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

2. © Nuffield Trust 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

3. © Nuffield Trust 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

4. © 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

5. © 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

6. © 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: 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

7. © 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 (£8m 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

8. © Nuffield Trust 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

9. © 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

10. © 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 parents to return to work

11. © Nuffield Trust 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

12. © Nuffield Trust Strengths and weaknesses of (three) different models Super partnershipMulti-practiceNetwork/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

13. © 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!