Collaboration for Survival
An LMC Position Paper on Proposals to Secure the Future of General Practice in Somerset
Published June 2015 Download here
The LMC Study Day on 14th May 2015 looked at some possible future directions for general practice, in particular what actions practices need to start taking now to secure their futures through these current turbulent times. The election of a Conservative government makes a fundamental change of direction Away from the Five Year Forward View unlikely, but it also means that any additional NHS funding will not be sufficient to meet to growing needs of the population and the demand for healthcare. The further £22B of internal savings required to maintain current services is not achievable, and given the workforce problems throughout the NHS, most especially in primary care, dramatic changes in the way every part of the service works are imperative just to sustain core functions. Meanwhile, politicians of all colours will continue to distance themselves from the necessary hard decisions about the NHS, so we should expect the turbulence to become very rough indeed.
The LMC Discussion paper Securing the Future of General Practice in Somerset makes the argument that, for the majority of practices, working collaboratively with colleagues is likely to be essential in evolving a model of primary care provision that is resilient, flexible and adaptive. This paper seeks to add some more detail, and to offer some practical suggestions.
Although a number of different terms are in use as collective nouns for a number of GP practices, we will for the moment continue to use commissioning federations and provider federations to draw the distinction, as there is no consistent agreement on the definition of alternatives like “consortia”
Principles for Primary Care Development
The LMC believes that there are three key principles that any primary care service model should consider:
- The system should be general practice led and demonstrably sustainable
- There should be list-based continuity of care
- The partnership model offers significant benefits and should not be abandoned without very good reasons
Although the workforce, resource and demand pressures driving change are pressing, collaboration needs to be mapped, organised and implemented at an appropriate rate and not forced to meet anyone else’s agenda. So, for example, transition dates do not need to be tied to the NHS financial year. The process should also be flexible enough to allow practices to move at varying paces so that those who choose or need to progress more slowly are not automatically disadvantaged.
It is also essential that change should be made only if benefits for the practice and its members can be seen. Whilst improving services for patients is laudable and a fine objective, practices as businesses must also see that there are direct benefits to be gained from involvement.These may not be financial, but they must be real and enduring.
At What Level Should Practices Organise?
The LMC firmly believes that GP practices need to work together in different ways to achieve all the benefits of collaborative working. Whilst moving away from the current pattern of nine multi-purpose federations will incur opportunity and reorganisation costs, we have started with the presumption that function should dictate form, and not vice-versa.
“Intermediate level” bodies have a range of roles for general practice, and it is important each role undertaken and organised at an appropriate level. There will always be a balance to strike between the obvious benefits of bringing functions together under one umbrella, and the need to perform each as efficiently and locally as possible. It is not yet apparent where this balance lies.
There are four main functions that practices are likely to wish to co-ordinate between themselves
1. Primary Care Provision
Provision of services under the current (and likely future) suites of primary care contracts is the essential purpose of general practice and must be our first priority. But practices are finding themselves sometimes perilously unstable, and we cannot – and must not – assume that any significant external help will be available to alleviate the problems of workforce, resource and demand that general practice is facing. The LMC believes that for most practices the only short to medium term solution is joint working. There seems to be an evolving informal consensus that initially practice collaboratives covering about 25-30,000 patients are likely to work best, at least in relatively urban areas, although these groups may merge further over time, or choose to offer extended services jointly. The net effect in Somerset would be to reduce the current number of functionally distinct provider units from 74 practices to about 20 collaboratives. Apart from the obvious benefits of workforce resilience, management capacity, better skill utilisation and greater business efficiency, such a change puts general practice in a much better position to take a full part in the wider realignment of health and social care services. There may also be an acceleration of the current trend for smaller practices to merge with others, but combining contracts is usually neither necessary nor desirable, especially if the character of each participating practice is to be preserved. However, it is essential that smaller practices are not overwhelmed by or subsumed into their larger neighbours – any structure adopted must ensure all practices’ interests are protected.
