1. 1. www.england.nhs.uk @robertvarnam #PMChallengeFund Delivering right access Dr Robert Varnam Head of general practice development robert.varnam@nhs.net @robertvarnam Sheffield PMCF 25 June 2015 bit.ly/20150625access
2. 2. www.england.nhs.uk @robertvarnam #PMChallengeFund 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.
3. 3. www.england.nhs.uk @robertvarnam #PMChallengeFund Hows it feeling? Figure 1 Proportion of patients reporting positive experiences of primary care services, England 2011-12 to 2013-14 11% of requests for an appointment are unmet 10% of those divert to A&E/WIC, 3% see a pharmacist instead, 12% get no care An estimated 2-5% of A&E attenders have not tried to obtain GP care
4. 4. www.england.nhs.uk @robertvarnam #PMChallengeFund 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 its 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. Hows it feeling? We DO care but its too hard to right now to deliver our potential
5. 5. www.england.nhs.uk @robertvarnam #PMChallengeFund In my work over the past few years, Ive encountered some persistent myths about general practice and change. They run quite deep and hold back a lot of potential. They dont just affect policymakers or politicians, either theyre often things primary care leaders believe themselves. The Challenge Fund is a great opportunity to achieve lasting transformational change in your area. But, to make the most of that, youre going to have to be confident in challenging five key myths. @robertvarnam #PMChallengeFund Myth-busting
6. 6. www.england.nhs.uk @robertvarnam #PMChallengeFund Myth One
7. 7. @robertvarnam #PMChallengeFund Myth 1: general practice is finished. Or, at least, not far off. There are some who talk as though general practice is finished, or as near as makes no difference. Sometimes, these are people within the profession, sometimes outside. When morale is low, its understandable for negative emotions to influence our assessment. But just look what happened when the government invited practices to apply for this innovation programme nearly two thirds of the country responded! And, with very exceptions, every proposal was for worthwhile change. The team here were nearly drowned by the work of processing it all. Thats not a part of the NHS thats dead, lacking in energy or in ideas. We just need to give general practice the headroom for it to fulfil the enormous potential it has. The creativity, plans and energy are already there. General practice is finished @robertvarnam #PMChallengeFund PM Challenge Fund 57 schemes 2500 practices 18m patients
8. 8. www.england.nhs.uk @robertvarnam #PMChallengeFund Myth Two
9. 9. @robertvarnam #PMChallengeFund Myth 2: Access is simple Weve been here before, launching a national programme to improve access in general practice. But Im struck by how simplistic much of the thinking has been on previous occasions. Weve treated access as though it stands alone as a feature of general practice. As though its meaningful to improve speed of making an appointment without asking who its with, or what kind of care theyre able to provide. Thats clearly nonsense, and we risk providing very poor value to individual patients and taxpayers if we dont acknowledge that access is one facet of a complex system of care. We similarly risk thinking that every patient needs the same kind of access. Just saying it like that, its clearly untrue. Yet how many times have we even you or I been involved in a change which was about moving from one monolithic, one-size-fits-all appointment system to another? In the first year of the Challenge Fund I was delighted to see that many schemes were actually aiming to deliver what Ive dubbed right access connecting the right patient with the right person, able to give the right care in the right place at the right time. And acknowledging that its right for some patients not to see the doctor, just as it is for some to have much greater confidence that they will, soon. Access is simple Right Access @robertvarnam #PMChallengeFund
10. 10. www.england.nhs.uk @robertvarnam #PMChallengeFund Myth Three
11. 11. @robertvarnam #PMChallengeFund Myth 3: if we just did this one thing Its probably human nature, but silver bullet thinking abounds in the NHS. Probably in your own team meetings. How many times, often with a sigh of frustration, does someone (maybe you) exclaim If we just did x/y/z, it would solve this? Sometimes, a single change makes a massive difference. But rarely. Every one of the innovations youre proposing is very sensible. Most have at least some evidence already. But none of them has ever been found to achieve all the improvement we need. Youre going to need several, combined. At best, silver bullet thinking will lead you disappointed and tired. At worst, itll discredit the ideas youre trying out, simply because someone allowed in the thought that just doing this one thing would achieve all your goals. Its almost never true. If we just @robertvarnam #PMChallengeFund
