You only have to spend a short time with NHS England’s head of general practice development Dr Robert Varnam to realise his enthusiasm and passion for general practice. He is also extremely positive about the future for the profession, a view that is perhaps not currently shared by many GPs on the frontline.
However, he believes that the government and senior management in the NHS have finally got the message that general practice should be at the heart of the health service – and are now prepared to invest money and effort to ensure it succeeds.
‘I feel optimistic about the future of general practice for the first time in 11 or 12 years,’ Dr Varnam says. ‘They’re taking general practice seriously - and we have some credible answers and solutions, not just more of the same.’
A GP in inner-city Manchester, Dr Varnam joined NHS England three years ago. Alongside his work in practice he has a background in academia where he conducted research into patient safety and quality improvement. He spent several years designing and running quality improvement systems with practices for the NHS Institute for Innovation and Improvement (a role he still holds) and as clinical lead for the RCGP’s Practice Accreditation Scheme.
He always wanted to help GPs be able to do their jobs better, but found himself increasingly frustrated that ‘many things in the system’ made it hard to do this. ‘In recent years many things have meant general practice looks under threat and that’s really concerning,' he says. 'Even if you’re not a GP, you can see that general practice is one of the reasons the NHS is affordable and one of the reasons the NHS is brilliant and we can’t let it go.'
This is why he took up his current post - at a point when, he says, NHS England was starting to look seriously at the problems in general practice and was open to finding solutions.
GP Forward View
A big part of the solution NHS England is proposing is the GP Forward View, which Dr Varnam helped to create. He believes the strategy is ‘absolutely essential’ to tackle the challenges faced by general practice.
‘When it first came out a lot of practices said it was very long and complex. But there are so many things wrong, that to believe there was a silver bullet would have been foolish. You need to be helping premises and IT and workforce and addressing workload. If you only did one or two of those things then some practices would have been OK, but you need to deal with the challenges across the board.’
The RCGP and BMA have both been critical about the rollout of the programme, saying money and support has been slow to reach practices. However, Dr Varnam says GPs are now starting to see the effects of extra funding.
Some 2,100 of the most vulnerable practices have now received money, hands-on support or both under the practice resilience programme and its predecessor the vulnerable practice programme. Meanwhile, over the next six to 12 months all practices will start to see more money coming through via their contracts, which includes increased funding for indemnity and other costs, says Dr Varnam.
There will also be more money coming into general practice from CCGs. During 2017/18 and 2018/19 CCGs should be spending around £3 a head, around £171m in total, to support initiatives in the GP Forward View that will help make practices in their area more sustainable. Dr Varnam also points to the £6 per head extended access funding that all CCGs will have by April 2019.
In addition, sustainability and transformation plans (STPs) will deliver more funding to general practice in the longer term, Dr Varnam believes. He says that STPs have recognised the importance of moving money to general practice if workload is to move into primary care.
However, he admits that some aspects of the GP Forward View have been slow to get off the ground, in particular funding for premises improvement. ‘In some parts of the country we didn’t have access to all of the right expertise to be doing some of the premises approval and planning and that was difficult for practices in those areas. But processes have been streamlined and staff are in place so finally people are moving on things that have been very, very slow for the first nine or 12 months.’
While extra funding is part of the solution, Dr Varnam believes that practices will have to embrace new ways of working to deal with a growing workload. He says collaboration between practices is the key.
‘I’ve spent a lot of the last three years, all the time leading up to the GP Forward View, trying to understand the challenges facing general practice and listening to GPs. And the three biggest things you most often hear GPs saying about their workload is, there’s too much of it; the complexity of paperwork has really shot up over the last three to five years; and the appropriateness of my clinical work is increasingly a frustration.
‘As soon as you bring a group of practices together and start to measure the work they’re doing – how many people see a GP and how many people could have been seen better by someone else – practices themselves are coming up with figures between 15% and 45% of GP appointments that could have been dealt with differently. And they’re coming to the conclusion that if they did things together they could share a physio, or two or three pharmacists, or train their receptionists in actively signposting.’
He says that of course primary care needs more GPs and other staff, but it will take time to train these people so in the interim practices need to look at what they are doing on a daily basis and learn from other practices that have ‘found a better way’ of meeting patients’ needs.
10 High Impact Actions
This is the idea behind NHS England’s 10 High Impact Actions, which Dr Varnam has been the driving force behind. These actions, he explains, are a quick route into how practices can make improvements and make themselves more sustainable. They aim to free up time to deliver more clinical care.
He says the response from CCGs and practices has been overwhelming and points out that some small changes can make a huge difference to many practices.
'We’d hoped that in 2016/17 maybe around a fifth of CCG areas would express an interest in some help. We got to the end of the financial year and it was nearly 40% – there are also places where they haven’t done it at CCG level but GPs have done it at their practice.
‘We’re seeing so far that every single one of the actions has impact. The impact varies between about 5% of GP time up to about 15% or maybe more.
‘It’s really easy to assume that every solution has got to be really big, but frankly most days if I had one or two fewer appointments the day would feel better and I’d do a better job. For some GPs if you save 20 or 30 minutes a day all sorts of other, bigger changes can become more feasible.’
But, again, Dr Varnam highlights the benefit of undertaking changes like this across a federation or in collaboration with neighbours. ‘You can get things done more quickly and make your federation way more meaningful,' he says.
‘If we don’t work differently we will be overwhelmed by workload. It’s right that the system is doing all it can to reduce inappropriate transfer of work from hospitals. But it is also right that the system is doing all it can to help people manage their work differently, because just carrying on doing the same doesn’t work for anyone – not for patients, GPs or the rest of the practice.’
Dr Varnam says that the support from NHS England is now there to help GPs and CCGs to make positive changes in primary care, which is why he is optimistic about the future.
‘We’ve gone from a situation where I was laughed at when I said we need to be concerned about general practice hitting a brick wall to finally having [NHS chief executive] Simon Stevens saying "yes primary care is at the heart of the NHS we need to do something and yes here’s money and yes here’s ideas",’ he says. ‘It’s such a relief.’