2. Intermediate Care Provision
It is an interesting question whether these collaboratives then need to be further clustered into provider federations, or they will naturally cluster in other ways, for example by aligning with referral pathways into secondary care, district council boundaries or other more subtle commonalities of interest. We suggest that for the moment this is likely to be secondary priority.Tendering for non-core work, developing extended primary care services, sharing business support services and other general practice support activity that needs to be done at large scale will generally be best organised at a high level, even if they are provided locally. Somerset Primary Healthcare Limited is obviously an ideal vehicle for this.
3. New Models of Healthcare
We think it is important to distinguish patient care integration work with community and secondary care providers as a separate functional strand to the provision of core GMS/PMS services, even if it is partly organised or delivered at one of the preceding levels. Although moving to new patterns of service organisation and delivery is essential, the risks for practices and patients should not be underestimated, and their needs need to be acknowledged during what could be a period of very rapid and potentially uncontrolled change. Adopting new working practices will involve a leap of faith as there is no time for the models to be fully tested, and we need to stay constantly aware that if practices are to continue to provide all the other required elements of primary care, they need to remain profitable, sustainable and progressive in their own right. Treatment of long term conditions and admission avoidance are not the only things practices do.
Whilst clustering around the acute trusts would make sense with the current configuration of NHS services, if our long term ambition is to shift the focus of care away from the structures – hospitals and so on – to a dispersed and functional model of care, it would be wise to ensure that practices are at least grouped in large enough units to be able to negotiate effectively with NHS commissioners and trust providers, whatever configuration they may ultimately have. With separate and slightly different models already appearing in the ‘Test & Learn’ pilots, it seems likely that practices will progressively join the models that prove to be successful, so the organisation of pilts will ideally allow for the possibility of such organic growth.
There is nothing to suggest that practices will cease to have a valuable role in contributing towards commissioning decisions, even if the long term future of clinical commissioning groups in their current form is not certain. Commissioning localities need to be large enough to have population relevance, but small enough to allow service changes to be made quickly, safely and with a minimum of formal process requirements. But as commissioning has become ever more complex and regulated it is also clear that the infrastructure required is large. That makes working at county level – a population of 550,000 – logical, with local input coming from a function rather than a structure: task and finish groups can be convened where and when required, meaning standing subcommittees and formal localities may not in the end be needed. For the moment a transitional arrangement roughly based on district council boundaries (Mendip, Sedgemoor, South Somerset, Taunton & West Somerset) seems a balanced compromise, especially as local authorities will have a growing role involvement with health services.
What Resources Are Available to Help?
There is a wide measure of agreement between all the interested parties – the area Team of NHS England, Somerset CCG and the LMC - that practice collaboration is either desirable or essential, depending on the circumstances. Collaborative provision of core primary care need not be expensive, and there are at least modest financial resources available in the system to encourage moves towards joint working. NHS England has employed a Primary Care Project Manager, Robert Connor, to develop a self-assessment tool for practices and to help them plan and implement business model change.
Somerset Primary Healthcare is in a strong position to provide the business support function that will be required, and by virtue of being countywide it can move learning between sites as well as sharing costs between several groups.
The LMC therefore plans to facilitate a county resource group, for convenience described as a Provider Support Unit (PSU) that will draw together legal (Adrian Poole from Porter Dodson), management (SPH), accounting (Andrew Spear from Lentells) , as well as other business and NHS skills to work on the resources that practices will need to formalise joint working. We anticipate that the PSU may be working at several levels at the same time, from looking at how the primary care component of a Symphony/Vanguard joint venture might be arranged down to what steps two practices might need to take to form a functional local GMS collaborative. What the PSU does, and how it works, will be determined by what practices want, but the Study Day demonstrated that there was widespread support for this work. An early objective will be to draft a generic Memorandum of Understanding for practice groups to use.
What do we do next?
It will almost certainly be a waste of effort, and possibly suicidal, to try and build an intermediate or new model collaborative unless you are confident that your practice can continue to provide core services for the foreseeable future. If you are in any doubt then a full five year business review is an essential first step. For many this will uncover risks and weaknesses that can best be addressed by joint working with other practices on the provision of core services.
