Latest / Embedded / What Makes a Successful GP Federation? | Embedded Conversations With Laura Norton. Ep 10.

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What Makes a Successful GP Federation? | Embedded Conversations With Laura Norton. Ep 10. · Embedded

0:02
Welcome to Embedded Conversations, the
0:05
podcast that explores what it takes to
0:06
embed ideas, innovations, and
0:08
partnerships inside the NHS. I'm Scott
0:11
McKenzie, and I work with NHS leaders,
0:13
commissioners, and life science
0:15
companies to change patient pathways for
0:17
the better. This podcast brings those
0:19
ideas to life through shared stories
0:21
from people inside the system who talk
0:23
honestly about what works, what doesn't,
0:25
and what it takes to embed change in the
0:28
real world. If you're working in,
0:29
around, or with the NHS and you want to
0:32
understand how change really happens,
0:34
you're in the right place. Hi everyone,
0:37
and welcome to another episode of
0:38
Embedded Conversations, where, as usual,
0:41
we're going to explore the people, the
0:43
ideas, and the organizations that are
0:45
shaping the future of the NHS and what
0:48
they mean for healthcare leaders, for
0:50
pharma, for medtech, and medical device
0:53
companies. I'm Scott McKenzie and today
0:56
I am absolutely delighted to welcome
0:58
Laura Norton. Laura is chief operating
1:01
officer for Northwest Leicester GP
1:04
Federation and that's also the primary
1:06
care network she works in there as well
1:08
serving more than 112,000 patients
1:11
across 12 GP practices. Now with over 20
1:15
years experience across both provider
1:17
organizations and commissioning, Laura
1:20
has become one of the leading
1:21
operational voices in primary care. Her
1:24
work spans everything from GP contracts
1:27
and commissioning through to workforce
1:29
redesign, neighborhood working, and of
1:31
course service transformation. Under
1:33
Laura's leadership, the federation has
1:35
developed really innovative services,
1:38
including a women's health hub that
1:40
reduced secondary care referrals by over
1:42
35%,
1:44
created a new workforce model, and
1:47
positioned itself as one of the leading
1:49
examples of collaborative primary care.
1:51
So today, we're going to explore what it
1:54
really takes to build a successful
1:56
provider organization, why some
1:58
federations thrive, why others struggle,
2:01
and what the future of neighborhood
2:02
healthcare might look like. Laura, it's
2:05
an absolute pleasure to have you with
2:07
us. How are you?
2:09
>> Thanks, Scott. Wow. I'm not sure I
2:11
recognize the person that you've just
2:12
introduced, but that's very, very
2:14
flattering. So, thank you so much. I'm
2:16
really well, thank you. How are you
2:17
doing?
2:18
>> I'm good, thanks. I'm good. And in
2:19
fairness to you, I only tell it as it
2:21
is. I'm lucky enough I get to work with
2:23
you. It's that's the real um good thing
2:26
in all of this. I do work with you and I
2:28
was just saying to you before everybody
2:29
else joined, I'm coming to do a workshop
2:31
with you in the not too distant future
2:32
and really looking forward to that. So,
2:34
everything's good at my end.
2:36
>> Yeah. Fantastic.
2:38
>> Good. So, let's dive straight in.
2:40
Building an organization. you've worked
2:44
um in in your career both on the
2:46
commissioning and on the provider side
2:48
of the NHS. So if you look back over
2:50
your career, what do you think that
2:52
you've learned about what actually makes
2:55
real change happen? What does it take?
2:58
>> Yeah, that's an interesting question. I
3:00
think at the moment I think we're at
3:02
this uh period of significant change
3:04
within the NHS and I think everybody's
3:06
sort of trying to find their way. Um,
3:08
and we're at one of those crossroads
3:10
that we're at, um, you know, over the
3:12
years when we go PCT to CCG, CCG to ICB,
3:16
etc. And everybody, it's almost like
3:18
everything's thrown up in the air and,
3:20
um, and then we see where it lands. And
3:22
I think when you're in that position of
3:24
uncertainty, it can be really
3:26
challenging. Uh, so I've been um I've
3:29
been a I was a commissioner for about 10
3:31
years and then I've been at the
3:32
federation for about four years. And I
3:34
think that um the things that really
3:37
would make change happen in my
3:39
experience would be clear vision um and
3:42
sort of being explicit about the goal
3:44
that we're trying to achieve which I'm
3:46
not sure we have in the current
3:48
landscape would be my my my personal
3:50
view both locally and nationally. Uh and
3:53
I think unless we're really clear about
3:55
the goal, everybody's sort of running
3:57
around slightly clueless at times trying
4:00
to get there. I think leadership is also
4:03
really key. Um, and having like a clear
4:05
kind of um a clear a clear leader um who
4:10
who knows where they're going, takes
4:11
accountability, um is approachable, etc.
