General Practitioners Committee The Future of General Practice Richard Vautrey Deputy Chair

Essentials of General Practice Registered list Continuity of care Trust and confidentiality Holistic care Risk management Connection with the local community GP leadership Core contract for essential services

Diversity of General Practice Independent – but varying sizes – average 7233 Loosely federated Formal network Merged super-partnerships Multi-site chains

Essentials of General Practice What do GPs say are the top 3 factors essential to general practice? Continuity of care - 80% Trust and confidentiality between GP and patient - 61% Holistic care - 51%

GP pressures Factors that have a negative impact on GPs: Excessive workload -71% Unresourced work being moved into general practice - 54% Not enough time with their patients - 43% Constant contract change - 41% Excessive regulation - 39% Poor work-life balance – 27% Threat of evenings/weekend working – 25% Bureaucracy – 24% Negative press coverage – 24%

Workload pressures 93% GPs say heavy workload has negatively impacted on the quality of patient services  56% GPs working in OOH feel that at times their workload is having a detrimental effect on the care 8% GPs feel that 10 minute consultation is adequate 67% feel there should be longer consultations for patients with long term conditions 25% believe all patients need increased consultation time 68% of GPs believe that it is preferable to provide longer consultations of greater quality, even if it means waiting longer to see a GP for a routine appointment.

Impact of workload pressures 34% GPs are considering retiring in the next five years 17% GPs thinking about becoming part-time 21% GP trainees considering working abroad 68% GPs experience a significant but manageable amount of work related stress 16% GPs feel their stress is significant and unmanageable

Access and opening hours

GP Contract 73% GPs support continued GMS contract 80% principals, 61% salaried GPs 5% opposed, 22% don’t know 47% GPs support continued PMS contract 28% believe it should be an option for all 19% only for specific populations 18% opposed 35% don’t know

GP contract - APMS 5% think APMS is value for money 8% think APMS delivers good quality care 5% think APMS provides continuity of care

GP Contract 82% support the Independent Contractor Status principals 88%, salaried GPs 68% 55% GPs believe QOF should be reduced 21% want QOF kept the same 8% want QOF increased 81% GPs believe QOF funding should be transferred to global sum 17% GPs believe QOF funding should be used for local schemes

Premises 62% GPs support model of GP ownership 56% GPs would like to own their own surgery 28% GPs would like to work in 3rd party owned surgery 74% GPs want to work in premises alongside community staff 75% GPs want to work in premises with access to diagnostics and community based services

Technology 86% support use of telephone consultations 63% believe telephone consultations help manage demand 71% worried that email consultations will increase workload 63% worried about clinical limitations of email 56% worried video consultations will increase workload 50% worried about clinical limitations of video consultations

Essentials of General Practice What could help GPs better deliver the essential components of general practice: Increased core general practice funding (76%) Increased the number of GPs (74%) Longer consultation times (70%) Reduction in bureaucracy (64%)

GP recruitment What makes General Practice attractive? Being a generalist - 80% Continuity of care – 76% No night or weekend work unless I choose – 57% Job security – 33% Good work-life balance – 29% Flexibility for portfolio career – 26% Independence – 20% Opportunity to be a GPSI – 20% GP pay – 17%

New models of care 37% GPs in networks 52% believe GPs should work in networks in collaboration with other health professionals 12% believe networks should run secondary care 11% believe GPs should lead a single organisation delivering all primary and secondary care services 1% believe hospitals should a lead single organisation delivering all primary and secondary care services

Why Networks? Peer support/review Shared learning Providing strong single voice for GPs Shared policies Shared staff Shared service provision Bidding for and running community services Running struggling practices

Networks – legal structures Goals and ambition should determine legal structure Community Interest Company (not-for-profit) Company limited by shares Super-partnerships Need clear governance and financial arrangements – take advice

Network plans – questions to answer How ambitious are the members of the GP network? What are the strengths - and weaknesses - of the constituent practices? What facilities and resources will be available to the GP network? What is the profile of the local patient population? What health services are commissioners likely to be procuring in the future? How will running costs be covered? 20 November, 2018

NHS Five Year Forward View The NHS Five Year Forward View was published on 23 October 2014 It is a shared vision for the future of the NHS across six national NHS bodies The challenge is now implementation; we know: It will not be easy We need to learn from the past We’re going to need a different approach We’re up for it 20

