Pharma Market Access Insights - from Mtech Access

NHS primary care panel – the GP Contract and Operational Planning Guidance

• Mtech Access - Powered by Petauri • Season 7 • Episode 19

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What can we expect to see in primary care in the NHS given recent policy announcements and ongoing uncertainty? What does the new GP Contract tell us about the future of primary care? What are the biggest challenges facing primary care in 2024–25?

In this webinar, Karen Cooper (Senior Consultant – NHS Insight & Interaction, Mtech Access) spoke to a panel of NHS Associates about the current state and future of primary care and what this means for industry. Our panellists were:
- Jack Wagstaff (Place Leader, Surrey Heartlands Health and Care Partnership, Chief Officer for North West Surrey Health and Care Alliance)
 - Zafran Azam (Head of Medicines Optimisation and Delivery, Derby City Place)
- Dr Neil Forster (GP and PCN Clinical Director, Northumberland Medical Alliance)

We  explore:
- Where NHS primary care is heading and what this means for your strategy and business planning
- Prescribing and decision-making in primary care
- The implications of the GP Contract for PCNs, GPs, patients, and industry
- What this means for integration and the integrated care model
- Policy priorities in practice and what to expect in an election year
- How Pharma, Medtech, and Diagnostics companies can best engage with primary care leaders

Learn more at: https://mtechaccess.co.uk/nhs-primary-care-gp-contract/

Discover more about our UK market access services at: https://mtechaccess.co.uk/uk-nhs-insights/

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- [Presenter] Welcome to this Mtech Access webinar. At Mtech Access we provide health economics and outcomes research and market access services from strategy through to implementation. Our unique NHS relationships guide and validate everything we do in the UK. We work with over 80 NHS associates to bring our pharmaceutical and medtech clients authentic insights into the NHS. We can help you answer key questions related to the NHS, from how to communicate with integrated care systems, places and primary care networks, to how to capture pathways of care. Get in touch today to discuss your market access goals. First, though, I hope you enjoy the webinar.- Good afternoon, everybody, and welcome to this Mtech Access webinar on policy, GP contract, and primary care. My name's Karen Cooper and I'm a senior consultant in the NHS Insight and Interaction Team at Mtech Access, and it's my pleasure to extend a warm welcome to our speakers for today's session and participants that have joined today. For those of us that don't know us well, Mtech Access is a specialist market access consultancy and we provide strategy and solutions to help pharma and medtech companies bring interventions to market, and we also work as a collaborative partner to the NHS. So today we have Zafran Azam, Jack Wagstaff, and Neil Forster, who are experts in their field, no pressure, to share their wealth of knowledge and experience on primary care, the GP contract and network DES, and the NHS priorities and operational planning guidance. Their insights are sure to be thought provoking and provide valued perspectives that will benefit us all. So I'm thrilled so many of you could join us today and let's get right into it. And I'm going to come over to our panel and ask you to introduce yourselves. So if you could let us know what your role is and where you work, please. So I'll come to Neil first and then to Zafran.- Hi there. Hi Karen. Hi panellist and welcome everyone. I'm Neil Forster GP in Northumberland, GP partner for 20 years in the same practice. I've also got interest in occupational medicine and also clinical director of our federation up in Northumberland. So yeah, I'm interested in market access, strategic consultancy, and also thinking through some of the problems that face our industries. That's me.- Perfect. And Zafran?- Yeah, hi, my name is Zafran Azam. I'm Head of medicines optimisation and delivery at Derby City Place. I'm also lead on a lot of kind of programmes like respiratory self-care to name a few. I'm also a qualified coach and mentor and I'm very interested in talent management, workforce development, and organised system change as well as part of my kind of portfolio of working.- Okay. And last but not least, Jack.- Hi, really good to be here this afternoon. I'm hoping to get the recording of Karen's billing to play to my wife at home. So let's see if I can get that at the end, but that's really, really good to be with everyone. I'm Jack Wagstaff, I'm the Chief Officer for a partnership with 11 organisations in Northwest Surrey just under Heathrow Airport across primary care, community mental health, acute care. I'm the Exec Director for Surrey Heartlands ICB covering sustainability and financial recovery and the acting Chief Delivery Officer for Ashford and St. Peter's Hospitals on our new elective centre here. So if you hear any drilling, that's apologies. I think we're building something just over that wall.- Okay. Thank you. So as you can see, we've got a selection of perspectives from all different parts of the system, so I think this is going to be really interesting. Let's start strategically, so let's start by talking about the priorities and operational planning guidance. So we know that normally this is published in December. So to give people like yourselves chance to plan for the next year, this year it arrived one working day before the new financial year. So I'd be interested, because everyone was waiting, constantly waiting for it to be published. Finally it was published. It'd be interesting to understand your thoughts on the impact that had around your planning for this year or whether you just carried on regardless. So I'll come to Jack on that first.