4:15
And I think again um the current changes
4:17
that have happened within the NHS that
4:19
there's been a lot of good people that
4:20
have been lost. There's been a lot of um
4:23
things that have been really unsettling
4:25
for those that are remaining. So I think
4:26
overall it it becomes a really
4:28
challenging time at the moment. But I
4:31
also I'm always want to remain
4:33
optimistic and I think with adversity
4:36
comes opportunity. It does.
4:38
>> So I think we have to remain optimistic
4:41
that these things always happen. Yeah.
4:44
>> In different guyses and ultimately like
4:47
I think the NHS changes and modernizes
4:49
but sort of stays the same as well.
4:51
We're all people at the end of the day
4:52
and I think we will find the way but I
4:55
think we need that clear vision around
4:57
where we're trying to get to at the
4:59
moment. So I think that's a really good
5:01
point that you've just made and it it's
5:03
one I want to go and dig at just
5:04
slightly with you. I often say to people
5:08
what's the problem that you're trying to
5:09
solve? So whether it's a leadership
5:11
issue, it's a pathway issue, it's a
5:13
practice issue, what is actually the
5:16
problem we're setting out to solve?
5:17
Because if we don't know and understand
5:19
that, how are we going to know that
5:20
we've actually resolved the issue? So I
5:22
very much um kind of empathize with
5:24
where you are right now. It's almost
5:26
like somebody's come along and just
5:28
turned the NHS upside down and said
5:30
there's your new model, deliver it
5:32
without really having a road map. There
5:34
isn't really a this is the problem we're
5:36
trying to solve is my view of the world.
5:38
>> Yeah, I would agree. And I think even we
5:41
I'm sure we'll come on to talk about
5:42
neighborhood working later, but
5:44
>> it's just kind of makes me laugh that we
5:46
can't even define what a neighborhood
5:48
is. No one no one can define it. So if
5:51
and we've got so many it becomes then
5:54
like a a landscape where variability is
5:57
encouraged and that's I think damaging
5:59
for patients. So when we don't have like
6:02
clarity on our most basic things I think
6:05
it can be really challenging because
6:07
people then sort of fill the gaps don't
6:09
they? Oh, I'm going to be controversial.
6:10
I see you've opened the door and that's
6:13
risky.
6:14
>> Well, no, Scott.
6:16
>> I I don't mean it in and as in to be
6:18
awkward, but one of the things that I
6:20
find quite frustrating from a patient
6:21
perspective is patients don't experience
6:24
their care in organizations. They don't
6:27
get general practice, community
6:29
services, hospital trust, mental health
6:31
trust, community and voluntary sector.
6:33
That's not how they experience their
6:35
care. They experience their care in
6:37
pathways. And yet we talk we we format
6:40
the services around organizations
6:43
rather than around pathways. And again,
6:45
if I'm a wee bit controversial, I
6:47
actually think that's the opportunity
6:49
for a neighborhood in really simple
6:51
terms and knowing you as I do, I
6:53
actually think for a a federation like
6:55
Northwest Leicester, this actually might
6:57
be good because I think there's really
7:00
whether it's the acute trust you partner
7:01
with or community services or
7:03
potentially both of them. What we really
7:06
want to know is what's core general
7:08
practice, what's core acute, what's core
7:10
community and then where is the overlap
7:12
and how do we sort out the overlap. So
7:14
in simple terms, if you were going to
7:16
partner with, I don't know, district
7:18
nursing about um wound care, what's core
7:22
wound care in general practice? What's
7:24
core wound care for community and
7:26
district nursing? And then where is the
7:28
overlap where we don't know who owns the
7:30
patient, who's delivering it, where the
7:31
money sits. And if we fix that and and
7:34
the patient flows better, that to me is
7:37
what a neighborhood does.
7:39
>> Yeah. Absolutely. And that's what we
7:41
everyone's doing or trying to do
7:43
currently and has been doing for years.
