Latest / Embedded / Hospital Subcontracts in P. Care: What Actually Works | Embedded Conversations with Dr Paul Netts. Ep 6

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Hospital Subcontracts in P. Care: What Actually Works | Embedded Conversations with Dr Paul Netts. Ep 6 · Embedded

0:10
Welcome to Embedded Conversations. I'm
0:12
Scott McKenzie. I work with NHS leaders,
0:16
commissioners, and life science
0:17
organizations to help them navigate
0:19
changes to patient pathways. Changes
0:22
that actually stick. Not just pitches,
0:25
presentations, or good intentions that
0:27
fizzle out after 6 months.
0:30
I'm also the author of Embedded, a book
0:32
about what it really takes to land
0:35
ideas, innovations, and partnerships
0:37
inside complex systems like the NHS and
0:41
keep them there. My podcast, Embedded
0:44
Conversations, brings those ideas to
0:47
life. In each episode, I sit down with
0:50
the people who've either been in the
0:52
system or are currently working in the
0:55
system. real NHS leaders, commercial
0:58
innovators, and cultural voices who talk
1:01
honestly about what works, what doesn't,
1:04
and what it takes to embed change in the
1:06
real world. You can expect practical
1:10
conversations about power, trust,
1:12
commissioning, culture, and delivery,
1:15
and how all of those things collide when
1:18
you're trying to land a new project to
1:20
improve patient outcomes.
1:22
If you're working in, around, or with
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the NHS and you want to understand how
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change really happens, you're in the
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right place.
1:33
Hi everyone and welcome to the latest
1:36
embedded podcast. I'm absolutely
1:38
delighted to have one of my longest
1:41
standing customers, uh, Dr. Paul Nets.
1:46
Paul is a GP based in Newcastle upon
1:49
time and as I say very long-standing
1:52
colleague and customer really since the
1:54
very early days of the consultancy way
1:56
back in 20067
1:58
and over many years Paul's consistently
2:01
been at the forefront of rethinking how
2:03
care can be delivered differently not in
2:06
theory but absolutely in practice and
2:08
that's really what we're going to get
2:09
Paul to hopefully open up and and talk
2:11
to us about today because Paul genuinely
2:14
pushed the boundaries
2:16
of what primary care can do through his
2:19
leadership. He previously held a
2:21
hospital subcontract that enabled him
2:23
and the wider team to deliver services
2:25
that would traditionally have been
2:27
provided in secondary care much closer
2:29
to patients out in the community. And
2:31
that was long before it became national
2:35
policy. Paul was already demonstrating
2:37
what we would now call left shift from
2:39
hospital to community. And it was
2:42
absolutely there working on the ground.
2:44
So his work represents a real world
2:48
model of integrated care and action
2:50
where general practice, community
2:52
services, hospital care all aligned
2:54
around patient need really improved
2:57
outcomes and system efficiency. Now, at
3:01
the time when the 10-year plan and Lord
3:03
Dar's vision are calling for exactly
3:06
this kind of transformation, Paul's
3:08
experience offers us a real practical
3:10
insight into what's possible, what's
3:12
hard, and what genuinely works. So,
3:14
Paul, it's an absolute pleasure to get
3:17
you on the podcast today, mate. How are
3:19
>> you? Thank you very much, Scott. That's
3:20
very kind of you.
3:21
>> Not at all. It's just how it is. That's
3:22
the reality.
3:24
>> Well, well, thanks to you as well.
3:27
>> Well, yeah. Yeah, I I played a part in
3:29
it, but in fact, let's start start
3:32
there. Um, can you kind of talk to me a
3:37
little bit and for mostly for the
3:38
listeners, explain what it means for a
3:41
GP to hold a hospital subcontract and
3:44
how that's different from the kind of
3:46
more traditional models of care that we
3:48
have in the NHS. It's a good place to
3:50
start actually.
