Latest / Embedded / What Really Drives Decision Making in General Practice Embedded Conversations With Andy Pow. Ep 4

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What Really Drives Decision Making in General Practice Embedded Conversations With Andy Pow. Ep 4 · Embedded

• 0:03
  Welcome to Embedded Conversations, the
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  podcast that explores what it takes to
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  embed ideas, innovations, and
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  partnerships inside the NHS. I'm Scott
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  McKenzie, and I work with NHS leaders,
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  commissioners, and life science
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  companies to change patient pathways for
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  the better. This podcast brings those
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  ideas to life through shared stories
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  from people inside the system who talk
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  honestly about what works, what doesn't,
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  and what it takes to embed change in the
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  real world. If you're working in,
• 0:30
  around, or with the NHS and you want to
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  understand how change really happens,
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  you're in the right place. For those
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  that don't know me, I'm Scott McKenzie,
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  and today I am delighted to be joined by
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  someone with a wealth of frontline
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  knowledge and experience, Andy Pow. Andy
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  is a medical accountant with a deep,
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  actually deep, deep experience in the
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  financial and contractual side of
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  general practice. He's got a really
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  strong track record of navigating GP
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  contracts, partnership pressures, PCN
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  level decision-making, and we've just
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  been having a chat before we started
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  about the development of integrated
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  neighborhood teams. So, Andy brings a
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  real insidider perspective on what
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  really drives the behaviors in primary
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  care. So my plan for this episode is to
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  unpack some of the most pressing issues,
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  how the GP contracts are structured, the
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  real financial pressures on practices,
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  why the engagement with mittens
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  optimization or industry-ledd projects
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  often stalls, and Andy, I'm hoping, will
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  also share his views on how US companies
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  can better engage with practices and
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  networks and what the future might hold
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  for general practice with integrated
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  care and neighborhood teams. So Andy,
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  thank you for agreeing to come and talk
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  to me and joining me. It's absolutely
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  brilliant to have you on.
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  >> Yeah. Well, thank you very much for
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  inviting me along.
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  >> You've got huge experience and we've
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  often compared notes over oh many years.
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  I was trying to work it out. It's a long
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  time um that we've been comparing notes
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  with each other. So yeah, I'm really
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  really grateful to you.
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  >> Yeah. No, I've been doing this job now
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  for I hate to say it more than 30 years.
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  So, um, it's changed an awful lot and I
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  think we're about to go through another
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  period of change, although maybe not.
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  We'll talk about that perhaps later on.
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  Um, see how things develop. But I think
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  it's certainly a very challenging time
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  within the NHS at the moment.
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  >> I I'm with you. I was saying the other
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  day to one of the customers, I don't
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  think I've ever known it as challenging
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  as it is right now. We often talk about
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  the money back dropdrop, but the reality
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  is for general practice, they're
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  drowning in workload, but they're not
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  getting the investment to cope with that
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  workload.
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  >> Yeah. So, I mean, certainly over the
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  last few years, investment has very much
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  stalled.
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  >> Um, and and whilst the government, and
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  you have to remember in the NHS, when we
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  talk about the NHS, it's split between
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  the countries. So, England, Scotland,
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  Wales, Northern Ireland. So, I think
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  we'll just really concentrate on
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  England, which is my specialism. But you
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  know over the past few years it's been a
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  very tight uplift in terms of funding.
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  Um yet most people don't realize that GP
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  practices are effectively independent
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  businesses contracting their time to the
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  NHS
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  >> which means they are just like you know
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  Tesco's and all your shops in that you
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  know ultimately you've got income coming
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  in and you've got your expenses you've
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  got to incur. So when you had a period
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  of income being very tight and expenses
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  as we know have gone up um because of
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  the the inflationary impact um in the
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  economy you've got a really problem
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  problematic position and then you
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  combine with that then the demand that's
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  being placed on them. Um I mean the
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  sheer number of appointments that are
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  now going through general practice has
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  just gone uh you know it's gone through
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  the roof. Um lots of reasons for that.
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  Um, partly it's it's the better ability
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  to do different types of appointments
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  which will actually encourage people to
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  use things more, but secondly the
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  pressures in terms of the secondary care
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  system. You know, if if someone's stuck
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  on a waiting list, they're not getting
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  better. Um, they're going to
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  miraculously solve their problems. In
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  fact, they're going to get worse over a
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  period of time. So, that's going to
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  result in a recurrent amount of work
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  that they are now doing in in terms of
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  dealing with that.
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  >> So, yeah, two different sides of the
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  pressure really.
