1. www.england.nhs.uk @robertvarnam The future of general practice Dr Robert Varnam Head of general practice development @robertvarnam Worcester 14 Oct 15

2. It’s 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 it’s a big but – just doing more of the same is simply not going to cut it any longer. Not just more of the same

3. Health & wellbeing-promoting care ‘Right access’Consistently high quality Holistic, personalised, proactive, coordinated care Comprehensive, joined-up care for a registered population, shaped around them in the community bit.ly/nhs5yfv ‘Wider primary care, at scale’

4. Phone first. Community diagnostics. Practice based paramedics. Pharmacy first. Web consultations. Primary care led urgent care centre. Minor injury service. Physio first

5. Direct specialist advice. Condition management training. Shared records. Care coordination. Hospital in-reach. Care home ward rounds. Virtual ward. Primary care-employed specialists.

6. Social prescribing. Travelling health pods. Peer-led walking groups Health coaching. Befrienders. Schools outreach. Community development.

7. 1. What kind of care? (video) 2. What kind of work? 3. What kind of organisation?

8. www.england.nhs.uk @robertvarnam Delivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Step change in partnership working acute & specialist community services voluntary & community sector public health housing education

9. www.england.nhs.uk @robertvarnam The creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Highly capable infrastructure & leaders Transformational system leadership Engaging, inspiring & supporting the team Service redesign, innovation & improvement Ops management, HR, etc Business intelligence

10. www.england.nhs.uk @robertvarnam All of the above requires primary care to operate at larger scale. This may provide economies of scale which will sustain providers through the current workload challenges. More fundamentally, working at- scale is necessary to generate the kind of critical mass required for working in greater partnership as a credible system partner in the local health and care system. In operational terms, it allows financial and staff headroom to be created, making service improvement easier, and it increases the attractiveness of primary care as an employer for staff from other parts of the health and care system. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected At-scale organisational form Attractive system partner Sustainable platform for expanded services Intrinsic headroom Credible NHS employer

11. www.england.nhs.uk @robertvarnam In the course of the transition to being more corporate entities, it will be important for primary care providers to include measures to preserve and even enhance aspects of the status quo which are essential to the value of primary care. The role of primary care at the heart of the local community, and connected with people and their families throughout their life, is a valuable aspect of its ability to contribute to wellbeing and population health. Similarly, the personal continuity of care provided in general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally, the small scale nature of traditional practices creates a level of personal commitment and discretionary effort which the NHS can ill afford to lose. It should be noted that all three of these potential benefits of the traditional ‘cottage industry’ model of primary care organisations are already waning in England. Patients at larger GP practices already report lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement of many salaried GPs. Providers will need to ensure there are specific measures in place to ensure that the personal touch is not only preserved but enhanced. This is likely to have implications for ownership models, organisational culture, structures and processes, as well as the design of teams and clinical care models. At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill. 3. What kind of organisation? Bigger Personal Capable Connected Deliberate design to stay personal Lifelong family care Integral part of the community Personal LTC & EOL care Sense of commitment & ownership for all staff

12. www.england.nhs.uk @robertvarnam 2. Create shared purpose (video) A sense of shared identity sufficiently strong to allow collaboration that crosses boundaries of organisational sovereignty. We share ideas, data, resources We will adopt a standard approach We can call on each other A purpose beyond ourselves, orienting us around the needs of our patients. Commitment to us and our purpose sufficiently strong to make compliance unnecessary