It's probably too late for General Practice

Sorry to bang on about it, but evolution is inexorable.

Sometimes it's good news, as it has been for chickens, sometimes it's bad news, as it has been for orangutans. 

In business evolution is trickier, few companies evolve once they become successful.  They keep doing what they have always done, leaner, meaner and slicker, but essentially the same job.

Often it's the new entrant that occupies the evolutionary niche, they are not bound by the old ways, they can do out the way it should be done now. 

In the world of technology nobody occupies super computer, desktop, laptop and mobile.Apple are close, desktop, laptop and mobile in their stable. however in general it's new entrants occupying the growth sector off mobile computing.

What does this matter to health?  

We have our super computers aka hospitals, we have our desktops aka general practice, but the NHS is woefully behind when it comes to the mobile. We're too invested in our buildings, our ways of doing what we've always done. 

Dr Now, Push Doctor and Babylon are not bound by old models they are emerging into the mobile space, one of them will succeed.

Right now every GP will say "that's alright for a few, but I'll still be needed" 

That's true, but rather like the BBC, you may be joined by a wealth of other channels, other suppliers. You may get left with the hardest to solve stuff, the most expensive and least profitable. 

I think if I was the Secretary of State for Health I'd be seriously looking at how the NHS can go mobile. 

Move 111 into the world of portable apps, video consultation and e-prescribing. Staff it with medics, provide a service for the population who will otherwise leave the NHS.

Do it now before evolution leaves us behind. 

Please DO Innovation, not talk it.

I was checking out Twitter today between patients and found myself chuckling at pictures of Simon Stevens talking about Innovation to 200 + NHS innovators.

He was in the same room, at the podium, they were sat patiently.  

Undoubtedly there will be a few questions, but otherwise that's it, he'll breeze of and the masses will be left to recall the details from their selective memories.

It's not very innovative is it?  

I'm tweeting this while the IT technician fixes my machine from wherever he's based. 

I'll be back seeing patients soon.

All those suits in the room will still be in the room.  The words of wisdom from our leader will be lost and memories fade.

Wouldn't it be better to do Innovation, not talk about it? 

Wouldn't it be better for Simon Stevens to emulate Zoella and take up vlogging?  

Wouldn't that actually show Innovation rather than talk about it?  

That way his words would be preserved, the comments recorded and the audience would be larger.

Just thinking. 

The software prescription

Do you ever prescribe an  App? 

What's the price point for medical software? 

It's a serious question. The rise of the smartphone signifies a new age in medicine, the personal information age. Granted genomics and pharmacogenomics will change the face of medicine forever, but the world of personal portable tech means  that as producers and consumers of information that change is happening now.

As a GP I will shortly be asked to advise or recommend apps, devices, and software which will make the quantified self agenda a reality in practice.

Granted most of those apps will be self purchases, £0.79 thrown  away or invested dependant on the success of the outcome.

In medicine today patient focused software is the province of smaller providers, new entrants to health and care. These providers are the best hope at producing a disruptive solution to the challenge of personal portable health care.

Currently they have a model based on selling an app. This is empowering to the user, it's a familiar model, non threatening, non committal. 

Most NHS organisations have a service model so if they offer a personal, portable solution it's likely they will offer an ongoing service cost model.  

This isn't going to be a model that individuals will pay, we are used to non commitment to apps, we can use and delete as we like.  

Will we pay £25 a month for a mental health app that's as good as £25 of Prozac?  

It's unlikely that users of the NHS, who pay nothing or a capped £8+ amount will go for a service cost model. 

Commissioners may consider it as good value, but the population is likely to baulk at the price. 

If commissioners bulk purchase and then " prescribe" apps we are likely to see a huge challenge of compliance.  

So, do I have a solution?  

Perhaps, here's my suggestion. 

Users are used to app purchases, lite versions, in app purchases. 

They are used to choosing "their" app, engendering ownership. 

Developers and companies bear the cost of running and developing these apps.

The NHS needs to recognise the current model, offer familiar opportunities, both purchase and prescription, to end users or patients.

Cost models for this virtual medication need to be broadly similar to existing pharmacological solutions. 

Prescribing models too need to be similarly understood by patient and provider; personal choice, efficacy, concordance and cost benefit are studied and researched for drugs.

Technopharmacology or Technotheraputics now needs to move rapidly from philosophy to reality if we are to avoid electro snake oil, that would be really, really expensive. 

#GPNewDeal - we need a new model

Kirkby New Model General Practice

Executive Summary

This paper draws on the work carried out by Local Care Direct and Turning Point (LCD/TP) in developing their approach to services in General Practice. In addition other components are drawn from models of care in operation elsewhere in the UK or USA and gathered by the author. 
This paper outlines the model, its potential implementation pathway and seeks to demonstrate the cost neutral approach required to be sustainable in current economic times.