- Yeah, of course. I was particularly interested in around this year. I mean, I think we had a lot of informal sort of assurances that there wasn't going to be any drastic changes in the planning guidance, so we could make quite sensible planning assumptions based on the known factors. And I don't think there was anything in there that was hugely, hugely surprising for organisations and boards up and down the country. Although I think probably the biggest challenge in this planning round really is the quite, quite significant gulf between the operational planning requirements in terms of what the NHS and health systems and public bodies are asked to do and to deliver on the financial planning framework, which is very much about reducing costs, taking cost control, and constrained to resources and workforce and other relevance. And I think it's that sort of often what feels like quite, quite contradictory policy directions, which I think are really the issues that the organisations are wrestling with in terms of what do you prioritise, where do you really want to see gains, and what are you probably going to not do or put on the back burner as a result of those contradictions. I think is probably the real key challenge in the planning round this year.- Okay. Thank you. And Zafran, what about yourself?- So yeah. So for us, we'd already had, since July '23, the making more of medicines optimisation kind of opportunities document come out. We'd also had the national medicines optimisation opportunities came out in roughly round about August '23. So we already got a planning as to what we were doing for '23, '24. And in that document, we've already got an idea of what was going for '24, '25. We also understand the four key areas that all ICBs are working towards. So I think, you know, just like Jack said, for us it was more about more of the same, understanding what the ask is and having already got a plan for that in year and having a five-year plan as well, making sure there's nothing there that was an outlier that we needed to then pick up as a mandatory function or a core function as an ICB. So for us, we know what's coming and there's that Johari's window of unknown, and making sure there's nothing there that was a bit of a surprise. And I dare say I don't think much of it was. I think a lot of it is it's around the financials, around the workforce challenges and it's also around the actual pressures and it's how we are trying to unpick all that in that kind of, you know, very complex human adaptive systems that we exist in. So, again, it's been clear for us from quite early on last year as to what our kind of pre-priorities were as a system organisation, but then also it's compounded by ensuring that that's aligned to what then comes along. And so you do get policy, slight policy change and therefore that impacts the shift in terms of the overall system. But the five-year plan is the five-year plan and that's what we're trying to work towards I would say.- Okay. Thanks, Zafran.- You're welcome.- So, Neil, for you, how important is the operational planning guidance in your role?- It's difficult because there's so many other factors that are affecting primary care at the moment that we didn't see. We weren't really waiting for this document to come from on a practice level, because there's so many other issues and opportunities to address before that. An appointment within two weeks ask has already been mentioned prior to this coming out, and then the on the same day type access was already there as well. I think most practices are working to a on the day demand type model following on from what the COVID situation led us into really. So it really changed. So yeah, it's interesting how little of it is actually about, in the operational plan, is about primary care'cause the vast majority of NHS activity happens in primary care. You know, there's 1.3 million appointments a day in GP practises. So there's very, very little of that reflected in the document, but that's not really our major focus. Our major focus was probably the GP contract and how that was going to be negotiated and then came out. So that's probably a more important document for us rather than the operational plan. Yeah.- Okay. So already we can see the difference, you know, so Zafran's obviously focusing on the medicines optimisation opportunities document, you are focusing on GP contract and the planning guidance is, you know, is more relevant at Jack's strategic point of view, although that is-- It's a much higher level of like Jack is involved in, it's a much higher level of strategy than just practises.- Okay.- I was also going to say Karen, sorry, I was also going to say we have, for example, have the IPMO, Integrating Pharmacy and Medicines Optimisation, which is wider than just our ICB kind of medicines. It's about the kind of workforce delivery in terms of pharmacy. So there are, like Neil's already alluded to, there's different documents that people are working through throughout the system and it's then being able to unpick that, but there is a wider overarching strategy, if that makes any sense. So where people will focus on one arm of that wider strategy and plan, that plan is being pulled together centrally. So there is an overarching system-wide approach in how we do things and it's the fact that you can't do everything. So it's having experts in key areas to able to deliver that and deliver that really well. And I think the whole point of the plan is just to ensure that those stakeholders and those partners are actually heard, brought to the table, and actually they help to bring the solutions. So the whole point of documents is great and I get that completely, but there still needs to be co-creation and that's what all these documents are saying. They're not saying that that shouldn't be done. That absolutely has to be done as an integral part in order to achieve any successes, you know, for our patients and outcomes.