7:45
So it's presented as a new thing. And I
7:48
think when you speak to sort of groups
7:50
of like jobbing federations, ECN's, GPS,
7:54
whoever, they're like, I don't really
7:56
understand why we're presenting this as
7:58
something new because it's what we're
7:59
already doing. Um, but unless we use it
8:02
as a chance to address those gaps, I
8:04
mean, it's always wound care, isn't it?
8:05
It's always
8:06
>> It was the one that came came to mind.
8:09
So, and you know that's an ideal thing
8:11
where you've got people that are really
8:13
kind of vulnerable and usually older
8:17
poor outcomes anyway having a really
8:19
poor experience because everybody builds
8:22
their inclusion and exclusion criteria
8:24
and then the patient's stuck in the
8:25
middle fallen where they you know they
8:28
they're not they're excluded from
8:30
various different things and there's no
8:31
one there to meet their needs. So, um I
8:34
think at the moment it's down to
8:35
providers to take the initiative to
8:37
solve those problems, but often it's not
8:40
it's not funded appropriately. So,
8:42
you're doing it. It's the right thing to
8:43
do
8:44
>> because you see, you know, your older
8:46
population um or you see the workload it
8:50
causes and so you you fill a gap and
8:52
that's what we often do as federations.
8:54
We
8:54
>> Yeah.
8:54
>> find a problem when we solve it and the
8:57
money doesn't then flow out
8:58
unfortunately, which is um which is
9:00
hard.
9:01
>> Well, there you go. you've given me the
9:02
topic to get you to come back and talk
9:04
to me about because we could we could do
9:05
a whole session on unfunded work
9:09
together please.
9:10
>> No no no not today but for for now I
9:12
want to take you in a slightly different
9:14
slightly different direction. So one of
9:15
the things that comes up a lot and and
9:18
your federation is a good example of it
9:20
112,000 patients across 12 practices.
9:23
What is or has been the biggest
9:25
challenge in getting 12 independent
9:28
businesses to think and act as one
9:30
organization?
9:33
>> Um I would say probably trust is key. Um
9:37
and that has is the thing that makes or
9:39
breaks your um organization and your
9:42
collaboration because ultimately
9:45
all practices are different very
9:48
different and they they're independent
9:50
and separate for a reason and generally
9:52
I think my practice is better than your
9:54
practice or you think you've got better
9:56
access or the way I work is poor and we
9:59
don't those thoughts aren't always
10:01
vocalized but even in small areas you
10:04
have that um they don't work together.
10:07
They're not merged for a reason and
10:09
that's because they all work
10:10
differently. So getting people to put
10:12
that aside and um look at working
10:16
collaboratively
10:17
can can be a challenge. And I think when
10:20
I've seen um federations in other areas
10:22
that have kind of fallen by the wayside,
10:25
it can often be a breakdown in
10:27
relationships that that does it. Um and
10:29
once people stop kind of playing ball um
10:33
that you know that that those things can
10:35
disintegrate quite quickly. Um and for
10:38
us trust came over time and it's still
10:41
it's not always
10:42
>> it's earned isn't it? Trust is earned.
10:44
You can't demand it from the practices.
10:47
You have to earn it as as the
10:48
federation. That's absolutely key.
10:51
>> Absolutely. And for me I think what
10:53
we've and like we we deliver we're a
10:56
complete atscale provider.
10:58
at scale and that's again taken time
11:01
because people in our some of our
11:04
practices would still prefer everything
11:05
to be delegated down to practice level
11:08
um and from money to activity to
11:10
everything and I think that's normal
11:12
wherever you go and if you're working if
11:15
you're not from a primary care
11:16
background that can often be a bit of a
11:18
kind of puzzling if you're not from that
11:20
environment but I think it's something
11:22
that's completely normal um that in my
11:24
experience so that sort
11:27
scale working and that trust has been
11:29
built over time. And my key I think
11:31
would be like showing people what what
11:34
do I get for it? What's in it for me?
11:36
What do I get that I wouldn't have
11:38
otherwise got? And showing your value.