Model Components

The cycle of general practice; Access, Intervention and Follow Up, form the building blocks of the model. For convenience each of these components will be considered in turn before assembling the overall model

Access

Access is sine qua non for primary care. Patients value access over continuity for urgent problems and continuity over access for non urgent or personal issues. However in deprived areas where need is greatest the dichotomy of access and continuity becomes skewed to access at the cost of long term conditions management.(Anwar et al., 2012) Similarly as demands increase receptionists are finding it harder to juggle the multiple pressures placed upon them without further training or changes in role.(Hammond et al., 2013). Since the turn of the century many practices across the world have been using the concept of advanced access (Murray and Berwick, 2003) (Longman, 2012) this seeks to address the patients problems in a “same day” way, not always through face to face consultation. Results have generally been favourable,(Salisbury et al., 2007) but the challenge to existing systems, ways of working and personal habits is significant and requires strong leadership. The KNMGP model proposes to deliver access through a centralised call centre approach. See Fig 1.

Although there is a long history of telephone consultations in primary care evidence is growing which identifies the pitfalls and possibilities for telephone consultations (Car and Sheikh, 2003)(McKinstry et al., 2009) In the KNMGP model we place triage and care navigation within the same functional space, although it should be noted that call handling may occur in a single location, the provision of triage and navigation should be considered as location independent. Appropriate members of staff who are working in practices will be called upon to provide triage and navigation as required, rather than expecting only staff based only in call centres to provide 100% of the function.

Telephony is not the sole method of patient contact, e-mail and web based services should also be implemented. Currently most GP system suppliers are in the process of developing apps/ portals to enable patients to book appointments directly, or access online booking/ test results/ prescription ordering. These are all taken as patient initiated contact.

Existing call management software, VOIP telephony and patient record can enable this distributed way of working. 

Two other “access” methods exist alongside patient initiated contact. The call centre should use mined data to initiate contact with various patients or patient groups. This is distinct from telehealth which will be discussed later.

Fig 1 KNMGP Access concept.

The triage and navigation functions should be able to operate seamlessly from the patients perspective. Hand offs to other agencies may well be “cold” where data is passed but there is a delay involved in response to the patient, whereas transition from triage to navigation should be a “warm hand off” meaning the patient will have no delay in the proceedings.

Telephone based triage services have been received with mixed reviews, (McKinstry et al., 2009) especially when performed as in hours services, their use out of hours has been more openly received(Booker et al., 2013) and suggested as a means of demand management, care navigation and improved outcomes (Egbunike et al., 2010).

Electronic or online means of access often generate significant concerns in practitioners without experience of such methods, however published evidence suggests they have a role to play (Neville et al., 2004, p. -)

Intervention

Traditional models have a limited range of options at the disposal of triage services. Standard appointments, urgent appointments, occasionally telephone consults and less frequently non face to face interventions such as prescriptions issued without clinician/ patient contact.

The KNMGP model offers a wide range of options to the call centre and clinicians.

In most practices a small but significant proportion of patient management takes place without face to face contact. Medication reviews, appointment scheduling, resolution of scheduling issues and appointment can all occur without face to face clinical contact. However most diagnosis and intervention require clinician / patient contact, these interventions can occur as part of the call centre function, provided by clinicians based within practices, initial survey work at Wingate Medical Centre suggested 20% could be dealt with as non face to face or purely telephone consultations.

The call centre function clinicians and navigators have five in house opportunities which can be used for interventions. See and treat (2 in Fig 2 above) is essentially a walk in service, which dependant on local circumstances may be within the practice or alternate location. Routine booked appointment (3 above) is the familiar appointment system, however it should be flexible enough to offer variable length appointments as there is evidence to suggest this improves time usage and patient satisfaction (Sampson et al., 2013).

Patients with long term conditions often multi-morbid are becoming increasingly common (Smith et al., 2012a) and their management is challenging(Smith et al., 2012b) in single disease areas self care is becoming recognised as a useful tool (Taylor et al., 2012) whereas interventions such as exercise on prescription are struggling to make an impact(Pavey et al., 2011). We know that nurse led care is effective where good evidence exists but the flow experienced by the patient is often sub optimal (Stans et al., 2013) to correct this issue the KNMGP model proposes the use of compound consultations these are scheduled multidisciplinary consultations based on the Massachusetts General Hospital Ambulatory Practice of the Future model (Judge, 2005).

Although the functions within the compound consultation are noted as distinct tasks it is possible that they may be undertaken by various individuals dependant on skill set and patient needs.

A key change in the compound consultation is that the patient takes centre stage, remains in “their” room and the professionals undertake a “warm hand off” (Philibert, 2009) as required during the hour or so devoted to the patient in order that the patient participates in the transfer of information. 

The HCA function is that of greeter and co-ordinator of the compound consultation. In addition the general demographic details and data associated with basic clinical care can be captured.

The Behaviourist function seeks to agree the patient’s life needs and aspirations, setting out their agenda for self care.

