{"id":39318,"date":"2017-06-06T12:53:12","date_gmt":"2017-06-06T11:53:12","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=39318"},"modified":"2017-06-19T12:21:24","modified_gmt":"2017-06-19T11:21:24","slug":"richard-smith-where-general-practice-is-flourishing","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2017\/06\/06\/richard-smith-where-general-practice-is-flourishing\/","title":{"rendered":"Richard Smith: Where general practice is flourishing"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>We hear a constant chorus that general practice is underfunded, understaffed, and on the point of collapse, so I couldn\u2019t resist the temptation to visit a practice that is flourishing and has a bold vision for the future.<\/p>\n

Granta Medical Practices in Cambridgeshire currently serve 34 000 patients in four buildings. Soon they expect to add a fourth practice, bringing them to around 45 000 patients, which James Morrow, the managing partner of the practice, regards as optimal: \u201cYou then have about 150 staff, which is enough for everybody to know everybody. Management theorists think this an optimal number for an organisation or a unit within an organisation. Everybody knowing everybody and caring about them is central to how we work. People like working here. Patients give us positive feedback. We centre everything on patients\u2019 needs and wants. The CQC [Care Quality Commission] has rated us outstanding. We have a waiting list of doctors who want to come and work here. But, of course, things are not all perfect. We are in the process of changing from a small traditional practice to a larger organisation with big ambitions. We recognise too that there are many forces undermining general practice, some of them self-inflicted [see box]. The NHS will collapse if we can\u2019t revive primary care.\u201d<\/p>\n

Development of the practice<\/strong><\/p>\n

Fifteen years ago the practice was a traditional one with six partners in Sawston, eight miles from Cambridge. The population includes both masters of Cambridge colleges and a deprived population left over from industries that have closed. The partners realised that their building was not fit for purpose and set about getting a bigger building. A private medical facility company paid for and owns the building, but the partners were able to hire the architects and oversee the design. Importantly, they were able to complete a building that was larger than they needed at the time\u2014one fit for the future.<\/p>\n

The two storey building is a green one with geothermal heating, solar panels on the roof, and generous curved spaces inside. It was supposedly inspired by Frank Lloyd Wright\u2019s prairie style to fit in with the flatness of the Fens, but that link was lost on me. The practices share the building with staff from Cambridgeshire and Peterborough NHS Foundation Trust\u2014staff who may soon be joining the practices.<\/p>\n

Once they had the building the partners decided that they needed to develop a vision for the future. Morrow had recently joined the practice, and he was asked to write a paper on the future. Trained at Cambridge and Oxford, he\u2019d been a GP in Marlow, Buckinghamshire, for 12 years before following his wife, a surgeon, to Cambridge when she got a job at Addenbrooke\u2019s. By chance rather than design he\u2019d become a member of the 21st<\/sup> Century Trust and attended a week long meeting in Rostock, Germany, on preparing for an aging population. \u201cThat week,\u201d he says, \u201cwas the single most exciting, challenging, and inspiring week in my education.\u201d (I spoke at the meeting, but neither he nor I could remember what I said.)<\/p>\n

Morrow combined his paper with some scenario planning for the partners, and they decided that there were three possible futures for general practice: become a niche practice (in a remote area or serving a distinct population like the homeless); get bigger; or get out. They opted for getting bigger.<\/p>\n

They also decided at that meeting that they would need to appoint an experienced manager, somebody from outside healthcare with more experience and skills than the traditional practice manager. Eight years ago they appointed Gerard Newnham, who has an MBA and is responsible not only for managing the practice but also for helping develop the future.<\/p>\n

Crucially, the larger practice has been formed not from failing practices being swallowed up, but by three practices (and soon a fourth) with similar values and aspirations coming together. They have merged finances, lists, contracts, systems, and buildings. The merger is irreversible, and patients can attend any of the now four buildings.<\/p>\n

Inevitably, the mergers have meant lots of expenditure on lawyers and accountants, and the partners have met these costs themselves\u2014perhaps \u00a340 000 to \u00a350 000 in total.<\/p>\n

Managing the practice<\/strong><\/p>\n

The practices have 16 partners, and I was interested in how you can manage practices with 16 decision makers: doesn\u2019t that make for lower common denominator thinking, going at the speed of the slowest? In fact, the practices work rather like a company. The 16 partners form what might be described as a board, and the practice is managed by a team that until a month ago comprised five partners and three managers, Newnham plus managers of human resources and information technology. But now the team has split into two: one managing operations headed by Fiona Clark, one of the partners; and the other managing business development headed by Morrow.<\/p>\n

The partners recognise the dangers of going at the speed of the slowest and accept that not everybody will agree with every decision. Some would like to go faster, some would like to slow down. Yet they rarely if ever have to resort to a vote. Once a decision is made the partners act like the Cabinet and support the decision within the organisation and outside. Inevitably, this can cause discomfort: although something familiar to politicians, it can feel like dishonesty to GPs. The reality may be that it\u2019s hard to run a larger organisation with multiple partners, which is why the practice is exploring a different model of ownership (see below).<\/p>\n

