General Practice Taking Stock

1. Welcome to theNATIONAL SUMMIT ON QUALITY IN GENERAL PRACTICE Thursday 31 July 20149.30-4.00 p.m.

2. General Practice Taking Stock Dr Maureen Baker CBE DM FRCGP Chair of Council RCGP

3. British General Practice • Around 1.2m patients seen every working day • Increase in consultations from 300.4m per annum in 2008 to 340m 2012 (latest figures) • Increase in workload, static funding and falling resource is bringing general practice to its knees

4. Rising Demand Between 1995 and 2008, the number of consultations in General Practice rose by 75% to more than 300m. A sharp increase in consultations for those over 65 has contributed to this

5. The rise in numbers and complexity “Epidemiology of Multimorbidity” – Lancet, May 2012

6. “Epidemiology of Multimorbidity” Lancet, May 2012

7. A reminder about the money Traditional NHS inflation 5% • arctic’ scenario: real funding cuts (-2 per cent for first three years, -1 per cent for second three years) • ‘cold’ scenario: 0 per cent real growth in six years • ‘tepid’ scenario: real increase (+2 per cent for first 3 years, then +3 per cent for the next three years). Appleby J, Crawford R, Emmerson C. (2009) How cold will it be? http://www.kingsfund.org.uk/research/publications/ how_cold_will_it_be_html 2009).

8. General practice funding has fallen by 8% across Britain in real terms since 2005/06 – at a time when the rest of the NHS budget has grown by 18% Source: RCGP analysis

9. Not enough GPs: The general practice workforce crisis

10. Transformational change • Extended general practice delivered at scale (federations, super-practices etc) • Extended care of patients in their home (packages of care designed around patients’ needs) • Most effective use of generalist and specialist skills (eg. specialist is consultant to generalist rather than patient) • Clinical and admin teams working across interfaces (teams without walls)

11. Barriers to change • Lack of funding • Lack of workforce • Evidence gap on both clinically effective and cost effective management of multimorbidity • Current structures inhibit effective funding models and effective teamworking

12. What must be done? • Better planned resource over health and social care economy • Invest in general practice and community services with a view to supporting patients at home and avoiding emergency admissions • Mechanisms to allow effective teamworking across interfaces • Support our campaign – Put Patients First: Back General Practice • www.putpatientsfirst.rcgp.org.uk

13. National Summit on Quality in General Practice Patricia Wilkie, OBE, PhD, FRCGP (Hon) President and Chairman National Association for Patient Participation

14. Population changes England & Wales 1901 2013 Change  Population, million 32.5 57 + 75% Births, thousand 929 700 − 25% Deaths, thousand 550 500 − 10% Age 65 and over Proportion 5% 17% Number, million 1.6 9.7 6 times Source: 2013 ONS, 1901 various web sites

15. 1900 minimum official fee to consult GP 2s 6d 1977 19% of all GP consultations took place in the home Source: Roy Porter, 1997 2014 cost of GP consultation £60 2014 negligible Changes in cost and place

16. Dawson report 1919 • District hospitals and primary health centres staffed by GPs • Outpatient clinics with visiting consultants • Theatres • X-Ray • Ambulance and “communal” services • Labs • Dentistry • Maternity

17. Where we are in General Practice • GP and patient capacity • Demographic changes • Decline in acute illnesses • Increase in chronic conditions • Movement from hospital to community care • Increasing costs of health care • Increase in specialism in secondary care

18. The doctor A Good Doctor - not an aspiration Clinically competent, good diagnostician and up to date Involvement in care and wider health care Evidence based outcomes Continuity Good listener Felt that had enough time The practice Access - speed and simplicity Quick service for urgent problem Choice of practitioner Responsive practice Flexibility Use of technology Patient Participation Group Definition of Qualityfrom Patient Perspective

19. Meeting the challenge:what needs to change 1 • More varied consultation formats • Better use of telephone, skype, email, telehealth • Implications for patients, GPs and practice • Patients with several LTCs, carers, GPs and team to agree most appropriate way of working • Readily available outcome data • PPG in every practice

20. Meeting the challenge:what needs to change 2 • Appropriate funding of GP services • GP services are mainly free at point of delivery. Patients and the public now need to know the cost of running services. This information is necessary for us to be responsible citizens

21. I want it now! Doing better feeling worse • Medicine is a victim of its own success leading to increased expectations • These expectations may be unlimited and may be unfulfillable • We all have to redefine what is possible • This can only be done in real partnership between patients and doctors • Put patients first and back general practice

23. Welcome to theNATIONAL SUMMIT ON QUALITY IN GENERAL PRACTICE Thursday 31 July 20149.30-4.00 p.m.

24. Welcome back

25. How can we sustain and improve quality? Quality in General Practice 31 July 2014

26. Presentation title set in header Who are we? • The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. • We are here to support people working in healthcare practice and policy to make lasting improvements to health services. • We carry out research and in-depth policy analysis, run improvement programmes to put ideas into practice in the NHS, support and develop leaders and share evidence to encourage wider change.

27. Presentation title set in header Improving Quality in Primary Care: A Different Paradigm?

28. Presentation title set in header Different scale

29. Presentation title set in header Different safety challenges

30. Presentation title set in header Different ways of working

31. Presentation title set in header Different settings for care

32. Presentation title set in header What do we know? • Overcoming Challenges to Improving Quality • 14 Evaluation Reports (approx £40m improvement investment) • Range of sectors- but predominantly acute • Range of projects- but all about improving quality of clinical care • 10 generic themes

33. Presentation title set in header Ten Challenges • Convincing people that there is a problem

34. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one

35. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right

36. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’

37. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities

38. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement

39. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership

40. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership • Balancing carrots and sticks – harnessing commitment through

41. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership • Balancing carrots and sticks – harnessing commitment through • Incentives and potential sanctions

42. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership • Balancing carrots and sticks – harnessing commitment through • Incentives and potential sanctions • Securing sustainability

43. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership • Balancing carrots and sticks – harnessing commitment through • Incentives and potential sanctions • Securing sustainability • Considering the side effects of change

44. Presentation title set in header Ten Challenges • Convincing people that there is a problem • Convincing people that the solution chosen is the right one • Getting data collection and monitoring systems right • Excess ambitions and ‘projectness’ • The organisational context, culture and capacities • Tribalism and lack of staff engagement • Leadership • Balancing carrots and sticks – harnessing commitment through • Incentives and potential sanctions • Securing sustainability • Considering the side effects of change

46. Scotland – Sharing our learning Quality Summit RCGP London 31st July 2014 Dr Brian Robson, Health Foundation /IHI Fellow, Executive Clinical Director, Healthcare Improvement Scotland @brobson3

47. Scotland’s quality journey ‘This is not the end. It is not even the beginning of the end, but it is, perhaps, the end of the beginning.’ Sir Winston Churchill

48. As at 30/7/14

50. 5 million population • £11.4 billion health budget • Integrated health and social care system • 14 territorial boards • 1,000 Independent GP practices with 4,000 GPs Context is everything