Many long term conditions are amenable to nurse led care packages (Fletcher and Dahl, 2013) including the supporting of self care (Taylor et al., 2012) the compound appointment beds the role of the nurse as a pivotal figure and for many patients the nurse may be the final step in the compound consultation. However it is envisioned that the Nurse function will be able to seek support from Point of care testing services or near patient diagnostics as well as specialist GP services (GPSI). It is possible that the scheduling of compound consultations may allow specialist nurses traditionally based in secondary care to become part of the primary care team when the needs of the patients require specialist intervention.

 Point of care testing is still a relatively untested phenomenon (Al-Ansary et al., 2011) and further research is indicated to ensure its cost effectiveness, however, global trends in mobile technology and developments in laboratory services suggest that POCT will become a viable option in the lifetime of this model.

The GP function also has access to POCT and specialist services within the compound consultation. However the GP function remains the back stop for the patient with long term conditions, serving to resolve the issues generated when protocols are in conflict or medication outside of agreed protocol is required. It is anticipated that the time required for this function will be little different that currently involved in long term condition management, however the patient experience will be significantly changed.

Group Appointments are a proven intervention for engaging patients in the self care agenda,(Edelman et al., 2012)(Smith et al., 2012b), they can occur with a facilitator present ( more usually defined as Shared Medical Appointments ( SMAs)(Dickman et al., 2012)) or self facilitated. 
enabling patients to use the central triage/ navigation function to arrange attendance at these appointments should facilitate their attendance.

Specialist GP Services cover a range of topics which may include access to GPs with specialist interest or services previously based in secondary care.  GPSI functions are not universally distributed or accepted (Gérvas et al., 2007) and the evolution of primary care facing specialist services is still in progress (Bowling et al., 1997)(Beech et al., 2013) and as such this part of the model is clearly dependant on local variables. It is likely that access to specialist services will be via the traditional gatekeeper role, but facilitated by the triage/ navigation function.

Follow up

The  KNMGP Model allows for a more systematic and multifaceted call and recall system than traditional practices. The model blends traditional patient generated requests for follow up “call me in a week” with online access to services and pivotally, telemonitor triggers (Seto et al., 2012).  The data mining function is central to the practice model. Although initial data sources are likely to be in house data, captured from contacts in consultation, online service use and telemonitoring triggers there is huge potential for “big data” approaches (Murdoch and Detsky, 2013) to inform and assist in initiating call and recall. The field of data mining is still an emergent one(Marschollek et al., 2012)(Amini et al., 2013) but collation of data within an organisational footprint offers the use of tools such as PARR (Billings et al., 2012) to proactively schedule attention from physicians and telemonitoring services.
At this stage the architecture of the data mining element is uncertain. In the initial stages it may simply be a bank of regular searches producing a task list for contacts. As the technology evolves it is likely to become a proactive warning system based on real time intelligence.

Feasibility.

As referenced above the model has supporting evidence for each of its components. Many are at work in different parts of the NHS, but, to date, no single area has been able to combine the various components into a single model of primary care.

Currently primary care is under scrutiny for a model which has changed little since the inception of the NHS (Mathers, 2012) and both the Royal College of GPs and NHS England are completing major consultations on the future of General Practice (RCGP, 2012).

Initial cacluations within the LCD/TP organisation suggested that the model would be resource neutral given sufficient size and resource pooling to enable staffing and response issues to be met.

Within Wingate there has been an uncovering of significant levels of unmet need which mean this assumption is no longer likely to hold true. Further detailed modelling will be essential to validate the feasibility.

Source data

The UK general Practice workload survey 2006/7 (Information Centre, 2007).

Average patient list size of medical practitioners (excluding GP registrars and retainers) in general practice, by country, UK, 1964 - 2009 (Office of Health Economics, 2009)

Al-Ansary, L., Farmer, A., Hirst, J., Roberts, N., Glasziou, P., Perera, R., Price, C.P., 2011. Point-of-care testing for Hb A1c in the management of diabetes: a systematic review and metaanalysis. Clin. Chem. 57, 568–576.

Amini, L., Azarpazhouh, R., Farzadfar, M.T., Mousavi, S.A., Jazaieri, F., Khorvash, F., Norouzi, R., Toghianfar, N., 2013. Prediction and control of stroke by data mining. Int. J. Prev. Med. 4, S245–249.

Anwar, M.S., Baker, R., Walker, N., Mainous, A.G., 3rd, Bankart, M.J., 2012. Chronic disease detection and access: does access improve detection, or does detection make access more difficult? Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 62, e337–343.

Beech, R., Henderson, C., Ashby, S., Dickinson, A., Sheaff, R., Windle, K., Wistow, G., Knapp, M., 2013. Does integrated governance lead to integrated patient care? Findings from the innovation forum. Health Soc. Care Community.

Billings, J., Blunt, I., Steventon, A., Georghiou, T., Lewis, G., Bardsley, M., 2012. Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30). Bmj Open 2.

Booker, M.J., Simmonds, R.L., Purdy, S., 2013. Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emerg. Med. J. Emj.