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  >> Totally. you touch on on a number of the
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  real hot points that come up in my work
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  all the time that a p if the service
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  isn't there or the patient doesn't get
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  access to care and they feel unwell
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  they'll just keep coming and of course
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  the the contact point tends to be
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  general practice and I I often get the
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  the GPS and the practice team saying to
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  me a lot of the time people are just
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  asking can I speed up their outpatient
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  appointment which of course they've got
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  absolutely no control over so we're
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  losing a load of appointments on a
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  dayby-day basis to really no purpose
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  there's not much that they can do with
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  them. And of course, that backdrop that
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  you've just given us of the money, that
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  was really where I was hoping we might
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  start. Can you give the listeners a kind
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  of a quick overview of core contract,
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  how it's structured financially, and
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  what really does drive the income for
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  practice um for practices because one of
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  the things I highlight is they are one
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  of the few bits of the NHS that is
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  interested in the turnover and whether
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  they make any money. profit, turnover,
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  profit and cash flow. A lot of the rest
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  of the NHS gets fixated on turnover.
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  They see turnover as income rather than
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  actually working out the true cost of
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  delivery, but general practice can't
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  afford not to do that. So, I was hoping
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  you might share some insight for us.
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  >> Yeah. So, I mean, general practice, as I
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  said before, it's it's operated through
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  what's called the independent contractor
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  model, which means they are independent
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  businesses which effectively, you know,
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  contract their services to the NHS.
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  >> Yeah. And being the nature of the work
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  they do, the majority of their income
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  comes from one customer which is the
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  NHS.
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  >> And bizarrely enough, it's the customer
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  that defines the income. Um so, you
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  know, it's not it's not you, you know,
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  selling a service and you try and set
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  your price. Actually, the price is set
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  by the customer and you have to deal
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  with it.
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  >> Um GPS, most GPS still operate through a
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  partnership model. Yeah, there is an
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  increasing amount of um core providers
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  into the marketplace, but they tend to
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  built up their uh portfolio of GP
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  practices by more than just targeting
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  practices that are perhaps more in
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  distress and have gone out for tender.
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  So, they're not huge at the moment. So,
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  it's mainly a partnership model. Um, as
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  I said, the income um comes through a GP
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  contract. There's three different types
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  of the GP contract, but actually for all
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  intents and purposes, they are all the
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  same. um and the bulk of the income that
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  they therefore get through that contract
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  is l linked to the number of patients
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  that go on the list. It's very much a
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  bottoms on seat equal money that comes
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  in. Um which to me isn't probably the
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  best way of funding. Um but that's the
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  reality of what we've been left with and
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  this has been stuck now with you know
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  this is a contract that is now
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  >> in its 21st year. Um so it was designed
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  back in the early 2000s and things are
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  completely different now. So the major
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  majority of income comes through what is
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  called the global sum.
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  >> Yeah.
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  >> And the global sum is basically paid to
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  a practice on a monthly basis based on
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  what's called a weighted list size. So
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  they take the actual patients on the
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  list and apply a number of different
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  weightings. The biggest example age sex.
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  So if you got older patients on your
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  list compared with average you will get
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  a slightly higher waiting. Um but that
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  funding is £123
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  per patient per year on average. Um, and
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  you put that into the context of, you
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  know, what you're paying your vet for
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  your
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  >> your cat's insurance, what you pay Sky
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  for your your TV package. It is a small
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  amount of income and essentially there's
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  an all you eat buffet. You know, a
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  patient can come as many times as they
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  want.
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  >> Yeah. Yeah.
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  >> On top of that, there are other income
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  streams. Um there is a small income
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  stream that goes called the quality and
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  outcomes framework which is um designed
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  around doing certain things um for your
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  patients that that is meant to be around
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  quality and actually ensuring patients
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  are getting the right treatment in some
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  of the the clinical domains. um
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  practices also can um do further
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  services uh under what's called enhanced
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  services and these are either nationally
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  set um which are diminishing really
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  really the national ones are now limited
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  to to to vaccinations and minimizations
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  and and we'll touch perhaps on PCN's
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  later
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  >> um but locally it's really important
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  local will now commission uh their
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  practices to do um local enhanced
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  services and then there's a whole heap
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  of other income that some comes through
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  training um so when they train doctors.
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  Um they get a training grant, but it's
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  not huge. Um they get reimbursed for
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  their property or some of their property
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  expenses, but that's really limited to
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  the rent and rates. All the other
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  property expenses are, you know, heat
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  and light, um cleaning, etc. are a cost
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  of the practice.