How do we form a Core Work Collaborative?
There is no blueprint for this, though the main options are described in The LMC Discussion paper Securing the Future of General Practice in Somerset. Some of the business processes you should think about are described below, but when you reach the point of wishing to take things further, please contact the LMC Office for advice.
- Decide within the practice what options for collaboration are acceptable, what your essential terms are, and what conditions are negotiable.
- Meet with the other practice(s) to compare your plans, trying to keep a focus on the broader benefits rather than specific and narrow disbenefits. Agree a list of the positives you want to achieve, and a separate list of the obstacles that need to be overcome – this becomes your task list and each meeting should aim to see one or two things taken off it.
- Adopt a formal Memorandum of Understanding.
- Identify suitable change management and project management resources and draft a provisional timeline.
- Nominate people from each participating practice to join the working group, clarify what authority they have to negotiate and act on behalf of the practice. Appoint people from different practices to lead workstream subgoups if necessary – e.g. IT, medical staffing, premises etc.
- Start discussions on the adoption of common management procedures, processes and structures, including accounting. Set up a clinical reference group.
- Work out how you could share some specialist skills – e.g. Long Term Condition Specialist Nurses - between practices.
- Agree on some financial and cost brackets, target staffing and skill requirements, and sharing of executive management skills.
- Write and adopt a Shared Services Agreement.
- Agree a core management structure and provision (or combined outsourcing) of shared services such as payroll, HR and procurement.
- Agree shared contracts & target pay scales for staff, benchmark and agree variance for NHS targets such as prescribing costs and referral rates.
- Bring in expert help to look at premises ownership, leases and anticipated 20 year needs, start to consider how notional costs and rental will be allocated.
- Undertake a clinical staffing review, including profiling existing clinicians, looking at skill mix opportunities, employment and time allocation of salaried GPs, review locum requirements.
- Consider the possible role of clinical sub-contracting.
- Ensure that systems and legals are ready for any advantageous switch to a new contract vehicle if and when this becomes available.
So, what are the problems?
When the alternative is a collapse of your practice, it is surprising how quickly difficulties can be resolved.Some of the major worries, such as property ownership, may appear large from the practice perspective but for a large organisation there are all sorts of solutions, including setting up a property arm to buy in buildings and hold third part leases.This is not to say that the path is easy, but we know NHS England will be looking for solutions and not problems, and there is now extensive precedent for partnerships holding more than one NHS contract.
Working collaboratively is only one part of the set of changes practices will need to make over the next few years. Workforce, demand and cost pressures also mean working patterns, especially for GPs themselves, will have to change, and we will cover that topic in the next of this series of papers. But apart for the necessity of working together, and the sustainability and efficiency benefits that brings, there are indirect benefits as well.If the working day can be made more manageable and less stressful we should be able to attract ahigher proportion of new graduates in to training,provide GPs with the supportive team based environment that most young doctors prefer, and evenstart to reverse the trend forestablished GPs to protect themselves by part-time working.The advantages are considerable, and with good will, not so hard to realise.
Study Day Conclusions: Moving Towards Collaborative Models of Care
During the LMC Study Day participants considered a series of questions about possible next steps. Strands from the subsequent discussion are listed as bullet points below each question.
What do you need to consider in your Five Year Forward View Business Plan?
- Recruitment needs to be improved by casting general practice in a more positive light, possibly offering incentives to new GPs joining, and co-ordinating job advertising throughout the Region.
- Retention must be addressed by inclusivity in team working, better communication within practices, prioritising a better work/life balance and offering much more non-medical support to GPs.
- Skill mix is vital - we must think about primary care and not GP based services. Service integration, stability and managed integration are important. Can we develop a specialist nurse pool, salaried locums or pharmacist involvement? Is there value in formal participation in nurse training? Can we recruit or train nurse practitioners or physician assistants?
- We should make sure the links between core work and potential extended provider roles are explicit, and that continuity is maintained. Is it a good use of NHS resources to set up an new agency to provide long term condition care, or would the money be better spent within general practice?