11:41
And if you don't show your value,
11:43
>> you're probably going to fall by the
11:45
wayside. And I think you've kind of
11:47
touched on one of my kind of favorite
11:49
topics is that a lot of the time people
11:51
will often talk about governance and
11:53
structure and but the reality is and
11:56
what you've really highlighted is
11:57
success in a federation and that kind of
11:59
organization. What it really comes down
12:02
to is the culture and it's that I think
12:05
what you've done really well is built
12:07
the engagement, built the trust across
12:09
the the practices that have historically
12:11
worked independently and I know it's
12:13
something that you work at continually.
12:16
Do you think that is the secret? Is it
12:18
about the culture? Is it about the
12:19
environment that you create?
12:22
>> I think having good leaders is key. So
12:24
our like in terms of our clinical
12:26
leaders like we're very lucky in terms
12:29
of who we got and they're they're really
12:31
they're people that are generally like
12:33
well-liked well respected not divisive
12:35
individuals which really makes it easier
12:37
and like are a pleasure to work with and
12:40
sort of push that from the from the
12:41
front. So I think as a leadership team
12:43
we've got like a a shared culture that
12:47
then you hope trickles down. But yeah,
12:49
you just have to work at things and you
12:51
have to be willing to acknowledge when
12:53
things don't go right and what you can
12:55
learn from them doing it differently.
12:57
But as as I say, I think for us keeping
12:59
that innovative services, lots of
13:03
activity,
13:04
>> um some sort of return investment to
13:07
practices and whatever form that is in
13:09
activities or in profit depending on
13:11
your model. Yeah,
13:13
>> that I think that is really key because
13:14
I think then for the practices they if
13:17
they have a a grumble they think okay
13:20
things aren't necessarily perfect or I
13:22
would have preferred to maybe do it a
13:24
different way but this adds value and it
13:26
adds value for my patients therefore
13:28
it's worth investing the time in um and
13:31
I think that's just keeping that keeping
13:33
you know your practices engaged and
13:35
involved in that is key
13:37
>> and I think I mean you've t you kind of
13:39
touched on it in one of your earlier
13:40
points that there are federations that
13:43
fall by the wayside. But what you're
13:44
describing there is usually why they
13:46
fall by the wayside. It's usually
13:47
because they can't maintain the
13:49
engagement of the practices and we end
13:51
up it's almost like board versus
13:54
practice and that's never going to work.
13:56
That's never a model that's going to
13:58
last um in that environment. Is there
14:00
anything else that you kind of see as
14:01
the Yeah, that was the key to being a
14:04
successful federation versus the ones
14:05
that that don't make it.
14:08
>> Um I think that we have grown slowly. So
14:11
we have not been overly in terms of our
14:14
infrastructure. We've grown that over
14:16
time. we haven't been we we've been I
14:19
suppose in a way risk averse with some
14:21
of our um infrastructure and premises
14:24
and things because it people have needed
14:27
to go on that journey whereas I've seen
14:29
some federations who have invested
14:32
significantly in their staff team um as
14:35
a way to sort of deal with surplus um
14:38
income and then that is then really
14:40
difficult to maintain and it means that
14:42
the federation members think I've got I
14:45
question the value that this team is
14:47
adding to us. Whereas we run quite we've
14:50
run quite lean over the years and we've
14:52
made sure that we have spent our any
14:55
surplus on activity and delivering and
14:58
rein sort of reinvesting in clinical
15:00
services only. Um and that I think has
15:03
has helped because it means that we're
15:05
more able like we've got I I think you
15:08
all know and I think people won't mind
15:10
me saying that it things are challenging
15:12
at the moment. Some major financial
15:14
flows have changed. contracts have
15:16
ended. You mentioned the women's health
15:18
hub that's been really successful, but
15:20
the contract unfortunately is ended
15:22
because of the national financial
15:24
picture, not because of the performance
15:26
of our hub, but we, you know, we're so
15:30
we're having to run leaner than we have
15:31
before and diversify now um and look at
15:34
other income streams and that would have
15:36
been much more difficult if we had a
15:38
huge huge team.