- So I think it's a really challenging time to release planning guidance and health policy at the moment as well. It's obviously have anticipated to be an election year, so there'll be political pressure to promise everything in terms of waiting lists reduction and speed of access to primary care and availability of services and developments across all the business and being friendly to business and provision across different sectors. And then at the same time, a financial growth trajectory. I think we've just passed 43% of GDP being spent on health this last, last year. And that's grown by about sort of five or 6% in the last three or four years. So you've got a sort of out of control financial trajectory for the state overall and then a political dynamic that wants to promise everything to the public this year. And that creates a real challenge for people. And I think as Neil and Zafran have described, the art is in really understanding what are the key priorities that are going to give you value and where do you really want to focus your time and your limited resources to deliver the best, the best care and deliver the best organisational results as you have to be really quite discerning when you're looking at a document that has hundreds of deliverables in it and really understand the motivation behind some of that thing.- So thinking about our audience that are listening in today and looking through, we'll move on to the GP contract in a minute, Neil, and, you know, and the DES and everything, but just thinking about staying with the planning guidance. Reading through it, there's only five references to medicine within there. There are nine references to prevention, so, you know, one balances out the other, but there's only five references to medicines as such. Obviously there is an objective around medicines, but there's 32 references around productivity, 37 references around capacity, recovery is mentioned 18 times, and medicines is only mentioned five times and every single mention is talking about cost savings. Now obviously we're recognising exactly that around we're in a really cash strapped environment and a lot of money is spent on medicines, but the fact that it's only mentioned five times, I'm curious what your views are on that. Is it that the value of medicines in the NHS is undervalued or is there another reason? So what are your thoughts on that? I'll come to you Zafran first.- Thank you for that, Karen. Yeah, so medicines are used in almost all clinical pathways. We know that. And the spends of medicines, I believe it consumes the second largest share of the NHS budget in England. So as I've alluded to, even though it may have been mentioned five times, there will be pathways in clinical services that it will have an impact on. So it literally touches everything. So I don't think you need to overemphasise that there's a use of medicines. It's a bit like, you know, over instance the use of clinicians, without them, we just can't work, we can't operate. So there's always that kind of core assumption. And then beyond that, this national planning document, you've also got the documents that I've alluded to previously around the national medicine optimization opportunities, which then goes into detail for each of the ICBs. So I'm not too concerned about the fact that there's not a huge mention of medicines per se. I think that's already a caveat and already given, if that makes any sense. And I think when you talk about cost savings and efficiencies within our kind of system and a lot of the national papers that I've read and looked at, it's around best value. So it's not just about cost savings and efficiencies. it's also about how we do procurement. It's about how we do things and making, doing it once, doing it right. It's also about being mindful about the impact that that may have in terms of shaping other services. So it's being a bit more mindful and having a more integrated approach. And it does talk about efficiency savings, but it also talks about clinical safety as well. So, you know, so for example, polypharmacy is a huge area and a lot of the time you may be argued that de-prescribing actually doesn't save you a huge amount of money because of the amount of intervention required, the clinical intervention required. You know, if you speak to clinicians about when they're de-prescribing someone, for example, has been on long-term benzodiazepines, you know, for the saving you get in money for the reduction, for the time put in, you know, there's no value in terms of cost efficiencies there, in terms of medicines. But from a clinical and holistic point of view, is it the right thing to do? Absolutely. So it's about patient care and it's about shifting and ensuring we maximise savings, but without the detriment to the patient itself. And that's very mindful about how we and our approaches. So we don't do things just because it will save us money without understanding what that impact could be for our patients, for our key stakeholders, for our clinicians, for our consultants, the wider impact. And sometimes there's future planning as well where you may be getting things coming off patent and there may be a long term impact by doing something now because we are not thinking ahead, so that it has to be that kind of regional brain and regional thinking. So I'm not really too concerned about the fact that medicines aren't mentioned too much, because we know that they're high spend anyway and we know they're part of clinical pathways and services. And I'm not also too concerned, you know, in terms of just about cost saving because we get it,'cause it's not just about cost saving for us. So, so I think that's the difference. If the only thing that we thought was important was just saving money and not thinking about the patient and the system, then I think most of us probably wouldn't work for the NHS. That's not how it works really on the ground. And because we're all part of this wonderful organisation and system and it's part of the fabric of our country to be honest. So we all want to make a difference and we all want to try and leave it in a better place than where we came. So as a result of that, we're trying to do the best that we can, and money is going to be important 'cause money is tight. It's like being in a very thrifty household is how can we do things better knowing that we haven't got enough resource or making that resource stretch and that's what we're trying to do. So I hope that explains that a bit.