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  >> Um in terms of drugs expenditure, um the
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  majority of practices aren't dispensing
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  practices. You have you do have
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  dispensing practices in rural areas,
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  >> but there's a a small cohort of what's
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  called self-administered drugs. You
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  know, the good example is the flu
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  vaccine
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  >> practices will buy that in and will get
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  reimbursed by uh the NHS for that, but
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  they are not dealing with the overall
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  drugs budget of the practice. And that
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  that's a really important point to make
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  over. You know, it's not that they get a
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  massive budget to deal with the drugs
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  that the
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  >> yeah patient list that's not going
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  through the practice at all.
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  um they can also do private work um so
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  report fees and maybe some research but
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  really actually the majority of
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  practices 98 99% of the income will come
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  via this NHS contract
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  >> out of which they then have to pay all
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  the expenses so you know the bulk of the
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  expenses are staff cost by by far so all
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  the staff are employed
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  >> um by the practice um second biggest
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  cost tends to be premises but you've got
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  all your admin costs as well so just
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  like business
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  Um the peculiarity and there are many
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  peculiarities of general practice then
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  comes in terms of primary care networks
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  which many of your listeners will be
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  aware of but primary care networks are a
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  sort of weird
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  >> thing in that they are um commissioned
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  through the individual GP contract
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  >> so commissioned at practice level but
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  actually the practice has no overall
• 10:16
  control of that funding and effectively
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  it's it's a group of practices coming
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  together with a bulk of funding which
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  they have to go and use in certain ways.
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  Um so that dynamic has caused I think
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  some issues around uh where things have
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  worked and
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  >> you know perhaps when we talk about the
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  future I'm not sure I'm not convinced
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  that commissions really understand the
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  dynamics that already exist.
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  >> It's a great point that you make because
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  I think one of the things that I pick up
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  is in fact let's let's turn it into a
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  question for you. How much do you think
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  things like local incentive schemes,
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  local enhanced services and the PCN
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  money actually affect decision making at
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  practice level? How how big an impact do
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  you think that has?
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  >> So in terms of the local enhanced
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  services, so what local enhanced
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  services are is basically the local area
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  will sit down and agree
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  >> it wants its GP practice to do X Y and
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  Zed services and we'll set a tariff rate
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  for that. So if you work in the hospital
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  sector, you'll be very aware of that
• 11:14
  kind of sort of funding arrangement. Um
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  it's a hugely important income stream to
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  practices. Um it it's now the the second
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  biggest income stream. So below global
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  sum local enhanced services and local
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  funded schemes are are bigger than the
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  quality outcomes framework.
• 11:31
  >> Um so it's a really important funding
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  stream for practices.
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  The problem with them is that you don't
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  know they're going to exist more than
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  one year ahead.
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  >> That's it. That is the issue. Yeah.
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  >> And and and yeah, I think there's a real
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  worry at the moment when in terms of the
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  10-year plan and talk around moving to a
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  neighborhood model that if there isn't
• 11:52
  any national funding coming in to run
• 11:54
  these neighborhoods, well, where are
• 11:55
  local area going to get that funding
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  from? They're going to have to take it
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  out of local budgets. So, there's a risk
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  of money that will get shifted from,
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  >> you know, practice funding up to
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  neighborhood. Yet the cost sits at
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  practice level.
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  >> That's it. Yes.
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  >> So it's going to cause a problem and
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  PCN's are a very good example of that.
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  Then they create a PCN's.
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  They created this chunk of funding which
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  has to be dealt with at network level
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  yet the problems are actually at
• 12:18
  practice level. So
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  >> you get a lot of conflict at times in
• 12:21
  that
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  >> you might get a a primary care network
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  which generally can cover anything from
• 12:26
  30 to 100,000 patients.
• 12:29
  >> Yeah.
• 12:29
  >> Um where you've got practices in there
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  which will have different issues going
• 12:33
  on. Um and and and it's not you know
• 12:40
  what each practice needs out of that PCN
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  in terms of its staffing structure that
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  comes through that route will be
• 12:46
  different and it just creates conflict.
• 12:48
  >> Yeah.
• 12:48
  >> So it it you know it is
• 12:51
  >> local local funding is huge and local
• 12:53
  you know the importance of local funding
• 12:55
  is uh essential to practices. is I mean
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  I had a we had a meeting with NHS I I'm
• 13:00
  a part of a a trade organization called
• 13:02
  ASMA the association of independent
• 13:04
  precious metal accountants and we meet
• 13:06
  with the likes of the NHS NHS England
• 13:08
  and the BMA on a regular basis and we
• 13:11
  met with NHS England last year and
• 13:12
  talking about local enhanced services
• 13:14
  and that you know because it was so
• 13:16
  fundamental to the you know to where
• 13:18
  it's going and the risk for practices if
• 13:20
  that money shifts.