15:40
>> Yeah. Yeah, I mean I feel that that your
15:41
example of the women's health hub is is
15:43
a good um example of things not not
15:46
working out but bizarrely for me in that
15:50
when that work stops the activity
15:53
doesn't stop. The activity won't go away
15:56
and there is only one place that
15:57
activity is going to end up and that is
16:00
in secondary care. or the patient
16:02
doesn't get care at all in which case
16:04
for some of them their conditions will
16:06
decline and they will still end up in
16:08
secondary care. It's one of the um I've
16:12
done quite a bit of work around this and
16:13
I've got a couple of projects running
16:15
around this very topic um up in the
16:17
northeast across in the northwest and
16:19
down in the southwest and everybody has
16:23
reached the same conclusion. you know,
16:25
the women's health hubs came, there was
16:26
pump priming, but what ICB seem to have
16:29
spectacularly failed to do is to build
16:32
on the pump priming to build a
16:33
sustainable service. So, as a result,
16:36
like you've experienced, they're they're
16:38
closing down. But the activity won't go
16:40
away. It will just sit somewhere else in
16:43
the system. And for me, that's a real
16:45
missed opportunity to actually build a
16:47
long-term sustainable service. And yours
16:49
is a great example of it. Look at what
16:51
you achieved with the reduction in
16:53
volume. 35%
16:55
reduction in secondary care referrals
16:57
that is now automatically going to head
16:58
straight back to secondary care.
17:02
>> Yeah. And um we've actually we were
17:04
actually asked by the ICB in one of
17:07
their board papers to say we'll still do
17:09
it anyway for no money. Um basically
17:12
what kind of activity could can you
17:14
sustain once the money stops? But I
17:16
think there's a real ethical discussion
17:19
here because for our 12 practices,
17:22
they're used to their patients getting a
17:24
really good service, secondary care
17:26
level service that they can refer into
17:29
within a week, two weeks max. And if
17:33
that if that stops, it's really poor for
17:37
patients practices kind of
17:39
reputationally. It's a real struggle.
17:41
And patients actually don't want to
17:42
hear, "We're stopping this because
17:44
there's no money." they're not
17:45
interested in that. It so we either as a
17:48
small provider bear the brunt of doing
17:51
something for free. It's always the
17:53
smallest providers that have to do that
17:55
or we stop it and we then get the
17:57
reputational risk or reputational thing
17:59
of
18:01
>> actually why you stopped it but it's bad
18:03
for me.
18:03
>> I've got a middle ground for you. I've
18:05
got a middle ground for you. I think
18:08
that you do stop but you are very clear
18:11
with the hospital if you want to
18:12
subcontract us the work back we'll
18:14
happily take it back from you this is
18:16
left shift for me in action is because
18:20
the work that we're talking about here
18:21
so question number one does it need to
18:23
be done in hospital absolutely not
18:25
you've absolutely demonstrated it can be
18:26
done in primary care second question
18:29
could it be protocol driven could we
18:30
work under the hospital's governance do
18:32
this do that do this do that if that
18:34
doesn't work you send them to us
18:36
absolutely
18:37
Number three, are there going to be
18:39
backlogs and bottlenecks in that
18:40
pathway? Automatically there are, cuz
18:42
you're about to return that 35% of
18:45
referral that you took out back to
18:46
secondary care. What happens if we get
18:49
somebody that's a bit more complex? Can
18:51
we create a rapid escalation route? Of
18:52
course, you can. So then it comes down
18:54
to the one thing that nobody wants to
18:56
talk about, which is the money. But the
18:59
hospital will have a choice. either
19:00
absorbs the work and spends the money on
19:03
their expensive consultant and nurse
19:05
teams or it could subcontract the work
19:07
back to you as a left shift. It's
19:09
exactly what neighborhoods are supposed
19:10
to be about and designed to do. So I
19:13
think that might be your middle ground.
19:16
>> Absolutely. And I that is something that
19:18
we have tried to pursue. So it's not
19:21
something that we are having much
19:23
success with at the moment but we will
19:24
continue to try.
19:27
I'll have a conversation with you
19:28
separate to this because we might be
19:31
able to
19:31
>> we might be able to help.
19:34
>> Yeah. Well, that would be great. But
19:35
it's I think it's difficult when we're
19:37
you got to remember, you know, but I
19:39
think for anyone listening like
19:40
federations, we've got small teams like
19:42
we don't have a big team. So, you've got
19:44
your like your precious energy. Where do
19:46
I put it? Do I put it into working out
19:49
what our future is going to look like
19:51
with SMPPS, MMPs, how we work now with a
19:54
provider collaborative or do I put it
19:56
into stuff like this? And you've got to
19:59
it's really it's really difficult to
20:00
know that most impact.
