Speaking on the Andrew Marr show about Cameron’s Europe negotiations last week, Michael Heseltine described the complexity and difficulty inherent in structural change and merging small organisations into larger ones. Drawing parallels with the merging of ten discrete Kingdoms into a united England in the middle ages and merging 1,400 local authorities into 400 in the 1970s, he emphasised the difficulty of overcoming deeply held beliefs about how things should be organised. Although at a much reduced scale, it brought to mind contemporary challenges of coaxing standalone GP practices into larger organisations.
With further health policy announcements due this week, it seems inevitable that variants of the national GP contract will be used to accelerate the move towards larger scale general practice. It also seems likely there will be a move towards a new and more integrated relationship between general practice, wider primary care services and other health and social care providers.
Today’s report from the Nuffield Trust Transforming general practice: What are the levers for change? acknowledges the role of contracts and financial incentives in driving change and improvement. But the report also argues that these approaches must be accompanied by sophisticated support initiatives and reasonable expectations about timelines for delivering desired outcomes.
The current combination of national and local incentive schemes and contract performance measures risks overwhelming GPs and limiting their ability to engage with efforts to achieve sustainable, transformational change. All stakeholders in primary care development, including commissioners, NHS England, regulators and politicians need to need to identify a small number of priorities for change to be supported by a multi-faceted investment programme linked to a limited number of carefully designed financial incentives and contract changes.
It’s too easy to forget that general practice is a professional service delivered by people with a deep commitment to the well-being of their patients. Organisational changes on the scale envisaged for general practice require not only renewed infrastructure and excellent operational processes. They also require new professional relationships to form and trust to develop. I will only refer a patient for whom I am professionally responsible to a new, shared GP network service or an integrated health and care service if I trust it is as good as or better than the care I will provide myself.
It takes significant resources and organisational development skills to develop infrastructure and operating processes for new ways of working. It takes time, leadership and positive experiences to overcome deeply held beliefs about the status quo and build the trust and collaborative skills that are essential for success.
Transforming general practice: What are the levers for change ? identifies some of the ingredients for success – many of which are already in evidence in some areas. A rethink of our current dependence on micro incentives and a move towards larger scale change backed up by global budgets is at the heart of the new care models in the Five Year Forward View. A variety of innovative schemes are emerging for skills development in the primary care workforce. Re-design of professional training curricula has started although more radical changes are probably needed; and development of a minimum data set for general practice is under discussion. And so on.
But perhaps the most critical success factor is that which is in shortest supply: time. High-trust inter-professional relationships simply can’t be built overnight. They require time away from the day job to meet colleagues, recognise their skills, understand their limitations and agree new ways of working. And they need time into the future to build trust, based on lived experience that new working arrangements will work. Furthermore, a wider set of skills needed by primary care managers in areas such as operational management, business case development, actuarial assessment and risk management do not develop overnight.
A move towards large scale medical groups carrying capitated budgets – similar to emerging Vanguard organisations - was seen in the US in the 1990’s. Research into these groups by primary care academic Larry Casalino is instructive. He noted that a small proportion succeeded but most failed, offering five main reasons for this which are set out in his report. Failure to develop the necessary skills and failure to engage physician’s cooperation and commitment were central among them and he highlighted the importance of timely accurate data. Our own, Nuffield Trust research on the same topic described the blend of leadership, incentives and peer led support that underpinned change and improvement in a cluster of medical groups with budgets.
If we manage to create the right blend of levers for change, there is every chance that current initiatives to transform general practice will work. To achieve this, politicians and senior leaders in the NHS and its arms length organisations must create a substantial transformation fund. This is needed to free up professional time for participation in change programmes; to invest in the organisational development described above and to create the skills and infrastructure needed for transformation. Equally, we need rapid progress with a GP minimum data set and some careful methodological work to develop meaningful and reliable reports on general practice quality and outcomes.
Perhaps even more than money and data, we need realistic timescales to deliver desired outcomes and some relief from the wide array of targets, KPIs and other performance measures, that divert energy towards specific clinical activities and away from the underlying challenge of transformation. With the right support and the right data to assure progress towards specified goals, then successful scaled up GP organisations may well emerge.
A version of this blog first appeared on GP Online.
Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust and a General Practitioner in Greenwich.
Rosen R (2015) ‘Beyond the carrot and stick: transforming general practice’. Nuffield Trust comment, 17 June 2015. https://www.nuffieldtrust.org.uk/news-item/beyond-the-carrot-and-stick-transforming-general-practice