• 13:21
  >> Yeah. And of course, one of the other
• 13:23
  things with local enhanced services that
• 13:24
  frustrates the life out of me, and if
• 13:26
  it's frustrating me, I guess it
• 13:28
  frustrates you as well, is that we've
• 13:29
  got exactly the same services in
• 13:31
  different bits of the same ICB being
• 13:33
  paid different amounts of money. And
• 13:35
  there's just no standardization to it
• 13:37
  there. You know, you what you get in
• 13:39
  Bath is different to what you get in
• 13:41
  Bristol is what you get is again
• 13:43
  different to what they're doing up the
• 13:44
  road in Newcastle or in Hartley or
• 13:46
  wherever. There isn't really a
• 13:48
  standardized approach to it.
• 13:50
  >> No, there isn't. and and there is a
• 13:52
  massive variation in terms of overall
• 13:54
  funding.
• 13:54
  >> Yeah.
• 13:55
  >> If we had a situation where you know say
• 13:58
  for example on average a local area had
• 14:01
  to provide 20 of patient funding over
• 14:04
  what services it agreed I could agree
• 14:06
  you know I could probably see that
• 14:07
  because actually the idea of a local
• 14:09
  area deciding actually what it
• 14:10
  priorities are is really quite important
• 14:12
  in delivering healthcare.
• 14:13
  >> Yeah.
• 14:14
  >> The problem is we don't have that. We
• 14:15
  have some areas doing maybe56 pounds a
• 14:18
  patient and other areas maybe 3040
• 14:20
  pounds a patient. It's a vast vast
• 14:22
  difference and that just changes what
• 14:24
  you can do as a practice. It changes
• 14:25
  what you can do potentially as a PCN. Um
• 14:29
  >> and then people can people then tend to
• 14:31
  look at areas and oh they're doing all
• 14:32
  this great stuff. You know it's great
• 14:34
  that they're doing well great but
• 14:35
  they're doing it because they're getting
• 14:36
  the funding.
• 14:36
  >> That's it. It's exactly that.
• 14:38
  >> And the other areas that aren't doing it
• 14:40
  aren't getting the funding. So it it
• 14:41
  it's it's it's the biggest variation you
• 14:44
  get within GP practice funding is health
• 14:47
  services.
• 14:47
  >> Yeah, completely. Do you think that that
• 14:49
  leads to a misconception in the wider
• 14:52
  system about how financially motivated
• 14:55
  the GPS are? I my observation would be
• 14:58
  well I think that it's more headsp space
• 15:01
  and capacity than it is money. I think
• 15:03
  when the money is correct, general
• 15:06
  practice will create the capacity, but
• 15:08
  it's not I don't think it's the money
• 15:10
  that motivates them. But I'd be
• 15:11
  interested in your thought.
• 15:14
  >> Yeah. Yeah. I mean, money
• 15:16
  it's difficult because you could you you
• 15:19
  you're trying to put one big group of
• 15:20
  people into one category and GPS are
• 15:23
  different. Some are very money focused.
• 15:25
  >> Yeah, totally.
• 15:26
  >> And business focused and others are
• 15:28
  actually not. You know actually there is
• 15:30
  no training you get through your medical
• 15:32
  career that makes you into a business
• 15:34
  owner. Um it's something I do in another
• 15:36
  piece of work I do uh with an
• 15:38
  organization called Medics Money. We
• 15:39
  support training GPS in understanding
• 15:42
  their business. Um because they don't
• 15:44
  get that training elsewhere. Um so not
• 15:46
  all are money focused but actually
• 15:49
  they are having to run a business and if
• 15:52
  their business is limited to the income
• 15:54
  coming in and the expenses going out
• 15:56
  actually if they are getting more income
• 15:58
  in they generally will invest more in
• 16:00
  their practice.
• 16:00
  >> Yes they do.
• 16:01
  >> So um
• 16:03
  they're not motivated necessarily by
• 16:06
  income but they do understand how
• 16:08
  important it is and if you improve that
• 16:11
  funding it takes away some of those
• 16:12
  headaches.
• 16:13
  >> Yeah. you know, it's at the moment. I've
• 16:15
  talked to a few people recently um some
• 16:18
  some actually some larger practices and
• 16:20
  they're having to look at, you know,
• 16:22
  cost cutting, which is just unbelievable
• 16:24
  in the current circumstances.
• 16:26
  >> Um you and and what cost they're going
• 16:29
  to cut. Well, the biggest cost they've
• 16:30
  got is staff. So, it's going to have to
• 16:31
  be staff.