- Absolutely. Absolutely.- Yeah, so you were nodding, Neil.- 'Cause it's a real interesting change in how medicines optimization has morphed over the 20 years I've been involved in practise. And I think medicine optimisation has such a, we think of it as a scary cost saving exercise, but potential for pharmaceutical companies to maximise their product share, their market share with their products. There's a lot of opportunity in that meds optimisation. It used to be that we'd get a diktat that we'd change to the cheapest generic that was around without any sort of cost analysis of what that means to primary care in terms of the cost to change, the cost to change both in patient terms and destabilising their care, but also in practices in employment, staff to do two or three different follow up appointments. But I think now meds optimisation, now we've got the pharmacist teams involved and it's much more successful and it's much more focused on system benefit and patient benefit rather than being just a true cost exercise, a acquisition cost exercise, which is, you know? So there are opportunities in medicine optimisation. The other point I wanted to raise was about the interpretation of the operational plan. One thing is a massive opportunity is diagnostics. So there's a massive push to get early diagnostics done within six weeks, I think, about 95% by next year. So there's a lot of point of care testing that could be implemented. There's a lot of opportunity there for companies to work with ICBs, PCMs to try and take, achieve that target. So that's not something to be missed,'cause that's a whole sort of new area of near patient testing.- Yeah.- And if I could add to that. Sorry, Karen. I'm just going to say you're absolutely right, Neil. And then you've also got the health innovation networks, which were previously the academic health science networks and the NHS mandate for them to go and work with private industry third party providers to look at how they can use innovation, med tech to actually bring that into the NHS at a pace and scale. So, you know, we're not saying, you know, do a pilot here and that's it. We sort do a pilot here and scale there up. So there is lots of opportunities and I think the NHS has recognised that we need more the kind of the innovation than critical thinking. So you're right, Neil, there is a lot more kind of opportunity in terms of working dynamics and what that can look like in the future and even now.- Brilliant. Have you got any thoughts around that, Jack, before I move?- I wasn't surprised that it wasn't hugely mentioned in the plan guides and I think it's really interesting factor of medicines in terms of how it's sort managed strategically. I think you rarely have discussions about management medicines at board level across any of the organisations I've worked with. It's very much the domain in my experience of the chief pharmacist medicines optimisation, the professional strand that goes through that and that is managed as a function of all organisations. But rarely is the sort of strategic direction of medicine sort of debated at an organisational level, I think that's probably fair enough. I'm not saying that's right or wrong, it's just a factor I think. I think there is in inevitably a financial dimension to it in organisations and systems are put under a lot of pressure to be, you know, unit efficient essentially for a pricing point of view. But we've also had to see in recent years massive exposure to national supply chain vulnerabilities and international supply chain vulnerabilities that's really hit organisations across the board quite hard. So mitigating those sorts of pressures is really important. I think there's some really interesting thinking around the how we build wider value propositions for medicines and devices across the board. So at the moment the debate is too often overly simplistic between, you know, this cost is lower than that cost. Whereas actually we've been able to do things differently around actually that yeah, that one requires x less of district nurse time to administer in the community and therefore it releases 15% of workforce capacity and therefore the economic gain to the system is x and y or on the surgical side there's, I think, there's different sorts of commercial partnerships. I think we can be exploring that. That perhaps offer exclusivity of product, but then a different partnership around training or investment in facilities or things like that. I think we need to slightly move away from just competing on units of product and then more about strategic partnerships with organisations that are bit more holistic in terms of the knowledge and impact on healthcare, the healthcare business overall if you like.- Yeah. Thank you. I'm just thinking, Zafran, you've mentioned a couple of times, if I come to you, Neil, you've mentioned the medicines optimisation opportunities, the 16 national priorities. Could you talk a little bit about that, because we are asked quite a lot in terms of how policies like that decided on. So how do you decide which five you're going to implement and how is that, yeah, how's it decided and how's it communicated down through the system? So, you know, how's it come from your levels, Zafran, and what impact does it have on you, Neil? What level of influence do you have? I come to you Zafran.