Bowling, A., Stramer, K., Dickinson, E., Windsor, J., Bond, M., 1997. Evaluation of specialists’ outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners. J. Epidemiol. Community Health 51, 52–61.

Car, J., Sheikh, A., 2003. Telephone consultations. BMJ 326, 966–969.

Dickman, K., Pintz, C., Gold, K., Kivlahan, C., 2012. Behavior changes in patients with diabetes and hypertension after experiencing shared medical appointments. J. Am. Acad. Nurse Pract. 24, 43–51.

Edelman, D., McDuffie, J.R., Oddone, E., Gierisch, J.M., Nagi, A., Williams, J.W., 2012. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review, VA Evidence-based Synthesis Program Reports. Department of Veterans Affairs (US), Washington (DC).

Egbunike, J.N., Shaw, C., Porter, A., Button, L.A., Kinnersley, P., Hood, K., Bowden, S., Bale, S., Snooks, H., Edwards, A., 2010. Streamline triage and manage user expectations: lessons from a qualitative study of GP out-of-hours services. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 60, e83–97.

Fletcher, M.J., Dahl, B.H., 2013. Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care? Prim. Care Respir. J. J. Gen. Pr. Airways Group 22, 230–233.

Gérvas, J., Starfield, B., Violán, C., Minué, S., 2007. GPs with special interests: unanswered questions. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 57, 912–917.

Hammond, J., Gravenhorst, K., Funnell, E., Beatty, S., Hibbert, D., Lamb, J., Burroughs, H., Kovandžić, M., Gabbay, M., Dowrick, C., Gask, L., Waheed, W., Chew-Graham, C.A., 2013. Slaying the dragon myth: an ethnographic study of receptionists in UK general practice. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 63, 177–184.

Information Centre, 2007. 2006/2007 UK General Practice Workload Survey.

Judge, D., 2005. Ambulatory Practice of the Future.

Longman, H., 2012. Access: The call we’ve all being waiting for. Health Serv. J. 122, 22–24.

Marschollek, M., Gövercin, M., Rust, S., Gietzelt, M., Schulze, M., Wolf, K.-H., Steinhagen-Thiessen, E., 2012. Mining geriatric assessment data for in-patient fall prediction models and high-risk subgroups. BMC Med. Inform. Decis. Mak. 12, 19.

Mathers, N., 2012. From cottage industry to post-industrial care? The RCGP response to the King’s Fund report on the quality of care in general practice. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 62, 326–328.

McKinstry, B., Watson, P., Pinnock, H., Heaney, D., Sheikh, A., 2009. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 59, e209–218.

Murdoch, T.B., Detsky, A.S., 2013. The inevitable application of big data to health care. Jama J. Am. Med. Assoc. 309, 1351–1352.

Murray, M., Berwick, D.M., 2003. Advanced access: reducing waiting and delays in primary care. Jama J. Am. Med. Assoc. 289, 1035–1040.

Neville, R., Marsden, W., McCowan, C., Pagliari, C., Mullen, H., Fannin, A., 2004. E-mail consultations in general practice. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 54, 546.

Office of Health Economics, 2009. Average patient list size of medical practitioners (excluding GP registrars and retainers) in general practice, by country, UK, 1964 - 2009.

Pavey, T.G., Taylor, A.H., Fox, K.R., Hillsdon, M., Anokye, N., Campbell, J.L., Foster, C., Green, C., Moxham, T., Mutrie, N., Searle, J., Trueman, P., Taylor, R.S., 2011. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 343, d6462.

Philibert, I., 2009. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual. Saf. Health Care 18, 261–266.

RCGP, 2012. General Practice 2022 [WWW Document]. URL http://www.rcgp.org.uk/policy/rcgp-policy-areas/general-practice-2022.aspx

Salisbury, C., Goodall, S., Montgomery, A.A., Pickin, D.M., Edwards, S., Sampson, F., Simons, L., Lattimer, V., 2007. Does Advanced Access improve access to primary health care? Questionnaire survey of patients. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 57, 615–621.

Sampson, R., O’Rourke, J., Hendry, R., Heaney, D., Holden, S., Thain, A., Macvicar, R., 2013. Sharing control of appointment length with patients in general practice: a qualitative study. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 63, 185–191.

Seto, E., Leonard, K.J., Cafazzo, J.A., Barnsley, J., Masino, C., Ross, H.J., 2012. Mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. J. Med. Internet Res. 14, e31.

Smith, S.M., Soubhi, H., Fortin, M., Hudon, C., O’Dowd, T., 2012a. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 345, e5205.

Smith, S.M., Soubhi, H., Fortin, M., Hudon, C., O’Dowd, T., 2012b. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst. Rev. Online 4, CD006560.

Stans, S.E., Stevens, J.A., Beurskens, A.J., 2013. Interprofessional practice in primary care: development of a tailored process model. J. Multidiscip. Healthc. 6, 139–147.