20:03
>> Let me go that route with you then
20:04
because I think that's a great point to
20:06
make. So when somebody does approach you
20:07
with a new idea whether it's from one of
20:11
the practices a practice manager the
20:13
hospital a pharma medtech a device
20:15
company what what does make you think oh
20:18
yes let's explore that and equally what
20:21
makes you think uh no I'm going to
20:23
politely decline that one what's the
20:25
dividing line
20:27
>> so I think the starting point is around
20:29
like the data and the priorities so we
20:32
know what we've got a three-year
20:34
community health and wellbeing plan
20:35
which has like priorities based on our
20:37
local uh health outcomes for our local
20:40
people and that's based on data plus a
20:43
local survey that was done a few years
20:44
ago. So a lot of the work we've done
20:46
around mental health has come from
20:47
there. There's also the ICB's three
20:50
priorities. Yeah. So we try and do work
20:52
that aligns with those areas initially
20:55
um to make sure that it's something that
20:57
is is sort of needed um and we're going
21:00
to get a good return for investment by
21:03
doing something like that. So we usually
21:05
pull a lot of data um and we have a sort
21:08
of centralized hub whereby we can look
21:10
at all of our data centrally which helps
21:13
build a case for both if we should do a
21:15
piece of work and then monitoring
21:17
outcomes. Um so that would be the first
21:19
point. Then we look at how how we would
21:22
be able to deliver this. So practically
21:25
do we have staff with the skill set? Is
21:28
it something that can be delivered in
21:29
primary care or would we need um you
21:32
know the specialist viewpoint? Um and if
21:36
we we try and do things where we can
21:38
upskill our own staff is our preference.
21:41
So if we can you know invest in our own
21:43
staff teams and get them to do stuff
21:45
then that is always um you know a bonus.
21:48
So with mental health, ADHD, women's
21:51
health, some of those and CBD, we
21:53
usually try and find a member of our
21:56
team, send them on a course, get them up
21:58
to a, you know, really good standard and
22:00
they can then lead those sorts of
22:02
projects. Um, then it's a case of
22:04
funding. So is there fun, is there a
22:06
farmer that we can partner with who
22:08
would enable us to achieve outcomes we
22:11
already wanted to? So we have a lot of
22:13
farmer relationships which are
22:15
brilliant. we're quite picky about what
22:17
we do and who we work with.
22:19
>> Um, it has to be something that we would
22:21
otherwise have wanted to do and that we
22:23
know would add value to our patients.
22:25
Um, and then it's sort of like that we
22:28
go from there if it ticks all those
22:29
boxes. We have um one of our GPS um
22:33
wrote a list of principles which
22:36
>> Yeah, I love those. I love those.
22:38
>> Um, you know, is it good for patients?
22:40
Is it at least going to break even? um
22:44
is it work somebody else should be doing
22:47
all of those. So we work through those
22:49
principles um and we you know we try and
22:52
target our
22:54
>> you know precious time and capacity
22:56
where it's going to be best best
22:58
utilized. We also have members of staff
23:01
though who we freed up to do this sort
23:02
of project based work because I think
23:04
that's really key. You can't it's really
23:07
difficult when you're seeing patients
23:08
247 to also do this alongside. So we
23:12
have people who as part of their their
23:15
sort of working portfolio they have days
23:17
where they are working on projects
23:19
rather than they have a list of patients
23:22
um and that's been done through income
23:24
from other projects that we've then
23:26
invested to make sure we can have that
23:28
time and capacity and it's really helped
23:30
develop things like research and
23:32
projects.
23:33
you you're such you you are honestly
23:35
such a a a good example and I've got
23:38
high hopes for um how you'll then work
23:41
with the neighborhoods. I mean we
23:43
touched on it earlier it is one of the
23:45
big talking points right now in the NHS
23:48
and you kind of said a little bit you
23:51
know nobody really knows what a
23:52
neighborhood looks like. So from if I
23:54
turn it a slightly different angle for
23:56
you from your perspective, what would a
23:59
successful neighborhood look like and
24:01
and where do you think it's currently
24:04
not quite going right for you?