• 16:32
  >> It usually is. Yeah, it usually is.
• 16:34
  >> You take that pressure away. Actually,
• 16:36
  you're not worrying about actually
• 16:37
  spending all that time trying to manage
• 16:39
  and run a a reducing budget. actually
• 16:42
  you you're then back focusing on service
• 16:44
  provision. Um so it is it is really
• 16:47
  important
• 16:48
  >> with my audience in mind the the pharma
• 16:51
  tech and device company guys. One of the
• 16:55
  things I wanted you to explain is that
• 16:58
  are the GPS rewarded in any meaningful
• 17:00
  way if they release savings? So if we
• 17:02
  make a big saving in the prescribing
• 17:04
  budget, is there an incentive um for
• 17:07
  them doing that or is that fundamentally
• 17:10
  just not available? That's a kind of
• 17:12
  part that could work, but there's no
• 17:13
  real incentive for the practices cuz a
• 17:16
  lot of the projects that the industry
• 17:18
  guys will turn up with will save.
• 17:20
  There'll be savings attached to them.
• 17:22
  Who benefits from that?
• 17:24
  >> It's a really good question. I think
• 17:25
  that's really, you know, in the context
• 17:27
  of where the NHS is at the moment. It's
• 17:30
  really important for anyone in operating
• 17:32
  that space to actually know who you're
• 17:34
  talking to and who's actually controls
• 17:35
  the purse strings. going back I don't
• 17:38
  know how many years you'll probably know
• 17:40
  better than me we used to have um you
• 17:42
  know prescribing incentive schemes
• 17:44
  >> we did yeah
• 17:45
  >> um where you know essentially you save
• 17:48
  money in terms of the overall drug
• 17:49
  budget some of that flow back to
• 17:51
  practices to be able to invest in their
• 17:52
  practices
• 17:53
  >> I've not seen that for many a year now
• 17:55
  >> I'd say over 10 years over 10 years
• 17:58
  >> um so so generally you know it is you
• 18:01
  know ICBS will try and push down and
• 18:03
  we'll try and set um you know drugs
• 18:06
  expend expenditure control that
• 18:08
  practices have to try and perform to but
• 18:10
  there's no actual financial benefit that
• 18:12
  flows down to practices if they do that.
• 18:14
  So you are reliant on the practices just
• 18:16
  playing ball with the ICB. Um so again
• 18:20
  you know from your your you know
• 18:22
  listener viewpoint actually talking to
• 18:24
  practices about it isn't really going to
• 18:27
  particularly result in any particular
• 18:29
  benefit because yeah practices will be
• 18:31
  interested but they can't do anything
• 18:32
  about it. They're not going to see the
• 18:34
  benefit for it. you've got to be talking
• 18:36
  perhaps at the commissioning level. Now,
• 18:37
  how that commissioning level changes is
• 18:39
  going to be quite important because
• 18:41
  through the the 10-year plan and indeed
• 18:43
  what's you know the government have set
• 18:45
  out in terms of contracting the number
• 18:47
  of commissioners at ICB level and NHS
• 18:50
  England eventually disappearing into the
• 18:52
  department
• 18:54
  >> that's going to change who who's going
• 18:56
  to be making the decisions. So um there
• 18:58
  may be more local decisions but it'll be
• 19:01
  perhaps maybe at other you know the the
• 19:04
  I guess almost similar to the old CCG
• 19:06
  sort of population sizes.
• 19:08
  >> Yeah.
• 19:08
  >> Um but actually not a practice level.
• 19:10
  Now when it comes to IT slightly
• 19:12
  different scenario
• 19:14
  >> um with it the the main clinical systems
• 19:18
  tend to be again it doesn't actually
• 19:20
  flow through the practice.
• 19:21
  >> Yeah.
• 19:22
  >> Um the cost of that is picked up at
• 19:24
  commissioning level.
• 19:25
  yet other bits of the IT system where
• 19:28
  you know maybe you are looking at you
• 19:30
  know some scribe software or some
• 19:32
  software around registration
• 19:35
  management um then that tends to be done
• 19:38
  either at practice or PCN level um but
• 19:41
  you can have it at commissioning level
• 19:42
  so you can have it actually at three
• 19:43
  different levels and and again you know
• 19:45
  what you said about different areas
• 19:47
  being different that's exactly the
• 19:48
  problem what happens in Newcastle will
• 19:50
  be completely different to what happens
• 19:52
  in Bristol Bath um so which isn't pretty
• 19:55
  helpful if you're running a business
• 19:56
  trying to sell into the NHS, you know,
• 19:58
  that you've got to find out every time
• 20:00
  who actually I need to be talking to.