Taylor, S.J.C., Sohanpal, R., Bremner, S.A., Devine, A., McDaid, D., Fernández, J.-L., Griffiths, C.J., Eldridge, S., 2012. Self-management support for moderate-to-severe chronic obstructive pulmonary disease: a pilot randomised controlled trial. Br. J. Gen. Pr. J. R. Coll. Gen. Pr. 62, e687–695.

Who do you Google?

Listening to the radio today I heard  feature about a patient being told "not to google". 

As is turned out the story was about specialists telling the patient to stop researching their own symptoms. 

I have to say I agreed with Dr Gerada- I never say "don't" but usually point towards sites you can trust. 

In 2014 my team did some work looking at the site used by the health community of St helens and Knowsley, all staff, GPs, Hospital Specialists and Nurses use the network and we extracted the list of clinical sites used. 

The list is here  - its just the links, without the numbers or details. 

  Contact me via twitter @chrismimnagh if you want a copy of the links or the poster used in the RCGP Conference 2014.  
 

Mimnagh, C., Mullen, M., Mimnagh, M., 2014. Using “The Wisdom of the Crowd” to Source Resilient Internet Resources for Registrars., in: Future Proof? Resilience in Practice. Presented at the RCGP Annual Conference, RCGP, Liverpool.

Selling Health

I recently had some feedback over an article with as similar title to this one. 

The bearded anarchist heard my voice on his mind selling off the NHS, when what I wanted to get across was that health services have much to seek to other countries in terms of knowledge. 

It got me thinking that we actually don't sell health well at all. 

A recent sales talk from as timeshare company made meet realise how little we use the techniques of marketing to actually market the only product that matters- good health. 

We don't sell aspirational visions of our healthier futures, we don't offer packages designed to get the best out of your life. 

Instead we offer well managed decay into senescence and death. 

Wouldn't it be great if you received a brochure outlining all the ways you could maximize your self, save money, live longer and be happy? 

Even if you thought ", it's Not for me" you might still take away a message, want more for yourself, do more for yourself and even care more for yourself.

All Work, No Play

Today we had a field trip top a Primary care Centre, it's a different model of care, some similarities such as patients doctors and nurses, but some big differences in terms of money and organisation. 

The triage team are prepared for any patient coming in.

Medicine is a spectator sport, none of the people in seeing this GP are relatives, but it's nice to see how the doctor does it. 

There's a lot of potential for shared learning, but the cultural differences are fascinating.

Kunming City- Blade Runner territory. 

After a two hour delay we made it to our next stop, kunming city, a mere 1000 miles from Shanghai.

We finished with a formal dinner, very interesting, but worthwhile.

Sir Ian and the Chief Exec of Angel Hospital. 

China, in their hands.

I'm currently in China and usually would not use this blog for travel purposes, however Facebook usage is patchy in China, it worked at the airport but nothing since then.

However Clinical Creativity appears to work.

So, first thoughts based on Shanghai day one.

It's big, it's busy, it's crowded.

The food is interesting, but not inedible.  

I don't know what it was but it tastes ok.

The city is interesting, 

Colonial french design, circa 1934

The deal known as DevoManc had been across the headlines this week. It looks like the delegated budget for a greater Manchester area has been on the cards for a while and now its public. 

It's a bold move, a single budget for all the areas health and social care need. 

There will be huge tensions to manage. Prevention versus end of life, Social versus Primary care.

Advocates will tell me that the framing of such tensions as either or is wrong, and that we are all in this together.

However as long as there are different organisations each with different obligations to their masters there will be tensions. 

Whether there could ever be one organisation that flexed and drifted with the population I don't know.

it's going to be interesting trying though.

It's an organisation, Jim, but not as we know it.

The Five Year Forward View is a bold document which Simon Stevens seems to hope will survive political changes and whims in order that the NHS actually really does honest to goodness transformation into a twenty first century organisation. 

There loads of good stuff in there, models and frameworks rather than dictat and ideology.  

One of the most interesting parts for me is the Multi Speciality Community Provider ( MSCP). It's a neat concept that sees the patient delivered of a seamless service following the principles of integrated, right place, right time care.  

There is a slight problem with this concept.  

I'm willing to bet that right now Chief Execs and senior leaders across England are thinking "we could be that organisation" or worse still, there are probably DoFs thinking "we could scupper that organisation" . 

In their own worlds that's probably a sensible, aligned view to have, however it is a concept that arises from the same level of consciousness as the one that generated the need for MSCPs in the first place.  

As Einstein pointed out, that's not going to give us the answer. 

Now, as it's nearly Christmas, we're probably looking to organisations like Amazon to solve our troubles when it comes to presents, so let's get a delivery from them. 

Amazon is a model that could actually work as an MSCP.  

Suspend your disbelief for a moment.  

Amazon is a brand, I buy from that brand because it's right place, right time, trusted, close to home, flexible in its delivery approach and convenient. I don't need to look anywhere else.  

Amazon also isn't just Amazon.  

There's a good chance that if I want a specialist product, odd, unusual or bespoke, I can get it from Amazon, but it will be sourced by another provider. Whether it be John Lewis or a small shop in the back end of Brighton, my parcel will arrive, sometimes in the Amazon box, sometimes in the John Lewis box, but it arrives as expected after my organisation choice of Amazon has said it will. 