3:51
>> Yeah. Well, I mean, I think
3:54
your your listeners, I'm sure, will be
3:56
familiar with the normal contracts that
3:59
that um primary care has with primary
4:02
care agencies and but to to get one from
4:05
secondary care or certainly in our case
4:08
happened to be tertiary care
4:11
>> was was valuable because um I think that
4:15
the hospital were very open to it
4:17
because I think they felt that they had
4:19
a lot more control over what was going
4:21
on. Having said that, you know, you
4:24
there were negotiations to be made and
4:26
you it has to work for everybody clearly
4:28
else there's no point in carrying on.
4:29
However, they were
4:31
>> they were very amanable to it. In fact,
4:33
more amanable to it than I thought they
4:34
would be. Um but they they um
4:37
>> yeah,
4:38
>> and they weren't greedy, I don't think,
4:40
with what they wanted. Um and I think
4:42
that that was a sign of how keen they
4:45
were to do it. I can I can remember it
4:47
way back when it when it first happened
4:50
with
4:50
>> the GP Federation as it was in those
4:52
days was very early in its formation. In
4:55
fact, you were one of the GPS that
4:56
helped me
4:57
>> pull the federation together
4:59
>> and then the very first thing we got was
5:01
a subcontract for um ambulatory blood
5:04
pressure monitoring. Yeah. And as I
5:05
remember it was Jane who was the
5:08
cardiologist and Louise who was the
5:10
pediatric consultant had lunch with each
5:12
other as a as a start to the
5:14
conversation that
5:16
>> Jane mentioned to Louise oh we got a
5:18
subcontract and that sparked interest
5:20
and then all of a sudden you knocked on
5:21
my door and said Scott the hospital are
5:24
kind of amanable and interested in
5:25
subcontracting non-mediated IG pediatric
5:29
allergy. And I remember saying to you
5:30
right Paul you need to explain to me
5:32
what that is. Well I and yes I mean
5:35
obviously the the the the hospital have
5:37
they can't contract at that level with
5:39
with individual practices but so so it
5:41
had to go through the federation which
5:43
was fine.
5:44
>> Yeah.
5:44
>> Um and um what one of the advantages I
5:48
think from their from everybody's point
5:50
of view was the speed with which it was
5:51
done. It was done pretty quickly.
5:53
>> Yes.
5:54
>> Um and um
5:56
>> you know when when there's a will on
5:58
both sides you would hope that things
6:00
would move quickly. Honestly, obviously
6:03
with NHS things often move at a glacial
6:06
pace, but this was definitely
6:09
an accept refreshing exception that
6:12
proved the rule.
6:12
>> It really was. Just to again for the
6:15
listen benefit of the listeners, what
6:16
kind of services were you providing
6:18
under the hospital subcontract and go a
6:21
little bit further and just explain how
6:23
that arrangement really benefited the
6:25
patients compared to being managed
6:28
solely in a secondary care environment?
6:30
Well, we excuse me, we got the um
6:35
subcontract to provide pediatric allergy
6:39
outpatient services.
6:40
>> Yeah.
6:41
>> Um for the hospital. So, we being the
6:44
federation
6:46
>> um and myself and one of my other GP
6:49
colleagues um wanted to move this
6:52
forward. So, in order to do that, we re
6:57
we sort of drew up a a to-do list,
6:59
things we needed to get this done,
7:01
>> which included um going back to the
7:05
hospital and asking to employ their
7:08
staff.
7:09
>> So, it was a sort of which was a very
7:13
difficult concept for a lot of people
7:14
including especially the consultants to
7:16
to work out. So um we employed one of
7:20
the consultants to teach and supervise
7:23
us. We employed one of the allergy
7:25
specialist nurse to help us run the
7:27
clinic
7:29
>> and um
7:31
and essentially that that was that was
7:33
it. Um but we required training which
7:38
they provided. We required
7:41
um
7:43
as I say nurse help and initially we had
7:46
a dietitian as well although
7:48
>> um due to problems with the dietetic
7:50
service they weren't able to carry on
7:52
with that but that wasn't as big a blow
7:55
as we thought. Yeah.