Organising services<\/strong><\/p>\n

The difficulty of getting appointments with GPs is one of the nation\u2019s worries, but the Granta practices have gone some way to solving the problem. Through listening to the patients both informally and formally through their patients group, the team understood that many patients were willing to accept seeing any GP so long as they could see a GP when they wanted to. Indeed, suggests Morrow, continuity of care may be more valued by GPs than patients; and I couldn\u2019t help thinking that it\u2019s simply unobtainable in many parts of the country.<\/p>\n

So the practices have introduced a system that any patient with an urgent problem can be seen that day. They can ring at any time and will be seen that day between the contracted hours of 8am to 6pm. \u201cWhat if they ring at 5.30?\u201d I asked. \u201cIf they can get to a surgery by 5.50 we\u2019ll see them,\u201d answered Morrow. One GP and one advance nurse practitioner at each site provide this service, but there is flexibility\u2014the team can be increased if necessary. I visited on the day before Good Friday, and the practices expected to have five clinicians in their rapid access clinic at each site on the day after the Easter holidays.<\/p>\n

Almost half of patients (46%) are seen on the day they make an appointment, and it\u2019s unlikely that such a high proportion really needs to be seen that day. Morrow is aware of supply induced demand, and they do have a telephone triage service: people are usually rung back by a doctor within 20 minutes. \u201cBut,\u201d says Morrow, \u201cbeing patient centred means responding to what patients want.\u201d<\/p>\n

The practices also regard punctuality as essential for being patient centred. They discussed with patients when a wait becomes unacceptably long\u2014and the patients said after 15 minutes. The practices record data on wait times\u2014and currently it\u2019s about 4.6 minutes. \u201cMaking people wait,\u201d says Morrow, \u201cis just a way of saying I\u2019m more important than you.\u201d A knock-on effect of seeing patients quickly is that the car park is less likely to be full, and the main complaint of patients to the CQC was problems parking. (Ironically, the practice has space for 90 cars and is perhaps the largest car park I\u2019ve ever seen for a general practice.)<\/p>\n

As an aside, parking can be seen as a measure of just how patient centred an organisation is. Staff often take up most of the spaces around hospitals and practices, whereas a supermarket would never tolerate staff filling up the car park and customers having to walk long distances to shop. The Granta practices have no spaces reserved for staff, but they were not successful in trying to persuade staff to park outside in the road.<\/p>\n

Patients can book to see particular doctors and can do so up to six weeks in advance\u2014online if they want. The practices also employ two paramedics who do visits. \u201cTraditionally, GPs do (or did) home visits after morning surgery,\u201d says Morrow, \u201cwhich meant that if a patient has to go to hospital for tests they are likely to end up having to stay overnight. But if they are seen early in the morning they can get to the hospital and back home. And the paramedics love the work.\u201d This system has freed up the time of doctors.<\/p>\n

The practices have also redesigned the care of patients with long term conditions. They abandoned clinics for people with particular diseases and instead do a paper review of every patient with any long term condition once a year. If there is nothing new the patient is simply notified. If there is uncertainty, healthcare assistants see the patients first and arrange any necessary tests; the patients are then seen in a clinic. The clinicians then write to the patients or if necessary arrange further tests and visits.<\/p>\n

Raising clinical standards<\/strong><\/p>\n

The partners have appointed two doctors to maintain and improve clinical standards. The practices gather extensive data on performance, and the doctors responsible for improvement will work with clinicians whose practice seems to be outlying or struggling.<\/p>\n

Staff<\/strong><\/p>\n

The practices have 16 partners, all of whom are GPs, seven salaried GPs, two GP registrars, seven advanced nurse practitioners, 15 nurses, nine healthcare assistants, two paramedics, and 44 non-clinical staff. The advanced nurse practitioners see patients just like the GPs. I asked if the practices had a policy on the ratio of partners to salaried GPs and was told that the model of ownership is about to change (see below).<\/p>\n

I asked too about specialists. The practices have a visiting geriatrician for one session a week and are discussing organising ophthalmology and ear, nose, and throat services. I asked about specialists coming from Addenbrooke\u2019s, and so far the hospital is only interested in renting rooms rather than having consultants join the team.<\/p>\n

Vision for the future<\/strong><\/p>\n

\u201cWe have another 20 years to go in our story,\u201d said Newnham. One step will be formally to become a primary care home, an idea promoted by the National Association of Primary Care<\/a>. James Kingsland, the president, has spoken at the practices. The association defines the key features of the primary care home thus;<\/p>\n

\u2022 Provision of care to a defined, registered population of between 30 000 and 50 000<\/p>\n

\u2022 Aligned clinical financial drivers through a unified, capitated budget with appropriate shared risks and rewards<\/p>\n

\u2022 An integrated workforce, with a strong focus on partnerships spanning primary, secondary, and social care<\/p>\n

\u2022 A combined focus on personalisation of care with improvements in population health outcomes<\/p>\n

\u201cWe already are a primary care home,\u201d says Morrow, \u201cbut we want to become one formally.\u201d<\/p>\n