Amazon does not own John Lewis, or the small shop in Brighton, they are not the same organisation. 

Consider what would happen if a community foundation trust, multiple practices and a specialist provider decided, that rather than waste time waiting for a new Organistional form to arrive or be mandated, they would just get on and do an Amazon. 

That would be amazing.  

Thin materials on the edge of collapse

Prof Roger Kneebone is an interesting guy. Surgeon, GP, academic.

He's taken some interesting perspectives on surgical training, specifically around the Performance aspect. 

One of his collaborations was with a potter. The potter defined is craft as being

"Working with thin materials on the edge of collapse."

in truth l think this applies as a concept to all elements of medicine and beyond.

As an out of hours GP I am often called into situations where family support mechanisms are I the edge of collapse. Making something positive from those moments is perhaps the pinnacle of the art of out of hours care. 

Whether it's music, pottery, Surgery or general practice, we are all working with thin materials on the edge of collapse.

Steady as she goes...

Its been nearly five months since the launch of the access component of our New Model of General Practice. In that time we have learned a great deal about some of the theories and practicalities involved in meeting population needs for primary care. Heres a quick dissection of the learning so far on one theory. 

• Theory One.
  Stream work to ensure that productivity remains high. This concept involves separation of acute and routine work so clinicians remain in one mode of operation nd improve efficiency. 
• Learning Point
  Streaming work by clinicians reduces access to routine appointments and can stretch individuals performance to concerning levels. e.g. we learned that after 24 phone consultations we stopped making good decisions in terms of when to see or not see patients. 
• Answer one
  Limit number of phone calls per session to a safe, comfortable sixteen. Encourage clinicians to be aware of their own decision making processes. "Mindful consultations".

Its been a while.

If you have followed the various trains of thought on my blog you will know that I'm looking to make a difference to the care of patients in the system we call the NHS. 

I've not given up looking, but now the time has come to make some changes. 

My practice has embarked on a new model of general practice. We had to, we had no choice. General Practice UK has been a model which was once everything that was required by the population. Free access to a resource that was valued by the population and used only when needed. 

Although the NHS is valued as a brand, years of prodding and media bait have reduced value in General Practice to a position of under investment and increasing demand. Average yearly consultation rates have gone from 2.5 to 6 per annum and money has decreased. 

Our partnership has a big ambition, to generate the value and ownership required from the local population in a way that means the relationship shifts from a professional/ customer relationship to a partnership of care. 

Now, I know that such is the way of the NHS that multiple colleagues will now say "but we always engage our patients in decisions"  and "we've been doing it for years" and they may be right, in their own way but our system is changing in ways which are unique to us. 

A Double Blast From The Past

I found this in an old e-mail folder- its already 4 years old, but the trends are clear.

20 Years of Kirkby Primary Care: The Changing Numbers of Family Doctors

A nation that keeps one eye on the past is wise. A nation that keeps two eyes on the past is blind.

Introduction

The future of primary care is once again at a cross roads, this appears to happen every 10 years or so.   Changes such as locality purchasing, PCT, PBC, GPCC, CCG and now CCCs appear and mutate the very DNA of primary care.  It’s often said that General Practice remains a constant and that alterations in the delicate ecosystem will “destabilise” services. This belief, whilst comforting is not actually true. Primary Healthcare is a complex adaptive system, constantly changing and evolving to meet the demands of the system and the population it services.

This paper draws on simple demographic changes in the nature of practices and practitioners and attempts to pull out some threads for development which others may choose to fashion into a safety net or hangmans noose, depending on their preference.

Although as GPs we pride ourselves on continuity of care and accessibility the experience of patients based on their own experience does not always agree with perceived wisdom.

I recently came across some documentation from 1988, the year I qualified as a Doctor. This outlined some simple demographics for the GP population of Kirkby. The same information is available to day and perhaps the comparisons of the changes offer some insight into the changes we may expect or even create in the next twenty years, not for the patients but for ourselves as individual practitioners, the way we work and the people we are.  

As with all predictions there is a health warning. The more precise the prediction the less accurate it will become. So predicting the future demographic of primary care down to individual GP numbers is nonsensical, but broad strokes of strategic direction will for the most part be made real to greater or lesser extent.

The Population

Kirkby was developed in the 1950s as an overspill town for Liverpool, it reached its population maximum in the 1970s, 10,000 short of its predicted target and since then there has been a decline in the population numbers with a stabilisation and slight growth since the 1990s.

 

No data available for 1981 1991.

The ageing population demographic applies to Kirkby equally as to the rest of the county, however health needs are significant. NHS Knowsley Annual Report has full details.

The 1988 Position.

The St Helens and Knowsley Family Practitioner Committee document “A strategic statement for the development of Family Practitioner Services” provides basis demographics for the population of General Practitioners.

