Practice Manager Development Conference: Network: Etcvenues Password: Wifi5038

GENERAL PRACTICE
FORWARD VIEW
Practice manager
development conference
Network: etcvenues
Password: wifi5038
@robertvarnam #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
slido.com
# gpfv
@robertvarnam
GENERAL PRACTICE
FORWARD VIEW
The future of primary care
Dr Robert Varnam
Director of General Practice Development
@robertvarnam
england.gpdevelopment@nhs.net
STRENGTHS OF PRIMARY CARE
UK general
Personal practice
and is one of the world’s
population-orientated most complete
primary embodiments
care is central … of the values of primary care
if general practice fails, the whole NHS fails. Simon Stevens, General Practice Forward View
Holistic Dealing with the patient as a

person not a disease or part of the body
Accessible Personal care built on “Primary” …

a relationship from cradle to grave
first, foremost,
central, key
Comprehensive Handling wide range
of problems, managing clinical uncertainty
Community focussed Responsible for

a registered population, improving wellbeing
Central Coordinating and connecting

other teams, referring where appropriate
STRENGTHS OF PRIMARY CARE
Primary care doesn’t need reinventing, but liberating to deliver its potential
Holistic Current constraints:

Demand >> workforce + funding
Accessible Practices are set up to provide mostly

medical care
Hard to coordinate other inputs and ‘pull
in’ specialist support
Comprehensive
Too small and isolated to have significant
impact on population or system
Community focussed
Central
1948 CARE
Specialists
Community
services
Broader skillmix
FUTURE CARE
At scale
Emergency
care
Self Self
Care management /
social
prescribing Collaboration
with specialists
GENERAL PRACTICE
FORWARD VIEW
Working at scale
@robertvarnam
What size should we be?
20 100
✓ Personal focus ✓ Population focus

✓ Clarity ✓ Alignment
✓ Commitment ✓ Priorities
✓ Agility ✓ Partnerships
Don’t accept
either / or
solutions
Doing the right thing at the right scale
STP: 0.5-3m
Workforce & infrastructure planning
Large scale service reconfiguration
Major partnerships & shifts in
priority
Network: 100-900k
Finance, HR, governance, IT
Employment & career development
Specialist staff & services
Strategic partnerships
Population: wider determinants
Hub/home: 30-60k
Place of ‘belonging’
Acute care
Shared MDT
Population: proactive & preventive
care
Microteam: 3-4k
Continuity for complex
needs
Working at scale: Opportunities for practices
 Staff pooling
• nurses, reception & clerical staff, sessional GPs …
internal ‘bank’
 Overflow support
• phone consultations
• access hub (phone +/- face-to-face)
• home visiting
 Purchasing
• Indemnity bulk purchasing
• Supplies & utilities
 Shared functions
• Single CQC registration
• Single accounting system
• Policies & procedures
• Procurement
• Correspondence management
• IM&T (eg support & maintenance, intranet, web, social media)
 Specialist functions
• HR
• Finance
• Clinical governance
• Business intelligence @robertvarnam #GPforwardview
 Planning
• Workforce
• Infrastructure development
• Service reconfiguration
• Public health
 Provision
• Acute care
• Community pharmacy
• Dentistry
• Optometry
• Social care
• Housing
• Welfare
• Voluntary sector
 Traditional healthcare roles
• Pharmacists
• Specialist nurses
• Physiotherapists
• MH therapists
• Paramedics
 Wellbeing workers
• Social workers
• Care navigators
• Health trainers & coaches
• Welfare advisors
 Sharing ideas
 Testing new ideas
 QI expertise
 Patient engagement
 Analytics
• Population health analytics
• Priority setting
• Benchmarking
• Realtime measurement
 Project management
 Recruitment
 HR
 CPD
 Career development
• New options
• In-house portfolio career
• eg
• Leadership
• Mentoring
• Service improvement
• Research
Working at scale: Opportunities for practices
GENERAL PRACTICE
FORWARD VIEW
Online consultation systems
bit.ly/gpfvonlineconsultations #GPforwardview
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Better service for patients

Connects to the most
appropriate help
Gives patients more
control
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Information about
symptoms and treatments
Find local services
Ask a query, send a
clinical consultation
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
£45 million over three years