Radical upgrade in prevention Efficiency & investment The future NHS The core argument made in the Forward View centres around three ‘gaps’: Back national action on major health risks Targeted prevention initiatives e.g. diabetes Much greater patient control Harnessing the ‘renewable energy’ of communities Health & wellbeing gap Radical upgrade in prevention 1 Care & quality gap New models of care Neither ‘one size fits all’, nor ‘thousand flowers’ A menu of care models for local areas to consider Investment and flexibilities to support implementation of new care models 2 Implementation of these care models and other actions could deliver significant efficiency gains However, there remains an additional funding requirement for the next government And the need for upfront, pump-priming investment Funding gap Efficiency & investment 3

New Models of Care Initially the new models of care programme will focus on: Blending primary care and specialist services in one organisation Multidisciplinary teams providing services in the community Identifying the patients who will benefit most, across a population of at least 30,000 Multispecialty Community Providers Integrated primary, hospital and mental health services working as a single integrated network or organisation Sharing the risk for the health of a defined population Flexible use of workforce and wider community assets Integrated primary and acute care systems Coordinated care for patients with long-term conditions Targeting specific areas of interest, such as elective surgery Considering new organisational forms and joint ventures New approaches to smaller viable hospitals Multi-agency support for people in care homes and to help people stay at home Using new technologies and telemedicine for specialist input Support for patients to die in their place of choice Enhanced health in care homes

Vanguard Sites 269 applications 29 selected 9 PCAS 14 MCP 6 care home provision

Multispecialty Community Providers What they are How they could work Greater scale and scope of services that dissolve traditional boundaries between primary and secondary care Targeted services for registered patients with complex ongoing needs (e.g. the frail elderly or those with chronic conditions) Expanded primary care leadership and new ways of offering care Making the most of digital technologies, new skills and roles Greater convenience for patients Larger GP practices could bring in a wider range of skills – including hospital consultants, nurses and therapists, employed or as partners Shifting outpatient consultations and ambulatory care out of hospital Potential to own or run local community hospitals Delegated capitated budgets – including for health and social care By addressing the barriers to change, enabling access to funding and maximising use of technology

“Soft” MCP model

Directed MCP model

MCP with large scale provider network 20 November, 2018

Primary and Acute Care Systems What they are How they could work A new way of ‘vertically’ integrating services Single organisations providing NHS list-based GP and hospital services, together with mental health and community care services In certain circumstances, an opportunity for hospitals to open their own GP surgeries with registered lists Could be combined with ‘horizontal’ integration of social and care Increased flexibility for Foundation Trusts to utilise their surpluses and investment to kick-start the expansion of primary care Contractual changes to enable hospitals to provide primary care services in some circumstances At their most radical they could take accountability for all health needs for a register list – similar to Accountable Care Organisations

PCAS – dominated by FT

Collaborative Care Provider Organisation

Patient priorities Top three priorities across life stages: Appointment within short period Enough time in consultation GP knowing medical history Seeing same GP each time seen as ideal but willing to see regular team as compromise Some differences between groups: Younger patients favour convenience over continuity, vice versa for older patients Patients with young children & LTCs most distinct groups Having a modern building, appointments at weekends least important priorities

GP Models 5 GP models tested with patients: Small GP-run practice with 2 GPs Large GP-run practice with 10 GPs Regional multi-site model with 60 GPs Practice based within hospital setting Large practice run by commercial company Large GP run practice consistently most popular Small GP-run practice seen as unrealistic given current pressures Network model seen as compromise between large and multi- site practice

Self-Care Participants recognised misuse of services as valid problem As a result participants agreed on need to promote greater use of self-care Felt appropriate that message to come from GPs or DH / NHS England

Conservative Government priorities “7 day a week access to your GP and deliver a truly 7-day NHS” Same day appointment for everyone over 75 5000 more GPs by 2020 Improve transparency with access to information Committed to Five Year Forward View and extra £8bn Continue to pursue integration of health and social care

Risks and challenges Competition or collaboration Service provision within locality and/or outside Domination by one group over another Accountable Care Organisations Merged budgets Single provider or lead provider with sub-contracts Time limited contracts Impact of efficiency savings

Future of General Practice Retain essentials of general practice Core and separate general practice contract Independent contractor status Optimum size of practice connected with community Working together to be “both big and small” Building teams around the practice Collaborative clinically led community service provision

What’s needed to secure the future of General Practice Sustained and significant funding investment More GPs, nurses and support staff Good quality practice management Longer consultation times Investment in urgent before routine care OOH Building teams around the practice Investment for working at scale Premises development Promotion of General Practice Culture change in NHS