The document also outlined a number of challenges such as computerisation which would need to be addressed for primary care to develop. 

The data is not clear as to WTE figures simply stating GP numbers age and Gender. Aside from trainees there was no mention of salaried or long term locum posts.

This data would appear to be based on performers’ list details alone and so the 2011 data can be sampled in a similar blunt way.

Comparisons

Numbers of GPs. 

The table below illustrates a stark truth- the overall numbers of GPs have changed little since 1988. However the expansion of the primary health care teams has been massive.

	Drs	Trainees
1988	28	3
2011	33	3

 In 2011 all practices have some nurse support, the community teams have increased in size with new posts such as Community Matrons, Practice based pharmacists and Independent Nurse prescribes completely unpredicted by 1988 data.

The Options service has also been excluded from the data since the nature of that service is a pan Knowsley one and the model of employment means that actual WTE data vs. Individual Names not available.

Who are the Doctors?

In 1988 25% of the Medical body was female, this has increased to 33% by 2011, however this is still short of the current 42% national figure and the 50% Male: Female figure leaving Medical School. Given the increased uptake of part time work by GPs who are also main carers for children it should be expected that more of our population of Medics will be female in the next decade.

Have we aged well?

It would appear that with the notable exception of Dr Ford we have indeed aged well as a population. Although Dr Ford has since retired from practice the figures were generated at a time when Colin was still active.

 

Over the next 20 years we can expect 20% of or GP population to retire and be replaced and the figures do not appear to be a cause for concern regarding sudden departures. However the pension changes and external factors may simultaneously force retirement n some and prolonged working life on others. A solution may arise in practitioners “winding down” and becoming part time, at the same time as younger female medics are seeking part time employment.

What kind of Practices do we work in?

This data is the most interesting to note, given that the overall numbers appear to have changed little, has the nature of practice also changed little?

The answer would appear to be a significant shift, possibly to the extent of polarisation.

 

In 1988 the largest practice in Kirkby had 5 GPs whilst there were 8 who appear from the data to have been in single handed practice, a total of 16 separate medical facilities.

By 2011 there are no longer any lone practicing GPs in Kirkby with 16 GPs working in 5 2-4 doctor practices and 18 working in a brace of 9 doctor practices. This gives a total of seven medical practices.

This wholesale centralisation has multiple drivers, not least concerns over isolated practitioners, economies of scale and estates infrastructure development which have all conspired to develop the reduction in practice numbers and increase in practitioner team size which is clearly evident.

Where now?

As mentioned these are interesting times for the NHS and Kirkby and the vie of a world twenty years behind us does not predict the future, however it does show where we were, where we are and hence where we might go.

The NHS faces the Nicholson Challenge- a reduction of activity and expense to the tune of £20 Billion is required by the NHS. The coalition government strategy is forcing GPs to embrace a broader role in the commissioning of services, with subsequent impact on day to day care activity and for the Kirkby GPs questions remain about the viability of a commissioning unit with 50, 000 patients and 33 GPs.

The changes in the nature of practices observed might suggest development of a  co-ordinated approach, hub and spoke services, a collaborative environment. The reality is that we are not established in such a way at this time.

The new town centre development offers a potential catalyst, with the co-location of walk in services, practices and the facilities associated with St Chads and the Kirkby health suite there is a golden opportunity to develop a different healthcare system for the population. One which maximises the potential of collaboration between practices, uses the demographics of our General Practice environment to the fullest and as a result provides a new deal for the Kirkby population.

As one local GP suggested we should “Consider ourselves as mid size company with 8 practices [inc options], £75m turnover and lots of employees and 50k customers.”

Dr Chris Mimnagh June 2011

Applitivity

Ok, it is a made up word. 

However recently I met a colleague at a commissioning group event. He is a true entrepreneur, always looking for the next source of potential gain. He was keen to tell me that new ideas were all well and good, but what mattered was making them work, putting them into action. He is particulaerly good at that, the implementation, not the creation. It got me thinking- what is his adjective? What is his preferred thought process?

So my suggestion goes like this:

Innovation equals ideation plus implementation. 

It's easy to describe someone who is good at ideation, generating de novo concepts or taking various problems and solutions and creating a new concept. 

We call them creative, they have creativity. 

So what is the descriptive term for an implementer? Someone who takes that idea and makes it reality? Someone who sees a place where the words first nano watch can be read? 

Can I suggest the are applitive, they have

applivity (adj.) the ability to apply novel solutions to unique situations.

It's a Big Data World After All

I recently had the opportunity to mix with some really smart people at a Big Data Seminar. There is a lot of interest right now in the topic, althpough along side the interest there is a lot of Hype. 

The best comment which cut through the hype and described the situation came from a Professor who said "Big Data is like teenage sex- everybody wants it, everybodys talking about it, but nobodys really sure whose doing it!"

My job was to present a Health Perspective and suggest what was missing from the current landscap that could be a target for further development. 

Perhaps not surprisingly given my love of the strategic, my observations suggested that in terms of big data we have three axis along which any "big data" activity can be plotted. 

