1. www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development @robertvarnam Worcester 14 Oct 15

2. www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development @robertvarnam Worcester 14 Oct 15 bit.ly/1501014future

3. www.england.nhs.uk @robertvarnam

4. www.england.nhs.uk @robertvarnam

5. www.england.nhs.uk @robertvarnam An example of this in practice at the moment is the Prime Minister’s GP Access Fund. Now covering a significant proportion of the country, practices in this are implementing quite wide-ranging redesign of their services, acknowledging that extended hours are only one part of good access. The practices participating in this programme are already beginning to implement many of the transformational changes envisaged by the Five Year Forward View. This is generating valuable learning about the specific changes required, including the ways in which the system can make progress easier and more sustainable. Wave one Wave two 57 schemes 2500 practices 18m patients The PM Challenge Fund bit.ly/PMCFresources1 Applications covered 2/3 of the population!

6. www.england.nhs.uk @robertvarnam Right Access Right Access

7. www.england.nhs.uk @robertvarnam One of the things motivating me as I first looked outside the walls of our practice, to lead some local service redesign for diabetes, was fear. A fear that general practice, despite being a service depended on by the country, had a very uncertain future. In fact, I was afraid that general practice was being run into the ground. Although NHS spending was rising, with growing amounts of staff and money, the majority was going elsewhere in the system. Even though we were talking increasingly about the importance of providing more care outside hospital, the investment was going inside hospital. What future for general practice?

8. www.england.nhs.uk @robertvarnam The founding principles of UK primary care are admired the world over, and rightly so. General practice is a jewel in the crown of this country. Right now, general practice feels in a bad place. Constrained, hemmed-in and, to some, marginalised. Whatever the state of things in your part of the country, in general, I think it’s fair to say that, at the very least, general practice is currently constrained from delivering its full potential. We need to see increases in funding, a growth in the workforce, and improvements to premises. Without those, existing services may not be sustainable. What future for general practice?

9. www.england.nhs.uk @robertvarnam But something else has been happening in general practice, too. People are working on some quite new approaches to care and the very organisations we work in. This too was a big theme in the Call to Action. We asked what practices were working on, and what would need to be done for improvements in care to be sustained. And we heard a very big set of messages about the future bit.ly/c2aGP bit.ly/nhs5yfv How are things? Where are you heading? What are you working on? How can we promote, support & sustain improvements?

10. www.england.nhs.uk @robertvarnam So why are people talking about change? It’s partly about the pressure we’re under right now, and partly about the huge opportunity to do something better. And, for once, the same changes that would help with one are also necessary for the other. PressureOpportunity

11. www.england.nhs.uk @robertvarnam At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again. That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s needed. However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase. And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases. So the population of people who need what only primary care can offer has grown, the amount of time they need has grown – and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs. This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis where the population’s need is. Scottish School of Primary Care Why change?

12. It’s too easy to approach challenges just by thinking we need more. The NHS has a well established habit of this – new initiatives, new challenges or opportunities are usually met by us talking about more. More money, more staff – or both. And, we know that, in general practice, we do need both more money and more staff. BUT – and it’s a big but – just doing more of the same is simply not going to cut it any longer. Not just more of the same

13. www.england.nhs.uk @robertvarnam So why are people talking about change? It’s partly about the pressure we’re under right now, and partly about the huge opportunity to do something better. And, for once, the same changes that would help with one are also necessary for the other. PressureOpportunity

14. www.england.nhs.uk @robertvarnam

15. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

16. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

17. Health & wellbeing-promoting care ‘Right access’Consistently high quality Holistic, personalised, proactive, coordinated care Comprehensive, joined-up care for a registered population, shaped around them in the community bit.ly/nhs5yfv ‘Wider primary care, at scale’

19. Phone first. Community diagnostics. Practice based paramedics. Pharmacy first. Web consultations. Primary care led urgent care centre. Minor injury service. Physio first

20. Direct specialist advice. Condition management training. Shared records. Care coordination. Hospital in-reach. Care home ward rounds. Virtual ward. Primary care-employed specialists.

21. Social prescribing. Travelling health pods. Peer-led walking groups Health coaching. Befrienders. Schools outreach. Community development.

22. www.england.nhs.uk @robertvarnam Wave one Wave two 57 schemes 2500 practices 18m patients

23. www.england.nhs.uk @robertvarnam Right Access Right Access

24. www.england.nhs.uk @robertvarnam “Right access” in the Challenge Fund Wider primary care at scale Reshape demand Active front-end Contact modes Match capacity & demand Rapid access model Extended hours Release capacity Service redesign team Broaden skillmix Complex care model Premises I.T. Workforce Service components System enablers bit.ly/PMCFresources1

25. www.england.nhs.uk @robertvarnam 1. What kind of care? Great access to high quality services including proactive, person-centred coordinated care Safety Effectiveness Experience

26. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

27. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

28. www.england.nhs.uk @robertvarnam 2. What kind of work? Deliberate design for segmented needs (one size does not fit all) Greater multiprofessional teamworking bring new skills work to the top of our skills Partnership with patients & community Longer consultations with fewer patients GP not always 1st port of call Direct access diagnostics ‘Pull-in’ specialist advice

29. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

30. 1. What kind of care? 2. What kind of work? 3. What kind of organisation?

31. www.england.nhs.uk @robertvarnam 3. What kind of organisation?

