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

2. 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

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

4. 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 %
Holistic care - 51%

5. 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%

6. 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.

7. 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

8. Access and opening hours

9. 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

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

11. 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

12. 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

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

14. 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%)

15. 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%

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. “Soft” MCP model

26. Directed MCP model

27. MCP with large scale provider network
20 November, 2018

28. 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

29. PCAS – dominated by FT

30. Collaborative Care Provider Organisation

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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