24:07
So we were one of the um wave one
24:09
participants in the air hit program um
24:12
with two other federations that we
24:14
already work really closely with and
24:15
have a really good relationship with and
24:17
we um our cohort was older patients uh
24:21
housebound patients with COPD. Yes. So
24:24
we have already done sort of six months
24:26
of neighborhood working if you like with
24:29
the MDT approach and
24:32
>> uh it's been a sort of very time
24:34
intensive cohort to do because they were
24:36
all quite um you know people that were
24:39
quite unwell and had a lot of
24:41
co-orbidities and were housebound so
24:43
needed a lot of support. Um and on on an
24:45
individual level some of the outcomes
24:47
for them has been great being very time
24:49
consuming and obviously unfunded. So the
24:53
that clinical time was you know
24:56
significant
24:58
um and also there's the coordination
25:00
aspect of it because the the end meeting
25:03
and talking about the patient isn't the
25:05
work the work starts after that when you
25:07
have to go and do the things. So we've
25:09
had really good engagement from
25:11
secondary care, community, adult social
25:14
care. They've been brilliant and it's
25:15
been nice in terms of development of
25:17
relationships. But I think we need to
25:20
take we need to formalize for me how
25:23
that looks, what a neighborhood is, um
25:26
what the expectations of these sorts of
25:28
groups are, and then how this is going
25:31
to be funded. Uh that's a key that how
25:34
that funding flows out for that clinical
25:37
time. That's that for me is a real key
25:39
one. It's that it's usually where most
25:42
of my conversations I would say get
25:45
stuck is that the the development of
25:49
neighborhoods has been there you go pass
25:50
the ball. We want you to develop
25:51
neighborhoods but there's no finance
25:53
behind it. There's no time set aside for
25:55
it. There's no road map to do it. Uh
25:58
most of us have got like you got COPD
26:00
that seems to be the national. Well,
26:01
it's frailty, COPD, and then a free
26:03
choice of what you want to work on. But
26:05
with no funding, who who I mean, can you
26:08
imagine Warbertton saying to the
26:09
supermarket said, "You know what? We'll
26:10
just bake the bread and not charge you
26:12
for it." There's no other walk of life
26:14
would expect to not be paid for the work
26:17
they do. Yet the NHS seems to believe
26:19
general practice h has the ability to do
26:22
that. That's a real frustration.
26:25
>> I agree. And I think for in northwest
26:26
Leicester we're lucky that our we are a
26:29
neighborhood if you like but other parts
26:32
some other parts of even Leicester they
26:34
don't work in that footprint now so
26:36
they've got to go on that journey to
26:39
build those relationships to enable them
26:40
to work as a neighborhood before they
26:42
can even think about doing the work. And
26:45
we we're lucky as well that we already
26:47
deliver stuff at scale. So that's been
26:49
all right. But for some other areas that
26:51
they're not they
26:52
>> Oh god. Yeah.
26:53
>> And I think there's you know this whole
26:55
the alignment with the primary care
26:57
networks. Yes.
26:58
>> There's an expectation I think that for
27:00
neighborhoods a lot of the ARRS staff
27:02
will be involved. Yeah. But for a lot of
27:05
places the ARS staff deliver core work.
27:08
So
27:08
>> absolutely
27:09
>> won't be there won't be comfortable
27:11
conversation around that. Um, and we
27:14
need to start it early and be explicit
27:16
around what we want so providers can
27:18
respond and get themselves at least in a
27:20
room talking about how they will
27:22
transition from the way they work now to
27:25
the way they're expected to work.
27:28
>> So for for us it doesn't it isn't hugely
27:30
different. We're quite fortunate in
27:32
that. Um but
27:36
for other for other areas it feels I
27:38
think really challenging and they it
27:40
feels like they're a long way off and
27:42
the funding is essential for them
27:44
because they need to get that clinical
27:46
buy in and it just the outcomes won't be
27:49
there for patients unless we get the
27:51
structures right.
27:52
>> Agreed. So, I'm sensing that you I don't
27:56
want to put words in your mouth, but I
27:57
am sensing that you might see
27:59
federations where they exist becoming
28:02
kind of the natural support stroke
28:04
delivery organization for neighborhood
28:06
services. Or am I completely wrong? Do
28:08
you see something else emerging?
28:10
>> That would be nice because I'd still
28:12
have a job. Um, and
28:13
>> I think that is what will happen.