• 20:02
  >> Um, so essentially, yeah, the control of
• 20:05
  that expenditure isn't really and the
• 20:07
  benefit of making savings isn't really
• 20:10
  at practice level, unfortunately.
• 20:11
  >> Yeah. I mean, I mean, it is an area I do
• 20:13
  little bits of work with where we might
• 20:16
  propose to a commissioner, there's an
• 20:18
  opportunity for a saving here. you could
• 20:20
  have 50% of that saving in return for
• 20:24
  50% of it coming back to the networks,
• 20:27
  the federation, the whatever that's
• 20:29
  actually going to deliver the work. And
• 20:30
  I'm often amazed that that just doesn't
• 20:33
  land. It just gets, you know, either
• 20:35
  ignored or completely rejected. I I do
• 20:38
  find that frustrating because that I'd
• 20:40
  rather have 50% of something as 100% of
• 20:43
  nothing, but we are up against it.
• 20:45
  >> Yeah. Yeah. Um,
• 20:49
  >> do you think so looking at where we are,
• 20:52
  we've looked at the kind of the
• 20:53
  contracting models, the how the money
• 20:55
  flows and and such like, do you think
• 20:57
  we're actually at a point now where
• 20:59
  we're heading towards a new funding
• 21:01
  model for general practice? And and if
• 21:03
  we are, how quickly might that happen?
• 21:06
  And what would you, if you were
• 21:08
  negotiating it, what would you like to
• 21:09
  see?
• 21:11
  >> So, I'm going to be a bit like a
• 21:13
  politician here and say yes.
• 21:15
  Um so yes yes we are heading towards a
• 21:17
  new funding model. Okay. Government well
• 21:19
  the government had committed to a
• 21:21
  renegotiation of the GB contract within
• 21:23
  the current parliament term
• 21:25
  >> and I believe those discussions initial
• 21:28
  discussions are going to set off uh in
• 21:30
  the autumn of this year.
• 21:32
  >> Okay.
• 21:32
  >> Um so there will be some movement on
• 21:35
  that. We have the 10-year plan that's
• 21:37
  come in which has created
• 21:39
  >> two new entities, a single neighborhood
• 21:41
  provider and a multi- neighborhood
• 21:43
  provider. um used that we've kept the
• 21:45
  threeletter NHS acronyms there so um but
• 21:49
  people like me that just use the three
• 21:50
  letters can carry on coping with it but
• 21:52
  um single neighborhoods 50,000
• 21:54
  population multi- neighborhoods around
• 21:56
  about 250,000
• 21:57
  that's going to be interesting how they
• 21:59
  fit that round communities
• 22:00
  >> totally but I I I suspect it'll be
• 22:03
  fairly fluid um so we're going to see
• 22:07
  stuff going through neighborhood
• 22:09
  >> Mhm. But the difficulty is how that then
• 22:12
  interacts with primary care networks who
• 22:14
  have kindly sat you know sat at that
• 22:15
  certain that smaller neighborhood model.
• 22:18
  Um we're going to see a new GP contract
• 22:21
  model being proposed. Um the other thing
• 22:24
  the government have mentioned is they
• 22:25
  want to move change the waiting factors
• 22:27
  in the global sum particularly to uh to
• 22:31
  take account of more deprivation issues
• 22:33
  and quite rightly so because actually
• 22:35
  deprivation is never dealt with properly
• 22:36
  through the global sum. Yeah.
• 22:38
  >> So, it's interesting how they're going
• 22:41
  to fund that bit. They're going to fund
• 22:43
  it by taking away money from ICBS,
• 22:46
  particularly in deprived areas. So, it's
• 22:49
  kind of like robbing Peter to pay Paul.
• 22:51
  >> Paul. Yeah. Yeah. Yeah.
• 22:52
  >> So, we shall see see what's going on
• 22:53
  there. So, yeah, we're going to get a
• 22:56
  new model appear. The no though
• 23:00
  >> comes in by the view that actually there
• 23:02
  isn't a lot of money in the NHS at the
• 23:04
  moment.
• 23:04
  >> The biggest issue. the the settlement
• 23:06
  for the NHS has now been agreed for the
• 23:08
  rest of the parliamentary term. It's a
• 23:10
  lower level than it's ever been
• 23:12
  >> um in in terms of real growth.