7:57
>> So we could do it very quickly with
8:01
relatively few people. We needed rooms
8:03
but we um were able to do that in the
8:06
surgery so that that wasn't an issue.
8:09
Um and so
8:13
we were contracted to supply the
8:15
services but we went back to the trust
8:17
to get the staff to help us to do that.
8:19
>> So um and it meant that the hospital
8:24
were happy because they knew the people
8:26
>> that that we were employing. They
8:28
trusted them.
8:29
>> Yeah.
8:29
>> Um they jumped through all their hoops.
8:32
Um,
8:33
and also it got us a connection with
8:39
secondary care that was close and
8:41
workable and also a two-way thing as
8:44
well.
8:44
>> You know, whilst we learned a lot more
8:47
from them,
8:49
>> there was a lot that we could to tell
8:51
them about primary care and and and that
8:53
sort of thing. So, it's been it's been
8:55
everything that I hoped it would be.
8:57
I've got to say feelings. I remember the
9:01
very early days because I remember when
9:03
we as you say but there was quite a bit
9:05
of negotiation around the business case
9:07
to sort it out and what the contract was
9:08
going to look like and all of that the
9:10
kind of the technical bits that went on
9:11
in the background
9:13
>> but I also remember the kind of the joy
9:17
of the very early patient feedback about
9:19
the fact that they liked the fact it was
9:21
in general practice there was a tram
9:23
stop. There was a great big free car
9:25
park and I didn't have to turn up two
9:26
hours early to try and get a parking
9:28
space like I did at the hospital. Oh,
9:30
and if that didn't work, there was a bus
9:31
stop literally right outside the
9:33
practice. So, the patients engaged
9:35
really quickly with the service. We
9:37
didn't have any lumps and bumps with
9:38
that. There was no real objection to
9:40
moving it from in hospital into local
9:43
general practice in the east of the
9:44
city. It worked really well. No, we I
9:47
mean and we we we did the the the
9:50
appropriate feed forms which have
9:52
consistently said all those things, you
9:54
know, free car parking is seems to be a
9:57
huge thing, isn't it? And and but just
9:59
access in general, but people travel
10:02
from, you know, throughout the region.
10:03
We've got people traveling from from the
10:05
west coast to the east coast to come and
10:07
see us and they still don't seem to
10:08
mind.
10:09
>> So, um it it has been a success from
10:12
that point of view. There's no two ways
10:14
about it. What are the beyond that kind
10:16
of the the day-to-day delivery? What do
10:18
you see as the the operational and the
10:21
financial benefits of the model for the
10:23
practice, the trust and potentially the
10:26
wider system?
10:28
>> I think that excuse me financially um
10:34
everybody won really. I think.
10:36
>> Yeah, true.
10:37
>> Um certainly um the federation one, um
10:43
having moved to block contracts was was
10:46
was a bit of a a a kick in the teeth
10:48
actually, but
10:49
>> it was a bit
10:50
>> um but initially we were paid um case by
10:55
case. So
10:56
>> um that worked very well because we um
11:02
>> we we negotiated a price for our
11:04
services from from that um
11:08
uh from that money. Um we were only
11:11
seeing follow-up patients.
11:12
>> Yeah.
11:13
>> For clinical governance reasons, they
11:15
they felt that it'd be best if they had
11:17
already been seen by a consultant, which
11:19
is fair enough.
11:20
>> That was absolutely fine. I remember
11:21
that. Also, because we would we were
11:23
doing a lot of the follow-ups, it freed
11:25
up the consultants to see more new
11:27
patients and therefore the tariff is was
11:31
£100 higher for a new patient than it
11:33
was for a follow-up.