28:15
>> Um, I think we've got to be willing to
28:17
evolve, haven't we, and work with
28:19
others. So we have already had
28:22
discussions locally about what the
28:24
footprint might be because obviously we
28:26
may be too small to be an you know an
28:30
MMP in our own right so it's who we'd
28:32
work with etc. Um and I think we've got
28:34
to be flexible about what that outcome
28:37
looks like and willing to work together
28:39
in different levels of scale. So you
28:41
might
28:42
>> you know your PCN scale or whatever
28:45
replaces that and then you know go
28:47
working up the the pyramid and be
28:49
willing to work together and build
28:51
building those collaborative
28:52
relationships. But I think got to keep
28:54
an open mind because if we're too fixed
28:57
um
28:57
>> I think that's yeah I do agree. I do
29:00
agree. I think I think the more flexible
29:02
you are the more likely to succeed you
29:05
are because you'll be able to address
29:06
the things that kind of kind of are
29:08
thrown at you and come towards you.
29:09
That's very much the Northwest Leicester
29:11
way in reality.
29:12
>> We try but there's also the risk I think
29:15
people need to understand the risk of
29:16
not doing it. So you know it's often
29:18
being what's I I talked earlier about
29:20
what's the benefit of for the of being
29:22
in a federation and it's we get extra
29:24
appointments or we get this you I think
29:27
now for those that have avoided
29:30
at an at scale kind of participation I
29:32
think the risk of not doing that is
29:34
really significant for them now because
29:37
there are large there are large
29:39
organizations yeah that have their eye
29:41
on this sort of work so it do you want
29:45
to play nicely Scott should we play
29:47
nicely and put our differences aside or
29:49
should we let someone else come in and
29:50
then do it for us and that is really key
29:54
and I'm not sure people quite get that
29:56
at the moment. So I know partners in in
29:59
other other places who take a really
30:01
good drawing quite happy pling along
30:04
they don't feel the need for anything
30:05
else and when I've spoken to them and
30:08
said how would you feel about X Y and
30:10
Zed that it's it isn't on their radar.
30:13
So, I think it's people being comfy with
30:16
the fact that it might not always be I
30:18
might not always want to go to the
30:19
meeting with Scott because I think my
30:21
practice is better or I think my PCN's
30:23
better than your PCN, but if I don't do
30:27
it, there's a bigger threat and a bigger
30:29
risk. So, rather than fighting
30:30
internally, we need to realize that the
30:32
threat lies outside.
30:34
>> It's, you know, I didn't have this on my
30:37
my things to ask you about today, but
30:38
I'm going to sneak it in anyway soon as
30:40
you just opened again. You've opened the
30:41
door. Um if you look at where we're
30:43
going and how quickly we're going. So we
30:47
started out with six advanced foundation
30:49
trusts. We've now got 23. There's
30:51
another trunch coming behind that. Two
30:53
of the first six have already been told
30:55
you meet all the criteria to be comm
30:58
commissioned as an integrated health
31:00
organization. In other words, a pyramid
31:02
system where the top of the pyramid owns
31:04
the budget for primary care. If GPS
31:08
don't see that as a threat, I have no
31:10
idea what's going to waken them up
31:11
because and again maybe a controversial
31:15
view, but what do hospitals really know
31:18
about running local general practice?
31:21
Not a lot would be Scott's observation.
31:23
And that for me is the model that you've
31:25
just described. That's where it fits.
31:27
The federation being the catalyst and
31:30
the owner of being able to deliver top
31:32
quality local general practice. But if
31:35
the GPS don't see that, I I despair of
31:37
what the future might look like.
31:40
>> Yeah, I agree. And I think it is risky
31:42
particularly because it's it almost
31:44
looks like all income apart from core
31:46
GMS income is up for grabs in that pot
31:49
at the moment. That's it.
31:50
>> You know, through your PCN or you know,
31:52
you know, through your federation that
31:54
there are the income and services are
31:57
going to flow in a way that you can
31:58
control. If all that money goes and sits
32:01
elsewhere, um I think it's really it's
32:04
for for practices that are challenged
32:05
financially, which a lot of them are
32:07
because you know GMS has been eroded. We
32:10
know the cost of um you know the minimum
32:12
living wage has increased. Yeah. All
32:14
which is great for staff but really hard
32:16
for providers to bear that cost. Yeah.
32:19
>> It puts it puts the individual practices
32:22
at threat if they don't have that
32:23
collective.
32:24
>> Absolutely. And
32:26
>> we have an IHO near near us as well. you
32:29
know, we've got a good working
32:30
relationship with with them and we do we
32:32
collaborate at the moment.
32:33
>> Today's conversation has struck a chord.
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