• 23:15
  >> Um
• 23:18
  in most areas, certainly in the
• 23:19
  secondary care sector, they're still
• 23:21
  operating in deficit. Um so they've got
• 23:23
  to bring that deficit down to zero and
• 23:25
  generate some spare capacity to actually
• 23:27
  fund the community side. So I'm
• 23:29
  struggling and I you know as we've had
• 23:32
  discussions I'm struggling to see where
• 23:33
  the money's going to come from to fund
• 23:35
  this.
• 23:35
  >> It's been theible
• 23:38
  change.
• 23:38
  >> Yeah. To get any sizable change you're
• 23:40
  going to have to dual run things.
• 23:41
  >> That's it. That's the point I keep
• 23:43
  making. Yeah.
• 23:44
  >> You can't just shift say right hospital
• 23:46
  you're going to shrink because community
• 23:48
  is going up. Actually community's got to
• 23:51
  go up first to actually create the
• 23:53
  capacity for the hospital to shrink
• 23:55
  which means double running costs.
• 23:56
  >> Yeah. And it's just not factored in
• 23:58
  anywhere.
• 24:00
  >> No. So I think yeah that's that's
• 24:03
  yes something will happen but no I'm not
• 24:07
  convinced it's going to be as wholesale
• 24:09
  as perhaps the government have made out
• 24:11
  in the 10 year plan.
• 24:12
  >> Um I was I was going to make that my
• 24:14
  last question but you've actually given
• 24:16
  me an extra thought.
• 24:18
  I'm now that I've got you I'm going to
• 24:20
  keep you for a minute more. Um so with
• 24:23
  that in mind we we're going to see
• 24:25
  something. I'm with you. we are going to
• 24:26
  see some sort of new contracting round.
• 24:29
  Um how do you see the role of general
• 24:31
  practice evolving in that new wider
• 24:34
  integrated care system neighborhoods and
• 24:38
  do you see a time coming again keeping
• 24:40
  in mind the listeners where valuebased
• 24:44
  contracting or outcomesbased
• 24:46
  commissioning might be the route forward
• 24:49
  with general practice. So rather than
• 24:50
  like we had waff input driven we do all
• 24:54
  the inputs but nobody really seems to be
• 24:56
  measuring the the outcome. Do you see
• 24:58
  that change coming where we might be
• 25:00
  more outcome focused rather than input
• 25:02
  focused? I promise you that's my last
• 25:04
  question for you.
• 25:04
  >> Yeah.
• 25:06
  >> So pra I think this is where the level
• 25:08
  is quite important. Yeah. Um at practice
• 25:10
  level the problem we've had is when
• 25:14
  we've had these sort of uh reward-based
• 25:17
  systems you know you do this you will
• 25:19
  get paid that generally you get paid in
• 25:21
  a rears
• 25:22
  >> yes
• 25:23
  >> for that whereas actually the way
• 25:24
  general practice is set up it's you know
• 25:26
  it's cost base is fairly fixed the
• 25:28
  majority of it staffing the majority of
• 25:30
  it the rest is is premises it's going to
• 25:32
  be pretty similar month in month out so
• 25:34
  you've got a regular cost going
• 25:36
  >> and we've had a regular income um so
• 25:39
  whilst things like the global summer
• 25:40
  regular you know qua you get you used to
• 25:43
  only used to get 30% paid like three
• 25:45
  months after the year end yeah it's
• 25:47
  dropped to 20%. Um but other rewards as
• 25:51
  well um through the the PCN route get
• 25:53
  paid once you've you know the year's
• 25:56
  completed it's quite difficult to run a
• 25:58
  business you went to Tesco's and told
• 26:00
  them um sorry Mr. Tesco is actually, you
• 26:02
  know, your your patients are only your
• 26:04
  sorry, your customers are only going to
• 26:05
  pay you 80% of the grocery bill now and
• 26:08
  as long as they're happy with it,
• 26:09
  they'll get 20% down the line. Um,
• 26:12
  they're going to say we can't run our
• 26:13
  business that way,
• 26:15
  it's really difficult to do that. Yeah,
• 26:17
  >> I think when we move to the neighborhood
• 26:19
  levels and the perhaps maybe I'm
• 26:22
  probably talking maybe the multi-
• 26:23
  neighborhood provider which is that big
• 26:25
  250,000
• 26:27
  >> that has to be designed around trying to
• 26:29
  get outcomes changed.
• 26:31
  >> Um so I think there has to be definitely
• 26:34
  some kind of reward and incentive in
• 26:37
  that system to be able to do that.
• 26:39
  >> Yeah. But again, I do worry um I do
• 26:42
  worry about, you know, simple cash flow
• 26:44
  here and and the working capital needs.
• 26:46
  We've had, you know, we've come across a
• 26:48
  few PCNs which struggled when they had
• 26:51
  to scale up in just in terms of managing
• 26:54
  the cash flow.