The practices are also keen to implement the Buurtzorg model of care<\/a> developed in the Netherlands.\u00a0[The link is to Buurtzorg USA, as the website has the benefit of being in English.] In this model nurses take charge of a neighbourhood and are responsible for all care, bringing in doctors and other health and social care workers as needed. The aim is to centre the service around patients and their needs and values, empower the patients, and keep patients in their own homes, reducing the need for care in hospitals and nursing homes. The model began in the Netherlands in 2006 and has now spread to Sweden, Japan, and the United States. In the Netherlands the model has been reported to make substantial savings while improving care.<\/p>\n

Changing the model of ownership<\/strong><\/p>\n

As I\u2019ve said, the staff from the Cambridgeshire and Peterborough NHS Foundation Trust may soon join the practices. This means that the practices will be managing district nurses and therapists, including physiotherapists, occupational therapists, and speech therapists. (Social workers, who are employed by Cambridgeshire County Council, will remain separate, and Morrow said that integration with social care is currently \u201cnot brilliant.\u201d This is another area where the practices want to develop services for their patients and talks are underway with the Council about aligning more fully.)<\/p>\n

Initially, the community staff will continue to be paid by the NHS Trust, but the longer term aim is for them to be employed by the practices. \u201cBut this can\u2019t happen with the present partnership model,\u201d explained Newnham, \u201cthe risk to the partners would be too large. Partners have unlimited liability.\u201d So the practices are looking at other models, and the preferred model is a \u201cJohn Lewis type model,\u201d where all the staff own the organisation and are paid a salary plus an annual bonus based on the profits (or whatever anodyne word you prefer). People have talked about the whole NHS adopting this model.<\/p>\n

The practices will work with the Judge Business School (Cambridge University\u2019s business school), lawyers, and accountants to try and develop the right model. One problem is that only a GP partner can hold a General Medical Services contract with the NHS, but there should be ways around the problem.<\/p>\n

Zombie practices<\/strong><\/p>\n

\u201cAbout 20% of the general practices in Cambridgeshire are zombie practices,\u201d says Morrow. A zombie practice is one where the salaried GPs earn more than the partners. Such practices are not sustainable. \u201cImagine,\u201d says Morrow, \u201cthat you\u2019re one of four partners in a zombie practice. You don\u2019t want to be the last one standing who has to pick up all the redundancy costs. There\u2019s a big incentive to get out, worsening the circumstances for the partners who remain.\u201d<\/p>\n

I asked if the Granta practices have a role with zombie practices. \u201cOur model is based on practices with a similar vision wanting to come together. Crunching together or taking over drowning practices doesn\u2019t work well.\u201d<\/p>\n

The NHS and national bodies<\/strong><\/p>\n

One of the strong impressions I was left with after my visit was of an island of excellence and innovation surrounded by a struggling system.<\/p>\n

Relations with the clinical commissioning group (CCG) have not always been good, but have markedly improved with the current executive team. The Granta practices have so far been somewhat isolationist, building their own future but without much regard for the CCG or NHS England. \u201cBut that has to change,\u201d says Morrow, \u201cWe can\u2019t achieve all the change we want to achieve without the support of the CCG and NHS England. We\u2019ve been rather remote and self-reliant, but now we are working hard to build and improve relationships.\u201d<\/p>\n

Morrow\u2019s wife works at Addenbrooke\u2019s, and he\u2019s met with the new chief executive, who is interested to try and work together. Things are progressing well, but Addenbrooke\u2019s has a structural problem: the local population needs a district general hospital, while Cambridge University needs a hospital at the forefront of science. The result is an unwieldy organisation with a structural deficit of \u00a380 million.<\/p>\n

The Granta practices want to be sure that their patients can get access to high quality, affordable secondary care. A population base of 50 000 allows for some services traditionally delivered in hospitals to be delivered locally, and the practices are trying to make that happen, including consultants not from Addenbrooke\u2019s. But they are also talking to other practices that are coming together in larger groups with the idea of being able to provide still more services.<\/p>\n

Sustainability and Transformation Plans (STPs) are the NHS\u2019s mechanism for trying to reshape services, but Morrow has little confidence in the local STP delivering for primary care. He thinks that the NHS at the centre is preoccupied with hospitals and has little understanding of how general practice works. He also thinks that if general practices were able to buy and sell goodwill, which they cannot at the moment, then that could lead to more rapid development in general practice.<\/p>\n

Morrow belongs to neither the BMA nor the Royal College of General Practitioners. Both, he thinks, lack vision, have no other strategy apart from asking for more money to preserve the status quo, and play to the lower common denominator.<\/p>\n

But aren\u2019t the Granta practices being selfish by developing services for their patients and ignoring others? We discussed this several times, and their view is that it\u2019s hard enough to develop services for 50 000 people and that if they worked as well at trying to develop services for the whole area they\u2019d probably get bogged down and fail. \u201cIt\u2019s better for us,\u201d said Newnham, \u201cto develop a model of what might be and hope that it can be an example to others.\u201d<\/p>\n\n\n\n
Box: The forces undermining general practice, according to James Morrow<\/p>\n