12. 12. Its 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 its 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. 13. @robertvarnam #PMChallengeFund Myth 3: if we just did this one thing Its probably human nature, but silver bullet thinking abounds in the NHS. Probably in your own team meetings. How many times, often with a sigh of frustration, does someone (maybe you) exclaim If we just did x/y/z, it would solve this? Sometimes, a single change makes a massive difference. But rarely. Every one of the innovations youre proposing is very sensible. Most have at least some evidence already. But none of them has ever been found to achieve all the improvement we need. Youre going to need several, combined. At best, silver bullet thinking will lead you disappointed and tired. At worst, itll discredit the ideas youre trying out, simply because someone allowed in the thought that just doing this one thing would achieve all your goals. Its almost never true. If we just @robertvarnam #PMChallengeFund
14. 14. www.england.nhs.uk @robertvarnam #PMChallengeFund Myth Four
15. 15. @robertvarnam #PMChallengeFund Myth 4: Our good ideas are all we need When youve been working on a set of ideas for what changes to make to your service, its natural to become quite attached to them. You may have had some feelings of resentment lately as people have asked you probing questions about them, through the due diligence process. The trouble is, the consistent experience of people leading large scale change is that 70% of efforts fail. Not just in the NHS, or in healthcare, but worldwide in every industry. And one of the big factors causing that depressing experience is a belief that good ideas are enough. Theyre not. Theyre obviously necessary, but Im afraid theyre not sufficient. Along with the WHAT of your change, you need the HOW. The strategies, tactics and methodologies by which you turn the good idea into a movement of people and a plan of action. If you dont skilfully lead people, if you dont use an effective improvement methodology, if you dont measure right the evidence shows you risk failing. Well do all we can this year to support you with the HOW of change. Id ask you to start by commiting to have plans which combine the how and the what, and which unleash your practices commitment by clearly articulating the WHY (well talk more about that later) Good ideas are enough WHAT HOWWHY @robertvarnam #PMChallengeFund
16. 16. www.england.nhs.uk @robertvarnam #PMChallengeFund Myth Five
17. 17. @robertvarnam #PMChallengeFund Myth 5: failure is not an option In the NHS, one can be led by a culture of regulation or performance management to fear failure or change. Even to be tempted to cover them up. Is that appropriate for innovation leaders? Do you know the significance of the number 5127? Its the number of prototypes James Dyson had to make before his first bagless vacuum cleaner worked fully. Is that 5127 failures? Of course not, its 5127 steps on the way to getting a good idea to work in the real world. Eddison once said I have not failed, I have found 10,000 ways NOT to make a lightbulb. If, at the end of this year, you tell us that every part of your initial plans was a fantastic success, I will conclude that you are either foolish, deluded or lying. Because they wont be. Everyone who has ever set out with an idea about making a service better has found that some aspects of the idea work first time, and others need to be tweaked. And some of our ideas just dont seem to work at least not in our context or with our implementation approach. Discovering that is not a failure, it is necessary. The failure would be not to anticipate it or not to spot it. If you encounter something thats not working as you expected, change it. It would be an appalling waste of public money and confidence if you didnt. Just do it with your eyes open and your brain engaged. Please dont make decisions based solely on instinct or opinion. If you suspect somethings not working right, measure it. Make a rational, evidence based assessment. And when you start finding things that need tweaking or possibly even stopping, please tell us as soon as possible. We really want to learn from your experience, including from failure. You should expect were going to ask why you think it needs changing. If we can, we may connect you with someone else whos done something similar and had a different result, to see if that helps you or we can learn more about the conditions for success. But failing to get every idea to work without any tweaking is not failure, its innovation. In fact, its life. We must not fail @robertvarnam #PMChallengeFund Learn from it!
18. 18. @robertvarnam #PMChallengeFundbit.ly/20150625access