11:34
>> So, they're happy from that point of
11:36
view. They were also happy because they
11:38
took all them there was a tariff for the
11:40
skin prick testing which was done 2/3 to
11:43
3/4 of our appointments. So they took
11:45
that um and also we bought their nurse
11:50
time um for for our clinic but the the
11:55
consultant who was running a parallel
11:57
clinic.
11:58
>> Yeah.
11:58
>> They used that time so they got a free
12:00
nurse out of it.
12:01
>> Yeah.
12:01
>> Um I think they also I think politically
12:05
it suited them well. It did. Um I think
12:08
to be seen to be supporting this I think
12:11
>> was something that they were pleased
12:12
about and they could sort of um shout
12:15
out to to primary care and you know we
12:17
we are engaging with you better together
12:19
was the
12:20
>> word of the of the of the sort of
12:24
movement of policy at the time. So that
12:27
it was a concrete example for that. Um
12:29
it helped them because they had a big
12:31
waiting list and we reduced that. I was
12:35
having a look at the papers cuz I know I
12:37
was coming to talk to you. So I went
12:38
back to that original business case and
12:41
actually it's eyepopping when you look
12:43
at the volume that adding you and the
12:46
other GP I'm not going to name them
12:48
because it's not it's not important to
12:50
>> but adding the two of you to that
12:52
literally quadrupled the volume that the
12:55
hospital could manage
12:56
>> and it meant as you say that we freed
12:58
the hospital team to be able to do the
13:00
first outpatient appointment when they
13:01
were still trying to work out mediated
13:04
non-mediated who is it safe to transfer
13:06
to the GPS But the other thing that I
13:08
loved about your approach was because
13:11
you based the consultant out beside you,
13:13
it meant that you never needed to call a
13:14
patient back or send them on. You
13:17
literally had the consultant working
13:18
alongside. It worked so well as a
13:21
concept.
13:22
>> Yes, it did. And and the other thing
13:23
that we found out is that we as GPS are
13:26
better at discharging people than the
13:28
hospital people are. Um because we know
13:32
what our colleagues can deal with.
13:34
>> Yes. And the consultants the consultants
13:37
in my experience underestimate what GPS
13:40
can do.
13:41
>> And so we're discharging people and
13:43
they're saying to us, "Oh, you should
13:44
should you be doing that? What about but
13:46
what about and you know said let's meet
13:49
and drink, you know, this is not a
13:50
problem." Um
13:52
>> and and if there if there's ever
13:54
anything around you know if there's a
13:59
nose and throat problem or there's um an
14:01
asthma problem or whatever that might
14:03
need something they always the
14:06
consultants always think to refer to
14:08
their colleagues when in fact
14:10
>> nine times out of 10 the GP can deal
14:12
with that. So it it's been a it it was
14:15
it's it's been interesting from that
14:17
point of view. I mean that leads in
14:18
really neatly to to you've kind of
14:20
opened another little area that I want
14:21
to look at with you which is when you
14:24
worked alongside the hospital
14:25
consultants as part of really a
14:27
multi-disiplinary team. Was it a case of
14:30
greater collaboration or did it create
14:32
friction? Was is there any lessons that
14:35
people need to be aware of? Was there
14:37
any friction or was it pretty
14:38
straightforward?
14:39
>> Well, I I think that's down to
14:40
personalities really. There there's been
14:43
absolutely no friction at all. It's been
14:45
a pleasure. As I say, I feel very very
14:47
lucky. I think we we have hit lucky to a
14:49
degree. But then I I think that
14:51
consultants select themselves. You know,
14:53
I don't think anybody
14:56
who consults who are willing to engage
14:58
with this sort of work want to listen to
15:01
what you have to say.
15:02
>> And I'm certain
15:04
>> if I had Louise here, she'd say exactly
15:06
the same back to you. Oh, I landed
15:08
really lucky.