Available for every practice
Part of wider digital
transformation
#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Support for planning and

procurement
Advice for practices to
maximise benefits
Materials and support to
engage patients
#GPforwardview
About Benefits Process Support
GENERAL PRACTICE
FORWARD VIEW
Is it beneficial?
Wide range of answers from different practices
Yes Not many

“access improved … better “No problems as such, but very
consultations … happier staff and few patients used it and we didn’t
patients … GP workload notice an impact on workload”
manageable”
Look beyond the headlines …

eg recent study - “unlikely to deliver hoped-for benefits”
• practices had no ‘clear rationale’
• no plan re likely costs and benefits
• insufficient training of non-clinical staff
• insufficient communication with patients
Br J Gen Pract. 2018 Jan 30;bjgp18X694853
bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

GENERAL PRACTICE
FORWARD VIEW
Is it beneficial?
Wide range of answers from different practices
Yes Not many

“access improved … better “No problems as such, but very
consultations … happier staff and few patients used it and we didn’t
patients … GP workload notice an impact on workload”
manageable”
But you knew that already …
Having it confers no benefit

Switching it on is a start
Using it to full effect could change your life

GENERAL PRACTICE
FORWARD VIEW
Benefits in practice
Improved access
More convenient access, connected to the most appropriate person first
time, signposted to self help ad community resources
• eg Unity Health, York: GP wait reduced from 2-3 weeks to 1 day, DNAs from 10% to 3 - 5%
• eg Larwood surgery, Workshop: named GP wait reduced from 1-5 weeks to a few hours
More efficient use of GP time

Clerical queries addressed by clerical staff, some problems resolved without
face to face appointment, tests done before appointment
• eg Docklands Medical Centre: 40% of contacts resolved without patient needing to come in, mean 2.9 minutes’
GP time
• eg Unity Health, York: 66% handled remotely, take <10 min for clinician
More effective consultations

GP can deal more effectively with the problem because details of the history and the
patient’s ideas, concerns and expectations known in advance
• one of the first things reported by many GPs
• it is hoped that future academic research will seek to quantify this

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I’ve got this headache, and it’s been coming and going for the past month or
so. I’ve never had it this often before. I’ve tried my usual painkillers, but
they’re hardly helping. Some weeks I’m needing them virtually every day.
History of tension type headache,

no previous prolonged or
recurrent episodes. Prescription GP call back
for Co-Codamol 8/500. No other
significant history.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
My head’s killing me and I ache all over. It’s been going on for three day, and
I’m really bunged up. My throat’s red raw. Today I’ve got a cough as well and
I’m hot and cold.
Signpost to self help

Normally well young adult. information / minor ailments
service

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I tried that new tablet for the migraine and it helped SO much. I think I felt a
little tired after taking it, but nothing much. Is it OK to stick with this one?
Should I throw the Zomig away? I’ve still got a packet from earlier.
Message back to patient

“That’s good news. Yes, let’s put this on
Longstanding migraine. Analgesia
limited help. 4/12 ago Rx your repeat medications now. Please let
Zolmitripan, no help. 1/12 ago Rx us know if the headache changes or the
Sumatriptan, asked to inform GP new Sumatriptan stops working.
of the result. Unopened packets of old tablets can be
returned to your pharmacy – thank you.”

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
I tried increasing the Amitriptyline tablets but I’m just getting worse.
Headache every day and I’m just so tired. Even just standing up, I get dizzy
and nearly black out. Please do something to help me.
Chronic tension type headache,

4/12 ago started Amitriptyline for Book appointment with
prophylaxis, titrated to max dose nurse for blood tests
1/12 ago, asked to inform GP of
results. Also menorrhagia and then follow-up with usual GP
previous anaemia.

GENERAL PRACTICE
FORWARD VIEW
Scenarios …
This headache is killing me and no one’s doing anything. I was meant to

have a scan from the hospital but I’ve not heard anything.
Anxiety, depression and

headache, possibly migrainous. Secretary to chase hospital
No help from any medication. appointment / provide patient
Neurology appointment 3/12 ago,
ref’d for MR brain. No with hospital contact details
correspondence since.