• 26:55
  >> You missed the month's payment, you were
• 26:57
  in uh dire situations.
• 26:59
  >> Yeah. Yeah.
• 27:00
  >> You know, hospital trust will probably
• 27:01
  get away with it because it's just a big
• 27:03
  budget, but actually these are all
• 27:05
  independent organizations.
• 27:07
  >> Yeah. So there's there's a big risk on
• 27:09
  that and you know anyone who's listening
• 27:12
  looking at going down this route um to
• 27:14
  me I would just say working capital make
• 27:17
  sure you understand your working capital
• 27:19
  needs as you grow these these these
• 27:20
  neighborhoods because if you don't it's
• 27:22
  going to fail. Um
• 27:25
  so
• 27:28
  I suspect yes there will there's going
• 27:30
  to have to be you know if we're going to
• 27:32
  drive cost reduction
• 27:33
  >> y
• 27:34
  >> we're going to have to start doing all
• 27:37
  the things you've talked about in terms
• 27:39
  of you know looking at drugs budget
• 27:40
  looking at technology changes that will
• 27:42
  drive real benefits um in terms of
• 27:46
  overall cost um and hopefully clinical
• 27:49
  care as well you know it's not just cost
• 27:51
  but focused on cost. Yeah, it's a great
• 27:53
  point.
• 27:55
  >> It is a great point because I think that
• 27:57
  one of the things that we've never
• 27:58
  really done is what I call measurable
• 28:01
  value. What's the measurable value of
• 28:04
  the input? So, I'm giving this an input,
• 28:06
  but what's the outcome? What's the
• 28:07
  measurable value that that input
• 28:09
  delivers? I don't think we've ever
• 28:11
  really looked at it like that. And for
• 28:12
  me, it's what's missing. It's what
• 28:14
  industry as well. It's what the pharma,
• 28:15
  the medtech, and the device companies
• 28:17
  need to start thinking about is if I
• 28:19
  work with, you know, PO McKenzie
• 28:22
  Pharmaceuticals, what's the measurable
• 28:24
  value that they deliver me as an NHS
• 28:26
  customer? I think that's where we're
• 28:28
  headed. They're going to be much more
• 28:29
  outcome focused rather than input
• 28:31
  focused.
• 28:33
  >> Yeah. I mean, you know, absolutely. You
• 28:35
  if you're going to be spending a million
• 28:36
  pounds, for example, you want to know
• 28:38
  actually how that's going to change.
• 28:40
  Yes, it you know it may change in terms
• 28:42
  of clinical outcome for for a group of
• 28:45
  patients
• 28:46
  >> but also if that million pounds is
• 28:48
  actually going to save me you
• 28:49
  know500,000
• 28:51
  >> as well as provide that clinical benefit
• 28:53
  for the patients in other parts of the
• 28:55
  system
• 28:56
  >> um then
• 28:58
  you know to me that's a no-brainer but
• 29:02
  it rarely happens in the GP space I mean
• 29:04
  we have so many contract you know small
• 29:07
  practices that fall over um financially
• 29:10
  And no one's ever measured actually if
• 29:12
  we just prop those up with the financial
• 29:14
  support they needed which is not a huge
• 29:15
  amount of money
• 29:16
  >> what it saves in terms of um you know
• 29:19
  referrals to hospitals and
• 29:21
  >> um the cost in the secondary care sector
• 29:23
  will be huge but no one ever measures
• 29:25
  that.
• 29:26
  >> No that's a real measurable value to me
• 29:28
  as well.
• 29:29
  >> Yeah it's always just measured on just
• 29:31
  where we are at today. It's not no
• 29:33
  downstream stuff coming in. Um, so yeah,
• 29:36
  I mean maybe hopefully things will
• 29:39
  evolve that way. I don't know.
• 29:41
  >> Let's wait and see what
• 29:44
  >> at some point having you back. Will you
• 29:46
  be happy to come back as things evolve?
• 29:48
  >> Yeah, absolutely. We'll be happy to come
• 29:50
  back. Yeah.
• 29:51
  >> Fantastic. Andy, thank you very much.
• 29:53
  I'm so grateful to you for joining me
• 29:54
  and being my first guest, and I'm going
• 29:56
  to hold you to that promise. We'll
• 29:58
  definitely get you back at some point.
• 30:00
  >> Brilliant. Well, thanks very much for
• 30:01
  inviting me along.
• 30:02
  >> Oh, it's a real real pleasure. Thank
• 30:03
  you, mate. If today's conversation has
• 30:05
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