15:10
>> Well, it's worked out very nicely. And I
15:13
think, as I said to you before, I think,
15:14
you know, there are, you know, we've
15:17
learned an awful lot more from them than
15:18
they have from us. However, there's
15:20
definitely been a two-way flow. You
15:22
know, we even did a, you know, a video
15:25
consultation of how to consult
15:26
consulting technique skills and that
15:29
sort of thing, which went down
15:30
phenomenally well with with with the
15:32
team. So, they are keen to know
15:35
>> um what's going on and it amazes me how
15:38
little they do know about primary care.
15:39
I mean, it's staggering. I mean, even
15:41
the ones that are primary care friendly,
15:44
um, which are the majority, but they
15:48
they they what they don't know is is is
15:50
is eye opening.
15:52
>> I get it in my work all the time, the
15:54
complete misunderstandings over how
15:56
you're contracted, how you funded, the
15:59
volume of work that you managed. There's
16:00
really no concept of what goes on in
16:02
primary care until they come and
16:04
actually work alongside you.
16:06
>> Yeah.
16:08
Um, do you think there's opportunities
16:10
in here for the pharma, medtech and
16:12
device companies to support and really
16:14
enhance the kind of the care through a
16:16
subcontract? Is that an opportunity?
16:18
>> I think without doubt it's an
16:20
opportunity. I I think that um
16:25
yes, it's a way and I think the
16:26
hospitals do
16:28
value it as a model. Yeah,
16:30
>> I think that um
16:34
pharma could definitely support
16:38
um projects in various ways um
16:45
as long as the you know the the
16:48
conversations initially setting it up.
16:51
It's got to be transparent.
16:53
>> Yeah. And I think I think that um I
16:57
think they have to be very clear at the
16:58
outset, but as long as it was set up and
17:00
the contract was was watertight to start
17:03
with, I think it would I think it would
17:04
work extremely well.
17:05
>> Yeah, I I agree. I mean, I agree with
17:08
that entirely. I think this is where you
17:09
really want a pathway over a product
17:12
approach. You want to talk to them about
17:13
an endto-end pathway.
17:15
>> What we're trying to do and achieve
17:16
right patient, right place, right time,
17:18
right healthare professional. And
17:19
exactly what we did with your
17:21
subcontract, the resources were put in
17:23
place to enable you to deliver the
17:25
contract. And I think if you do that and
17:26
do it well, industry's absolutely got a
17:29
role to play in being part of that
17:31
pathway.
17:33
>> Um, if we've got people listening in
17:36
today, and I'm sure we will have, either
17:38
GPS or federations or primary care
17:40
networks or even neighborhood teams who
17:43
might be considering a subcontracting
17:45
model. What's the one bit of advice you
17:48
would give them? What would you say to
17:50
anybody thinking that might be the way
17:52
to go?
17:54
>> Ring you, Scott.
17:56
>> That's very kind of you, but there must
17:58
be more to it than that.
17:59
>> Well, I mean, no, no, joking aside, I
18:01
mean, I do think some somebody with
18:02
management experience, you know, and
18:05
knows the the the both sides of the of
18:07
of the not both sides, but, you know, no
18:11
knows the whole picture very well. Your
18:13
help was invaluable, and we definitely
18:15
could not have done it without you. I
18:17
think that um you've got to be clear
18:19
about what you want to do.
18:20
>> Yes.
18:21
>> And um I think that as long as it's very
18:24
clear about what you want to do, what
18:25
the benefits are for the patients, what
18:27
the benefits are for the you know for
18:29
everybody and there are lots of things
18:31
that can be done. I know that um
18:34
uh one of the hematologists recently
18:37
approached us because they're doing a
18:38
sickle something for cickle cell with
18:40
GPS. So there there are things that are
18:42
appearing all the time and I think it's
18:43
just about having conversations with
18:45
consultants because there are lots of
18:48
they just they don't think about these
18:50
sorts of things. So I think that there
18:52
there are very
18:54
clear problems that could be
18:58
resolved, dealt with with primary care,
19:01
but but just have a very clear vision of
19:03
what you want to do
19:04
>> and
19:06
um get help from people that make sure
19:10
that you you don't miss anything out and
19:12
that help you with contracts, help you
19:14
negotiating if you haven't got that sort
19:16
of experience. I think you've got to be
19:17
honest with about what your skills are.