GENERAL PRACTICE
FORWARD VIEW
Do patients use it?
Yes … if they know about it and are encouraged by staff

• Where patients are not engaged by the practice, the service is hard to find on
the website or staff are not confident in describing the benefits, patient uptake
can be very low.
• This is not surprising, but it is sometimes overlooked by practices. Recent
academic publications confirm this.
Potential shift to ‘click first’ for patients:

eg Rydal practice (N London): 40% contacts online within 3 months
eg Unity Health (York): 87%
Use crosses the generations:
Potential shift to ‘click first’ for patients

• Rydal practice (suburban): 40% contacts online within 3 months
• Unity Health (suburban and student): 87% online

GENERAL PRACTICE
Is it ‘approved’?
FORWARD VIEW
Safety standards
• Detailed standards published by NHS England, October 2017, covering
legislation / standards for clinical safety, cybersecurity and information
governance.
• National approved suppliers established, January 2018, giving additional
assurance regarding essential functionality and financial stability.
Indemnity providers’ view

• Inform provider. No additional cost.
• Follow GMC and CQC requirements for good care, see in person if clinically appropriate,
don’t break confidentiality, check patient agreement with management plan
• Contact provider if…
• non-GPs are consulting (?additional cost)
• consulting with private patients (?additional cost)
• consulting without the record (?additional cost)
• consulting online with under 16s (may not be covered)

GENERAL PRACTICE
FORWARD VIEW
Policy information:
bit.ly/gpfvonlineconsultations
Case studies:
bit.ly/GPcapacitynet2
england.onlineconsultations@nhs.net
@robertvarnam
GENERAL PRACTICE
FORWARD VIEW 10 High Impact Actions to release time for care
Innovations from around England

that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
GENERAL PRACTICE
Innovations from practices

throughout around England that
release time and improve care.
GENERAL PRACTICE
Innovations from practices

throughout around England that
release time and improve care.
Broader skillmix
FUTURE CARE
At scale
Emergency
care
Self Self
Care management /
social
prescribing Collaboration
with specialists
GENERAL PRACTICE
FORWARD VIEW
Online Consultations: Making it work

Main room
in practice. Dr Minal Bakhai
Document Management: Maximising

Immediate and longer term benefits. Outlook room
Paul Deffley.
Clinical Pharmacists: Making the

Survey room
most of having one. Evelyne Beech.
@robertvarnam
GENERAL PRACTICE
FORWARD VIEW
Getting everyone on board. Creating a

View room
shared purpose for change. Angie Parks.
Setting up for successful change. Using

Survey room
every driver in the Change Model. Jo Godman.
Creating a plan that makes sense and Outlook

works. Using driver diagrams. Jayne Beasley. room
Implementing change in rapid cycles. The

Main room
benefits and the practicalities. Sue Collis.
@robertvarnam

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GENERAL PRACTICE

The future of primary care

Holistic Dealing with the patient as a

Accessible Personal care built on “Primary” …

Community focussed Responsible for

Central Coordinating and connecting

Holistic Current constraints:

Accessible Practices are set up to provide mostly

✓ Personal focus ✓ Population focus

 Testing new ideas

Online consultation systems

Online consultation systems

Better service for patients

Online consultation systems

Online consultation systems

£45 million over three years

Online consultation systems

Support for planning and

Wide range of answers from different practices

Yes Not many

Look beyond the headlines …

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Wide range of answers from different practices

Yes Not many

But you knew that already …

Having it confers no benefit

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

More efficient use of GP time

More effective consultations

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

History of tension type headache,

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Signpost to self help

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Message back to patient

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Chronic tension type headache,

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

This headache is killing me and no one’s doing anything. I was meant to

Anxiety, depression and

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Do patients use it?

Yes … if they know about it and are encouraged by staff

Potential shift to ‘click first’ for patients:

Use crosses the generations:

Potential shift to ‘click first’ for patients

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

Indemnity providers’ view

bit.ly/gpfvonlineconsultations @robertvarnam #GPforwardview

FORWARD VIEW 10 High Impact Actions to release time for care

Innovations from around England

FORWARD VIEW 10 High Impact Actions to release time for care

Innovations from practices

FORWARD VIEW 10 High Impact Actions to release time for care

Innovations from practices

Online Consultations: Making it work

Document Management: Maximising

Clinical Pharmacists: Making the

Getting everyone on board. Creating a

Setting up for successful change. Using

Creating a plan that makes sense and Outlook

Implementing change in rapid cycles. The