32. www.england.nhs.uk @robertvarnam No blueprint

33. www.england.nhs.uk @robertvarnam At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected

34. www.england.nhs.uk @robertvarnam Delivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Step change in partnership working acute & specialist community services voluntary & community sector public health housing education

35. www.england.nhs.uk @robertvarnam The creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Highly capable infrastructure & leaders Transformational system leadership Engaging, inspiring & supporting the team Service redesign, innovation & improvement Ops management, HR, etc Business intelligence

36. www.england.nhs.uk @robertvarnam Leadership Creating shared purpose Strategic planning & partnerships Leading through change Being a leader Improvement Patients as partners Processes and systems Using data for improvement Rapid cycle change Business Governance Operations management HR Business intelligence Capabilities Enablers Innovation spread Policies & permissions Contracts & incentives Infrastructure Productive federation Transparent measurement Capabilities needed by every federation What do teams and individuals need? These are interdependent How can the system catalyse & accelerate change?

37. www.england.nhs.uk @robertvarnam All of the above requires primary care to operate at larger scale. This may provide economies of scale which will sustain providers through the current workload challenges. More fundamentally, working at- scale is necessary to generate the kind of critical mass required for working in greater partnership as a credible system partner in the local health and care system. In operational terms, it allows financial and staff headroom to be created, making service improvement easier, and it increases the attractiveness of primary care as an employer for staff from other parts of the health and care system. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected At-scale organisational form Attractive system partner Sustainable platform for expanded services Intrinsic headroom Credible NHS employer

38. www.england.nhs.uk @robertvarnam In the course of the transition to being more corporate entities, it will be important for primary care providers to include measures to preserve and even enhance aspects of the status quo which are essential to the value of primary care. The role of primary care at the heart of the local community, and connected with people and their families throughout their life, is a valuable aspect of its ability to contribute to wellbeing and population health. Similarly, the personal continuity of care provided in general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally, the small scale nature of traditional practices creates a level of personal commitment and discretionary effort which the NHS can ill afford to lose. It should be noted that all three of these potential benefits of the traditional ‘cottage industry’ model of primary care organisations are already waning in England. Patients at larger GP practices already report lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement of many salaried GPs. Providers will need to ensure there are specific measures in place to ensure that the personal touch is not only preserved but enhanced. This is likely to have implications for ownership models, organisational culture, structures and processes, as well as the design of teams and clinical care models. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Deliberate design to stay personal Lifelong family care Integral part of the community Personal LTC & EOL care Sense of commitment & ownership for all staff

39. www.england.nhs.uk @robertvarnam eg Whitstable medical practice

40. www.england.nhs.uk @robertvarnam eg Cotswolds PMCF

41. www.england.nhs.uk @robertvarnam Lessons from the Prime Minister’s Challenge Fund Observations about at-scale primary care

42. www.england.nhs.uk @robertvarnam Association Network Federation Partnership Superpractice A federation by any other name… 5 yearsContemplation

43. www.england.nhs.uk @robertvarnam Clarity Buy-in Agility Size Alignment Priorities Partnerships 2300+

44. www.england.nhs.uk @robertvarnam Monthly colloquium Quarterly colloquium Committee Executive team The Boss Decision making Face-to-face visits Bulletin Online forum Surveys

45. www.england.nhs.uk @robertvarnam  Outsourced management  Spare time  New managers  Distributed leadership Leadership & infrastructure Vision-casting Data gathering Programme management I.T. Procurement Workforce Mobilisation Governance Practice engagement Patient engagement Stakeholder partnerships Analysis

46. www.england.nhs.uk @robertvarnam 1. Stop obsessing about form 2. Create shared purpose 3. Invest in development 3. What kind of organisation? Top tips

47. www.england.nhs.uk @robertvarnam Purpose > function > form 1. Stop obsessing about form Purpose > function > form a)Pick something to improve for patients b)Improve it together c)Build infrastructure to enable, accelerate & sustain

48. www.england.nhs.uk @robertvarnam 2. Create shared purpose A sense of shared identity sufficiently strong to allow collaboration that crosses boundaries of organisational sovereignty. We share ideas, data, resources We will adopt a standard approach We can call on each other A purpose beyond ourselves, orienting us around the needs of our patients. Commitment to us and our purpose sufficiently strong to make compliance unnecessary

49. www.england.nhs.uk @robertvarnam 3. Invest in development

50. www.england.nhs.uk @robertvarnam Leadership Creating shared purpose Strategic planning & partnerships Leading through change Being a leader Improvement Patients as partners Processes and systems Using data for improvement Rapid cycle change Business Governance Operations management HR Business intelligence Capabilities Enablers Innovation spread Policies & permissions Contracts & incentives Infrastructure Productive federation Transparent measurement 3. Invest in development What do teams and individuals need? These are interdependent How can the system catalyse & accelerate change?

51. www.england.nhs.uk @robertvarnam At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected

52. www.england.nhs.uk @robertvarnam 3. What kind of organisation? Federation design principles hold a contract register w CQC make decisions share ideas, systems, processes & staff employ staff create infrastructure The name is not important

53. www.england.nhs.uk @robertvarnam

54. www.england.nhs.uk @robertvarnam Purpose > function > form Where to start Purpose > function > form a)Pick something to improve for patients b)Improve it together c)Build infrastructure to enable, accelerate & sustain a)Pick something to improve for patients b)Improve it together c)Build infrastructure to enable, accelerate & sustain

55. www.england.nhs.uk @robertvarnam High Impact Actions to release capacity 1.Active signposting 2.Reduce DNAs 3.New contact modes 4.Digital primary care 5.Broaden the workforce 6.Productive work flows 7.Increase personal productivity 8.Partner with other practices 9.Care & support planning 10.Support self care 11.Develop quality improvement expertise bit.ly/RCpress151004