General Practice in 2019: What is the scale of your challenge?

Dr Vish Ratnasuriya shares some advice for General Practice in 2019

As we enter the festive season, it often brings the opportunity to step back and reflect on the year gone by, and think about our priorities for the year coming. I’ve been asked to share my thoughts, as perhaps a rare GP that inhabits the multiple layers that General Practice is soon expected to operating within.*

Let me start by acknowledging that life is General Practice is hard, and getting harder all the time. Winter Pressures, the flu season, the holidays; workload, workforce, funding, I think we can all define the issues.

Despite what can often feel like a sustained barrage, my first piece of advice is carve out some headspace to think about your future. 2019 is likely to be a year like no other for General Practice. Nigel Watson’s Department of Health GP partnership review will be announced, there is a premises review, and the biggest GMS contract review since 2004.

However to me most important is that General Practice will be redefined as a profession by the advent of primary care networks (PCNs) which will form a jigsaw puzzle of General Practice wholesale and without gaps across England. So it will be the next focus of NHS planning that intimately affects us and significantly funding for us, when the NHS long term plan is finally announced.

To me PCNs should firstly be networks of GP surgeries who will increasingly work more closely together, breaking down barriers between themselves and increasing providing services together to create collective resilience. Once this fragile skeleton of a PCN has been achieved, it is only then that you should look to flesh it out by integrate more closely with other services within health, social care, and the community. Whilst are important and may be the right thing to do for you patient, your practice, or your local health system, I believe you need to first release capacity for change to do them sustainably. So my second piece of advice is to work towards PCNs focussing on General Practice first when the funding comes, no matter what the system may suggest.

My final piece of advice is tailored to your situation below.

The struggling practice. You are likely here through no fault of your own, but rather the wicked issues that surround the profession. You plough on day-by-day for your patients, but my advice to you is to pause. Step back and look not only within, but outside your practice. You are linked the the success or failure of your neighbours, so embrace the headspace PCN funding should bring to create a workforce plan across your network. Embrace skill mix, new roles, and non-traditional but increasingly evidence-based ways to operate your business

The resilient practice. You identified your aging cohort of GPs and nurses, planning and now have ANPs and paramedics and have you eye on nursing associates and physicians assistants. You are proud of how you have streamlines processes both behind the scenes in managing clinical letters, and front of house by creating a digital front door. You now need to think beyond your practice. You are inextricably linked to your neighbours. If they fail, you face the pressure. What is your collective resilience link, have you planned together? Are you still duplicating services, rather than creating shared provision? If you’ve got that sorted, move to the next step below.

The Primary Care Network. Your practice is pretty resilient, and you are interested in a collaborative future around a neighbourhood. Just before you get swept away with integrating care, take a step back and check whether you can make General Practice more resilient. Are there further opportunities for breaking down the barriers between practices and sharing the load, a touch more? Whilst working with the community, and others in health and social care is rewarding, not many will have the best interests of General Practice in their mind when weighing up the competing interests of future health and care provision, so make sure you do!

The Network of networks. You are an at scale provider such as a federation, superpartnership or provder company. Unlike some you have planned for place based care. My sense is that unlike my own organisation, most will have got here with seed funding, so your challenge is sustainability. The time for one of transformation money being used for the day-to-day are gone. So your options are through multiple contracts generating revenue, but you will not have control over when and how these come. The alternative and perhaps more sensible approach is to consolidate. Look back to your networks. What are the duplicating that you can do better at scale? Can you add value in unique ways, as a body overarching should do? Creating these stronger foundations will engage your member practices, help them make sense of you in the PCN world, and demonstrate that you are the next evolution in the collaborative General Practice journey, rather than the competition.

The system voice. You a pretty well set up as a network of networks. You have strong governance and are representative of your members. Your next challenge is to become a peer to the trusts and councils, and take seat at the STP/ICS board as a GP provider. To do this, you will likely have to lead beyond your organisation, working with other ‘at scale’ providers and the LMCs. In many areas you will first have to educate the system that GP providers and GP commissioner are not the same, despite CCGs being member organisations. Once you have done that you need to create a collective voice for General Practice. This means working together and distributing leadership between you, which can sometimes feel uncomfortable. The prize is a seat at system level, where you can begin to shape rather than respond to what the future of healthcare looks like in your area.

You’ve done it already. You are one of a handful of examples across the country, so it’s time to take one more step. Whilst you may not feel like you have the time as you balance the day-to-day with shaping the future, I’d urge you to give hope to others who cannot see the summits you scale. Tell your story. The profession can learn from what’s likely to have been a difficult path, so please get in touch so I can hear and share on your behalf, or reply below to do it first-hand.

Wishing you and yours all the best for 2019!

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Dr Vish Ratnasuriya is a partner at Lordswood House Medical Practice with a personal list, which is a member of a PCN. He is Chair of Our Health Partnership (a superpartnership of 200 full equity partners arranged in 9 networks serving 400,000 patients) and on behalf of OHP he is full member of an STP board. He is the only GP provider nationally to be an STP system clinical lead.

For the RCGP he is clinical champion for collaborative General Practice and an Ambassador for his local STP

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