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New organisational models for general practice:

Dr Rebecca RosenSenior FellowThe Nuffield Trust

General PractitionerSouth East London

December 18th 201313/11/2013

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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

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• 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• .

Compelling case for change: (inter)national context

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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

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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

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Super partnership model

Main characteristics:

Keeping what’s good about ‘small and local’

Built on local general practice with local GPs

Delivery at scale: 80k+ 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

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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 conditionsSubstantial PCT investment (£8m over 3 years) in admin staff to support networks, IT, care planning and incentives for quality improvementFocus for peer led change and improvement with a linked education and training programmeCare coordination enabled by care planning, shared electronic record and monthly MDT mtgsPeer led performance review against KPIs for incentive payments

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Networks and Federations – Suffolk Federation

Formed between Suffolk GP practices, April 2013 Main characteristics: 40 original practices invested a fixed payment (30p 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

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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

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Proactive, population focused health careBromley 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 workArt use of art as a vehicle for breaking down boundaries and promoting better healthLearning – 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 parents to return to work

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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

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Strengths and weaknesses of (three) different models

Super partnership Multi-practice Network/federation

infrastructure for quality/efficiency

+/-

(needs ‘external’ investment)

Opportunity to diversify ‘practice-level’ income

+/-

Change prof. behaviour

(culture, internal management)

(standard operating procedures)

+/- (culture & local incentives)

Develop integrated services

+/-

GP prof. development

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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!