19:20
>> Yeah.
19:21
And um you know lots of GPS are not
19:26
business people because that's why we're
19:28
GPS. So I think that to have business
19:32
expertise is really important because
19:35
what happens at the very beginning
19:37
defines everything else.
19:39
>> You know what I I couldn't agree more
19:41
with what you've just said there. And
19:42
actually what that sent me thinking
19:43
about was the other contracts that then
19:46
came off the back of the work that you
19:48
did because we then ended up with Diana
19:51
Mansour in community services community
19:53
gy contract five bits of work on
19:56
subcontract. I then used the model. I
19:59
connected Newcastle hospitals to the
20:01
George Elliot Hospital in Niton and the
20:03
GP federation there, primary care war
20:06
and they ended up with hospital
20:07
subcontracts that kind of matched and
20:08
mapped against the model that you first
20:11
established in Newcastle. So we didn't
20:13
kind of do it and they go right we've
20:14
done that in Newcastle. Let's go and
20:16
start all over again with a blank sheet
20:18
of paper. We took the learning um into
20:20
other areas and I've had so many
20:22
different hospital subcontracts now.
20:25
things like well the gyne the cardiology
20:27
diagnostics insulin initiation in
20:29
titration GLP1 initiation
20:32
there's a whole plethora of different
20:34
things that can that model
20:35
>> I think a direct approach to a
20:37
consultant say look what can we help you
20:39
with I mean even as simple as something
20:42
as simple as that might bear fruit
20:43
because they'll have they'll have an
20:45
idea of what
20:47
>> they would want help with but they're
20:48
just probably too busy or they've got a
20:50
million one or other things where they
20:52
actually haven't thought about it or or
20:54
had time to make it happen. So a direct
20:57
approach saying look I'm interested in
20:59
respiratory I'm interested
21:08
>> it is as simple as that because if I go
21:11
to I can think of consultants today that
21:13
I could pick up the phone and speak to
21:15
and if I was to say to them you know
21:17
where are your bottlenecks your backlogs
21:19
yeah where where are you handing off
21:21
patients because you haven't got the
21:22
capacity they'll have a list of things
21:24
and it's then the point that you've just
21:26
made. Can you see a way that you could
21:28
actually support and deliver and work
21:30
alongside them and actually smooth out
21:32
the pathway? That's where the
21:33
subcontract is ideal.
21:35
>> And I think I think that consultants um
21:39
want GPS working in their clinic. One of
21:41
my that my appraiser was an adult
21:43
rheumatology um specialist and she said
21:47
if I've got a GP working in my clinic, I
21:49
don't have to worry about them because
21:51
of their breadth of knowledge.
21:53
>> That's what she said to me. So we're
21:54
valuable resource not just in primary
21:57
care but with with secondary tertiary
22:00
care as well. So I think I think the
22:02
definite opportunities there no
22:03
question.
22:04
>> Ah thank you Paul. What an an absolute
22:06
pleasure. I can't thank you enough for
22:08
coming on. This is exactly what I was
22:09
hoping we'd be able to share as
22:12
>> pleasures all mine Scott. Pleasures all
22:13
mine.
22:14
>> Thank you mate. Nice to see you. Thanks
22:15
again.
22:15
>> And you. Byebye.
22:16
>> Bye-bye.
22:20
If today's conversation has struck a
22:22
chord, it's probably because you're
22:24
dealing with similar challenges, trying
22:26
to move something forward in a system
22:28
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22:48
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22:57
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23:03
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23:05
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23:08
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Conversations. And if this episode got
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