© Nuffield Trust 30 June 2016

New Models of General Practice:

Practical and policy lessons

Rebecca Rosen Stephanie Kumpunen

Senior Clinical Fellow Fellow in Health Policy

Nuffield Trust Nuffield Trust

Project Team: Natasha Curry, Alisha Davies, Lucia Kossarova, Luisa

Pettigrew, Claire Currie, Holly Holder, Sandeepa Arora, Ruth Thorlby

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Overview

Drivers of collaboration and larger scale

Research aims and methods

National survey findings

Case study findings

Practical tips for sustainability

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Drivers of collaboration and larger scale

Push facto

rs

Pull

facto

rs

Reduced funding

Rising patient

demand Rising

administrative

demands

Workforce

shortages

New funding for

large scale GP

providers (e.g. GP

Access Fund)

New contracts for

extended services

CCG prime and

alliance contracts

Potential funding

for large scale GP

providers through

STPs

Policy on

extended and

seven day access

Threat from

alternative GP

contracts

Alternative GP

contracts

Large scale general

practice organisation Reduced funding

Rising patient demand

Rising administrative

demands

Workforce shortages

New funding for large

scale GP providers

(eg GP Access Fund)

New contracts for

extended services

CCG prime and

alliance contracts

Potential funding for

large scale GP

providers via STPs

Policy on extended

and seven day access

Local history and context:

- GP Fundholding

- Practice-based commissioning

- Delivering community services

Threat from

alternative GP

contracts

Alternative GP

contracts

Historic

relationship

between

GPs

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Research aims and methods

Aims

• Understand landscape

• Explore evolution and impacts of mature providers on staff and patients

• Determine whether changes in quality are measurable

Methods

• Surveys for commissioners and providers (with RCGP)

• In-depth analysis of case studies (interviews, documents analysis, staff satisfaction surveys)

• Analysis of trends in 15 national quality indicators

© Nuffield Trust and Royal College of General Practitioners

Findings: Collaboration is widespread

Data from GP survey

73% reported being part of large scale collaboration

44% formed in 2014/15

84% operate within single CCG

64% said they were a federated group of independent practices

© Nuffield Trust and Royal College of General Practitioners

Findings: GPs’ motivations for collaboration

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0−12 months (n=151 collaborations)*

13−24 months (n=100 collaborations)*

25+ months

(n=97 collaborations)*

• Developed

organisational

strategy

Within core services

• Invested in staff

training and

development

Beyond core services

• Extended

the range of services

available in primary

care settings

Activities reported here if cited by at least one-quarter of respondents in each maturity grouping

Findings: Key achievements

*We asked GP respondents to list all of the collaborations their practice is involved in. Most reported one collaboration (i.e. their main organisation), but some

reported up to five collaborations. This table reports the results of their main collaboration, of which there were 355, but only 348 provided the length of maturity.

Data from GP survey

Within core services

• Pooled human resources

• Developed back-office functions/processes

• Carried out peer review

• Invested in staff training and development

• Developed new ways for patients to access services

• Introduced more flexible opening hours

• Collectively invested in IT

Beyond core services

• Extended the range of services available in primary care

• Aligned clinical pathways

• Introduced new clinics

• Brought in new workforce from community and social care

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GP Care Ltd

Case studies: four archetypes of large scale general practice

Harness GP

Cooperative Ltd

Modality

Partnership LLP

AT Medics Ltd

• Four contrasting sites

• Archetypes of different organisation types

• Members of the Nuffield Trust GP Learning Network

• All mature organisations (oldest formed 12 years ago)

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Findings: Three overarching aspirations

Sustaining the delivery of core general practice

Delivering extended services in community settings

Leading whole system change through new

models of care

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Findings: Five key findings relating to sustainability

Efficiency and income

Governance

arrangements

Leadership and models

of change

Technology

Workforce initiatives

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Findings: Efficiency and income

Centralised management and admin • Registration and document processing

• Call and recall

• Processing referrals

• Data audits and performance review

Standardised organisational processes • Enhanced access through phone apps

(Modality)

• Claims management

• Standardised coding across practices

Income maximisation • QOF, enhanced & other incentivised

• Local commissioning schemes

• Medical education/GP training

Outreach support • Central office staff and resources allocated

to practices to help sort out problems

• Infrastructure from extended services also

helps with delivering core activities

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Findings: Technology

Numerous uses of technology

• Web based teaching across sites (eg AT medics)

• Intranet for regular communication

• Instant messaging for instant support across sites

• Technology enabled registration, information and access

for patients

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Findings: Workforce initiatives

Role flexibility within and across sites

• Reception and admin staff covering sickness/absences in other sites

• Staff employed centrally and deployed across practices (eg Harness nurses

providing clinics and supporting QOF and immunisations in different practices)

Skills development for extended and new roles

• Special clinical interests in doctors (and a few nurses)

• Extended HCA roles (eg phlebotomy)

• Career development opportunities

Role enhancement

• Peer learning networks and support across practices

• Rapid access to advice +/- resources

• Reduced isolation

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Findings: Workforce survey

8th GP Worklife Survey: 1 completely dissatisfied, 7 completely satisfied

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Findings: Governance arrangements

No ‘off the shelf’ blueprint

• Unlike legal form, no ready-made governance plans

• Shaped in response to (short & medium term) goals and values

• Varied accountability between board, execs and practices

Relationships with member practices

• Variation in extent to which executive team were able to ‘direct’

the day to day work of member practices

• Conversely in how much decision making authority and

professional autonomy remained with each practice

Board role to ensure necessary skills and resources available

• Operations, quality assurance, bidding, strategy

• Funds for technology , bidding, equipment etc

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Findings: Leadership

Visible leaders, present in practices

• Participating in education and training

• Modelling standards and values

• Spotting operational and quality problems incl. those to be

addressed by central teams

Regular contact with front line staff

• Builds trust and commitment

But…a lot of heroic leadership

• Long hours

• Stepping at short notice to fill gaps in clinical sessions/

address operational problems

• Part of the role, but how sustainable?

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Findings: Patient perspectives

Patient perspectives

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Findings: Patient perspectives

Patient involvement

• PPG interviewees mainly identified with their own practice

• None had been involved in initial decisions about linking practices

• Two had attended ‘central’ PPG meeting but were more interested in

influencing their own practice

Access

• Two had used shared/hub services and were positive about them

Patient priorities

• Main concern was about losing their ongoing relationship with their own

practice and their GP

• No evidence to date that this had happened, but need to involve

patients in ongoing service redesign to ensure concerns are addressed

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Practical tips: Larger scale can sustain core services

• Main opportunities relate to operational efficiencies, developing a sustainable

workforce and possibly also investment in technology, but to achieve this you must:

• Take the time to agree goals and values.

• Develop the simplest possible governance arrangements to deliver agreed

goals and be prepared for the these to evolve over time.

• Ensure appropriate resources are available to fulfil goals.

• Engage with patients along the way and work hard to combine the potential

benefits of scale with ongoing relationships with patients.

• Nothing will fall into your lap. It takes sustained hard work.

• Don’t leave it all to heroic leaders. You all need to play a part.

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www.nuffieldtrust.org.uk

rebecca.rosen@nuffieldtrust.org.uk stephanie.kumpunen@nuffieldtrust.org.uk

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