Operational Vs Strategic Uses

Single Vs Multiple Locations 

Personal Vs Population Perspective

In the three dimensional cube of the data we have applications which occupy all, bar two, areas within the domain of health. 

The two remaining holy grails are Strategic Population Multiple based systems and Strategic Personal Multiple based systems. Both of these two domains should have systems but as yet these systems do not exist.

I can collect my own health data, record it in an app, but much more interesting stuff could be gleaned from multiple sources including analysis of unstructured, perhaps socially generated data.

Similarly if we are to know whether a citys health will be suffering in two years time our best guess might be supported by data gathered from across a wide range  of media. 

All in all, my brain was hurting, but there is definately something in this big data lark. 

Who Trains the trainers?

There is a way to describe learning styles as a balance between pragmatic and theoretical, reflector and activist. I am it would appear an activist and learn best by "getting stuck in".
I've been getting stuck in to becoming a trainer in general practice and recently enjoyed the experience of taking part in the initial trainers course.
So who is it who trains the trainers?
The team I have met so far are a blend of all the above learning styles, but in addition they all share an ability to inspire. Each one of them is unique, but common traits emerge.
They are all enthusiastic about primary care. They are all committed to empowering the future trainers to create the best environment for new trainees.
Combining the opposites of ambition with practical achievements, inspiration with governance and reality with motivation is not easy. The breadth of sessions covered has already been significant.
But in answer to the question- who trains the trainers? - it's easy- bloody good GPs do the training.

Big Data, small issue.

I've been doing some thinking about BIG DATA recently. If you're not familiar with the concept the idea is that we are now at a time when technology is not confined to taking a "random sample" for study.
In the old paradigm it was impossible to know and analyse all the data in one topic, example customer preferences, so we asked a randomised or stratified sample. Now we have sufficient computing power to not just ask the customer, but to track their data, triangulate with other data sources and arrive at an answer which is based not on what the customers said but in what they did.
Making this computopia a reality is a matter of fusing certain existing systems and technologies together to fit the purpose.

And there is the issue.

All our current paradigm thinking is based on a model of science; asking a question to get an answer takes the form of a hypothesis. "What is the impact of neuropathy on life expectancies of diabetic patients?" The parameters create a defined subset, a population, a sample and controls out the variables, creating a baseline against which our sample group is compared.
Taking a big data approach is an alien one. Casting the data net widely across a population produces a population image, one in which the paintbrush consists of intelligent analytical algorithms and the appearance of the picture, like most modern art is a matter of interpretation.
The role of the artist could be defined as selection of the paints and canvas, with the inherent properties of the paint, it's colour or texture interacting with the brush to produce the final image.
Examples of biggish data include school results, ofsted and family income comparisons, biggish because the picture created used limited colours and a couple of brushes on a small canvas.
Big Data is a big leap on and in the case of school results would include additions of social media, travel patterns, benefits data, health records etc. More colours to create a more vibrant picture, one which may better suit the complex adaptive systems of our lives and when studied, like a work of art, small details may attract our eye, requiring the microscope of standard scientific method.

Given this fundamental change in analysis paradigm Big Data may find it hard to gain traction with those steeped in scientific method. Those who value complexity and chaos may feel equally uneasy, but ultimately until the practicalities of access and the mechanics of governance are the first hurdles for big data, with the dissemination challenges of acceptance and adoption further away.

Fad or Future? - to early to say.

Is my jam spread too thin?

Most of us living in the 21st century have complex lives, multiples pressures and demands on time. This is especially true of our careers, with portfolio careers becoming the norm rather than the exception.
Medics in particular have a propensity to attract work, consultants working 14 PAs i.e. 7 days a week are routine, and a part time GP is seldom inactive, so the question arises- "is my jam spread too thin?"
To answer the question you must first understand the question.
In an industrial sense, based on time and process any failure to deliver or be present would suggest inadequate performance. However, the question is a judgement based on jam, and not an industrial metric at all.
Assume your customers ( employers, service users, co- workers, staff) were to respond on your behalf. Their response would be a judgement, a perception. In the jam analogy it's a matter of taste and perspective, if enough of the bread is covered by a non uniform distribution such that there is never a bite of the bread which contains insufficient jam for the taste of the diner then the answer is a negative.
And there's the rub. It is a matter of taste.

Think about the problem

My house has a conservatory. When it rains it leaks. I can use a bucket to catch the water and when it fills I can always get a bigger bucket. I could of course look up at the roof and move the panels about to stop the leak. I could even go up and fix the overflowing gutter.
Of course the NHS would buy a bigger bucket- secondary care. We need to look to the root of the issue and fix the self care agenda - the leaky gutter.
Each of those areas can only improve if the knowledge and skills moves up, towards the problem. The bucket minders need to fix the roof, the roofers need to fix the gutter. It's possible while we're changing the system that the rain will feel wetter than standing watching the bucket fill.
We either do it or keep buying buckets - but we have no money.