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14 February 2017

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Dr Robert Varnam: ‘I’ve never been so hopeful about general practice’

The man charged with improving general practice talks to Angela Sharda about how practice managers are key to revitalising primary care.

As NHS England’s head of general practice development, Dr Robert Varnam has no easy task.

With his plans for changing consultation methods, reducing DNAs, developing practice teams and increasing social prescribing, the inner-city Manchester GP has a lot on his plate. But he does have the potential to make real change, which is already evident in his influence on the GP Forward Viewwhich promised a £2.4 billion investment in general practice. Just from speaking to him for a couple of minutes, it’s evident how he has managed to get to this position. His enthusiasm and passion for the NHS and particularly primary care shines through.

And it’s not only GP workload that he wants to address. As one of the architects of the Government’s £6 million Practice Manager Development Programme, he recognises that practice managers are the key to making positive changes in general practice and he has been working with the Practice Management Network on how the scheme can help managers to progress with their professional skills and training.

What are the biggest challenges in general practice at the moment?

‘I think the biggest is workload. Administrative work – which practice managers are responsible for – has been going up. Financial processing is much more complicated now there are multiple commissioners. The workload of reporting has been growing with the new Care Quality Commission (CQC) inspection regime and the fact that most practices are now reporting to NHS England, their clinical commissioning group (CCG), and their local authority. The managers and the clerical team are working so much harder than they were.

‘Then there is clinical demand from patients. We’ve seen a 12.5% increase in the number of GP consultations over the last decade, which is far more than the population has grown. That’s partly because expectations are growing, but also because patients have more complex needs. It’s no longer the case that general practice does the simple work and hospitals do the difficult stuff. General practice is now doing some of the most complex interwoven care and with a rapidly ageing population we’re seeing the complexity of work for practices go up really fast.’

Have you got any plans to help overcome these problems?

‘Yes. Some are to help the practice to meet demand. We’ve not been training GPs fast enough. Numbers of hospital consultants have gone up three times faster than the number of GPs. So we plan to increase the number of clinicians available with more recruitment, better retention and schemes for hard-to-recruit areas.

‘Some of that works quickly, so even this year we’ve seen more people in training places and hard-to-recruit areas. We’re also reducing the bureaucratic burden – simplifying payment and reporting systems. Practices have shown us how much duplication there is in reporting to the CQC and commissioners. Also we are reducing the burden of regulation, inspecting only the practices where there is a cause for concern, instead of everybody.

‘The last area is to reduce the clinical burden. Big changes were made to the NHS standard contract for hospitals last April to reduce the number of times a lapse in processes creates a GP appointment. Data suggest this will cut 4% of GP appointments.

‘The second area is to help more patients with self-care.’

But can’t self-care lead to misdiagnosis and more problems for practice staff?

‘At least 15% of GP appointments could be prevented by supporting self-care for acute minor illness. Then there’s self-care for people with long-term conditions like diabetes, COPD and heart disease. Patients can be trained in how to help themselves and where to go if things get worse. This can reduce GP consultations by 10-20%. And patients feel better themselves. So there’s a lot of work already happening.

‘Receptionists can also signpost. They never make a diagnosis or decide treatment; they let the patient know who can help them. Much of what GPs deal with could be handled by someone else – a test, a follow-up, an administrative question. About 7% of GP appointments are about something that should have been seen by the practice nurse, if the receptionist was confident enough to ask the patient.

‘But you need training to help receptionists do that signposting. We’ve got a new £45 million fund to support this. This includes training on spotting serious conditions. Sometimes patients ask for an appointment in the next two or three days and a well-trained receptionist should spot they need to be seen immediately.’

What about actions at national level?

‘Last April, there was an increase in funding through GMS, new money for indemnity cover, premises and IT development. The recruitment blackspots have had new bursary schemes.

‘We’re going to be funding new international recruitment, and doing a lot more work to improve return to work. Lots of people take time out, but returning to practice is a bureaucratic nightmare, so we’re making it simpler and cheaper.

‘Also, practices have been sharing solutions to workload problems. Hospitals have training for leadership, service improvement and management techniques, but general practice has been left to its own devices. So, part of the development programme is opportunities to train managers and admin staff and nurses and GPs with those skills.

How will the funding be split for the £6 million Practice Manager Development Programme?

‘We’re currently asking practice managers what they would like. What we’ve heard so far from practice managers is a clear message that first, they want more opportunities to network, and to share ideas and experience between themselves. We want to build on this observation that there are lots of really good ideas already – some practices take twice as long as others to do a certain task, and we could just learn from each other. So we’ve had a clear request for there to be more opportunities for every manager in the country to meet their peers and share examples, not just online but also face to face.

‘Some parts of the country have good networks already, but others have nothing. We’ve been asked if we can use our national funding to beef that up. So we’re currently speaking to existing networks like Practice Index and the Practice Management Network about how we could use our funding to make that happen.

‘The second request is for help with the professional development for managers. We want primary care to be revitalised. A lot of that change will have to be led by practice managers day to day. It’s amazing that practice managers get so much done so effectively, but they’re one of the least resourced professions in the NHS.

What’s your view on seven-day working?

‘I think it’s good that the NHS is seeking to fill in some of the gaps for patients. And we know that in general practice the gaps are not mostly at the weekends, they are mostly in the evenings and, in some parts of the country, mornings, where too many patients find they can only get an appointment if they present it as an emergency. And we know that’s not best for them.

‘I’m also pleased that in the way we’re rolling out the programme to improve access from now until 2021, the specification is very clear that the service provided for patients should match what patients actually need.

‘So it’s not about every GP working seven days a week; or every practice even being open seven days a week. It’s about working across a group of practices, and you should match the number of appointments and the supply to the actual patient demand.

Do you think the GPForward Viewwill rescue general practice?

I think it’s a really good start on the road – not just to rescuing general practice, but to help revitalise it. Over the last few years it’s been too hard to just survive, and to deliver all the things we know we could do. The GPForward Viewaims to stabilise practices and support them to work differently. Five years ago, I was deeply worried about the future of primary care but now, I have never been so hopeful.

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