scope of provision and create efficiencies whilst maintaining core small business model. Regional and national multi-practice models: Multiple practices distributed on a regional or national basis, owned by a single parent organisation which may be a traditional GP partnership or a public or private company. Community orientated practices : GP practices embedded in local community and taking a holistic, population focused approach to general practice – linking health and wellbeing to employment, skills and social networks © Nuffield Trust

Super partnership model Main characteristics: Keeping what’s good about ‘small and local’ Built on local general practice with local GPs Delivery at scale: 80 k+ patients: practice mergers Expanded general practice teams Clinically and quality focused, managerially smart Integrated planning and delivery of generalist, specialist and community services Provider-led population health care management Foundation for large education provider © Nuffield Trust

Networks and Federations – Tower Hamlets London Borough of Tower Hamlets has established eight GP networks Main characteristics: 36 practices were formed into 8 networks 2006/7. Geographically aligned. 4 – 5 practices per network. Initially formed to improve diabetes care, then extended to address other conditions Substantial PCT investment (£ 8 m over 3 years) in admin staff to support networks, IT, care planning and incentives for quality improvement Focus for peer led change and improvement with a linked education and training programme Care coordination enabled by care planning, shared electronic record and monthly MDT mtgs Peer led performance review against KPIs for incentive payments © Nuffield Trust

Networks and Federations – Suffolk Federation Formed between Suffolk GP practices, April 2013 Main characteristics: 40 original practices invested a fixed payment (30 p per patient) to join the federation – now 60. Membership organisation governed by a board of 9 GPs, 3 practice managers and the CEO Each practice has 1 vote for strategic decisions Covers a population of 539, 000 patients Formed to win contracts for extended services. Portfolio of services now covers: • Diabetes, Ultrasound, lymphoedema, cardiology and urology Diversifying roles into practice support including running a locum bank, HP and procurement © Nuffield Trust

Multi-practice models Main characteristics Partnership and PLC versions Run multiple practices and services through multiple contracts Variety of services offered: standard general practice; urgent care centres; walk-in centres Geographically scattered Variable governance arrangements Examples: The Hurley Group, The Practice PLC © Nuffield Trust

Proactive, population focused health care Bromley by Bow Healthy Living Centre Health – GPs, community nurses, health networkers, artists, gardeners, community care workers and a youth team to explore and create new ways of thinking about health in a holistic way. Enterprise – ‘Enterprise Hub’ - eight social businesses helping people return to work Art use of art as a vehicle for breaking down boundaries and promoting better health Learning – ESOL, sewing and art groups, plus opportunities for NVQ, HNC, HND qualifications (eg working within the centre café) Environment – a high quality environments which raise aspirations and boost self-esteem. Creche – supporting opportunities for working © Nuffield Trust parents to return to work

Making it happen: essential ingredients • Strong clinical leadership and GP engagement • Clear vision for the organisation(s) who are trusted by their peers • Time and skills in leaders/belief it’s work making the effort in followers • Infrastructure • IT systems for shared records and data analytics • Telehealth and telemedicine • Education and training • Organisation and workforce development • New models of governance • Skilled managerial support and resources for OD • Developing skill-mix and increase multi-disciplinary working • Financial logic • Contribute to financial stability of practices © Nuffield Trust

Strengths and weaknesses of (three) different models infrastructure for quality/efficiency Super partnership Multi-practice Network/federation +/(needs ‘external’ investment) Opportunity to diversify ‘practicelevel’ income +/- (culture, internal management) (standard operating procedures) (culture & local incentives) Develop integrated services +/- GP prof. development Change prof. behaviour © Nuffield Trust

Concluding thoughts • Need to decide core aims for working together and then decide which model fits best • Unlikely to get agreement between all local GPs. Let enthusiasts lead the way and others can follow if they want to • Develop clear values and goals and ensure local leaders communicate these to all involved – to develop organisational culture and drive change • Essential to have management skills & capacity to develop new models at pace • ? Need to have a single model in each CCG? • Minimum population? • Like minded? • Local rivalries vs burying hatchets! © Nuffield Trust