- Joint working was agreed to be the way forward, either by enlarging practices or collaborative working. There is security in size, but practices should retain their individual characters. What should federations actually do?
- Can we control demand? Would better patient education, especially for young people, pay dividends in the future? Should that involve social media and IT rather than traditional methods? What works to reduce footfall through the door?
- Meeting need: on the other hand, what about infrequent attenders and the hard to reach?
- Management integration needs to encourage local cohesion whilst reducing costs by purchasing at scale, contracting out or localising some services like HR and cleaning, having centralised business services for the group and proper change management plans. How do we make best use of SPH in this context?
- How do we make IT work at a larger scale? Can we ensure control of it moves to and stays in primary care?
What determines the right integration model for your practice?
- Define exactly what we are trying to achieve first.
- Location, location, location!
- Patient factors include age profile, health needs, levels of deprivation and their views of any proposals.
- GP factors include income disparities, property ownership, age, personality, and risk aversion of partners.
- Practice factors include remoteness/rurality, dispensing, historical relationships with other parties (practices, CCG, NHS England, other providers), wish to stay independent.
- Perception of need to act or “How much on fire is the house?”
- Models supported include a super-practice and a collaborative, but whatever is adopted will need proper documentation and to remain partnership based.
- The public facing elements of the practice should only change when it is specifically agreed that is the right thing to do.
- It would be easy to start by sharing some admin functions such as CQC documentation, management skills, training opportunities and some specific specialist staff.
- Primary care will best be served by horizontal integration and this should precede vertical association with acute or other trusts, though alignment with them would be advantageous.
- What is the best way of ensuring patient information and other IT is linked and available wherever and whenever needed?
- If NHS England considers integration a priority, it should provide support funding to support transformation funding for staff and change management input.
- Practices need to agree a shared collaborative vision whilst recognising that they are still theoretically in competition.
What external help do you need to move towards this goal?
- Identify the clinical and manager leaders to take schemes forward.
- Real new resources: money, energy and expertise, especially in facilitation and negotiation.
- Headroom – time to think and plan.
- The development of a clear GP plan that is not driven by anyone else’s agenda.
- A local specialist resource offering legal, accountancy, project management and clinical governance help.
- A high level “Advisory Board” to refine recommendations and identify and mitigate risks, as well as offering neutral advice. This should include LMC, SPH, Area Team and the CCG.
- Contract simplification to make room for change – SPQS has helped, but the Avoiding Unplanned Admission ES needs to go.
- Backfill for staff working on integration projects.
- A database on what has been done elsewhere in the country.
- Some framework protocols for local adaptation, including a plan for how to deal with any practices that collapse during the next few months.
- An agreed timeline for action.
- Someone to devise a plan for handling property assets and liabilities in each location, including the possibility of forming a “propco”.
- Exploration of the possibility of a single county wide integrated GP provider network.
What will the role of existing GP Federations in both the change process and the final model? Is the current number and configuration of Federations right for provider purposes?
- There is no right size - this depends on what local practices want and the personalities of the participants.
- Is there a role for Federations at all?
- The process needs to be non-bureaucratic, as when OOH Co-operatives were formed, so initially relationships may be informal.
- Integration and/or collaboration will be determined by local knowledge, referral pathways, and commonality of vision. Existing commissioning federations may not be relevant to this.
- Some existing commissioning federations may be too small to support new provider models and would therefore add little value.
- Ultimately provider consortia may need to be larger than current federations, and clustered around the four local acute trusts, perhaps supported by an overarching body (primary care led – LMC and SPH with CCG observers?)
- Provider federations could cluster around community hospitals, but only if the Partnership Trust becomes more outward looking.
- What do current federations actually do? Practices are far apart in progress towards integration so may be better left to coalesce naturally.
- It is important that federations stay small enough to be able to develop detailed and relevant local policies, whether as commissioners or providers.
- Secondary care integration should follow primary care integration, not the other way around.
- Some organisation at county level remains important -especially as the local authority, the CCG, the LMC and SPH are co-terminous.