- Yeah, sure, no problem Karen. So obviously there's 16 areas of opportunity. They're listed out in the national document. And then based on that, you then, obviously we take that back to your kind of SRO chief pharmacist, you'd use data, you'd use your prescribing advisors, you'd use your clinical leads, you'd need your lead GPs, and you'd work through what the key priorities are, whether are maybe potential savings over kind of key areas or whether there's, for example, something that has a real clinical kind of area that you think actually that's a safety issue, like for example, high opioid prescribing and how we can tackle that. So nothing is really done in isolation. It's done through, you know, that kind of collaborative working, that kind of critical thinking with key stakeholders. And then, nationally we've been planned, we need to develop a plan to deliver at least five of those national medicine optimisation opportunities. And we have to do that. So we have to, where it will improve local population and health outcomes and we need to make sure that these align to being, you know, that they complement the local medicines optimisation priorities. So we don't want to do something that actually has an a negative or adverse impact on what we're doing locally. So first of all there's a whole issue around alignment and then there's getting agreement. And then once that's agreement, then it's making sure that we've got the kind of the policy decision making right. So obviously there'll be like an area of prescribing committee or where that will go and be signed off and ratified, and where you've looked at other services like pharmacy, dentistry, and optometry to make sure that, you know, we're not doing something that's going to impact them and be harmful to them in terms of those kind of contractors as well. And then it's making sure that there's co-production wherever possible. And that's where you need the public and the patient's voice as well as the key stakeholders. And so then there's a bit about around about the learning, you know, like I said before about our do once approach. And that's what Neil was alluding to, we don't want to be doing stuff just for the sake of doing it and then having to do unnecessary duplication or having to add more resource in downstream. So just because we might not be doing that or somebody else is doing it doesn't mean that's a good use of anybody's resource. So that's kind of how we kind of plan it and manage it. And yes, where there are kind of key metrics like, you know, as Jack's talked about, right, in terms of, for example, unit price and cost savings, then obviously we'll attribute that, but some of it might be run actually well. We want to reduce the anti microbial resistance, so we're looking at anti-microbial prescribing and reducing that down to five day working. Or we might be high in opioid prescribing in certain areas, so we're look at new ways of working, innovation, bringing in technology, you know, helping patients in different ways and that holistic approach to helping to reduce that. Or it might be, for example, looking at antidepressant prescribing and how we'd want to work with wider holistic practitioners where we might want to work with social prescribers within place and PCN practices and what that would look like. But you can't do any of that. You can't forge it. It's just sat in a room somewhere on your own. You've got to have people involved and engaged at all levels. And the whole point of co-creation or co-production is that then you've got key people who've got ownership of that. So it's a real kind of system change. That's how you would then get down to those five kind of key priorities that they then got very clear for the year. So then people understand the why, they understand the how and the what as well, because, you know, how we're going to do and what that means for them. And then everyone's tackling it from that kind of whole issue. So that's why planning now is a lot more, you know, as Neil was saying before, it's not just about a gung-ho approach and going doing something, there's got to be planning and there's got to be some real engagement and then there's got to be some clear metrics. And for us, for those key national five indicators that we may take on, we've then got to have a confirm and challenge with the regional kind of NHS England to ensure that we are doing that as a system. But there's also something about shared learning across a region. So what's our neighbours doing? You know, what are they doing? What's worked well, what hasn't? So it's sharing that best practise. So it's been about more being more open and transparent about why you're doing what you're doing. There's no kind of, you know, backdoor kind of jobs being done or cloak and dagger. It has to be very open, and I think as Neil was alluding to, and we have to be very honest about that and that's honestly open conversations. Hope that explains a bit of it.- Yeah, absolutely. I'll come to Neil 'cause I mean that sounds ideal, Zafran, if that's how it's being decided. Is that your experience, Neil?- Yeah, well that's my experience anyway. That's what we are trying to do. So, you know, before we get shut down, that is what we are trying to do. Absolutely. You know, that's the aspiration.- Yeah, absolutely.- I think that's the best practise and I think that, you know, you have to work as a team, because the way that this is deployed is through other parties. You have to get everyone on board with why you're making that change. Why you're making a change? It's just a cost saving and that cost is never seen. The team that's doing the used expending their resource actually never see those cost savings. So that's one big mistake that people make is that the actual prescribing budget affects general practise funding, which it doesn't. So if I prescribe something very expensive, it doesn't mean I have less money. If I prescribe something very cheap, it doesn't mean I can save, I get to keep that money. Nor does it mean that that money actually comes back into primary care, and so it is a really hard thing to motivate. So previously it was just a dictation that you wanted to change. You had a target to get everyone onto certain particular medication. And it wasn't always scientifically clear as to how they'd chosen that medication for people to change to. And there wasn't a good economic argument if people had a clinically safe control, let's say the blood pressure, why would you want to destabilise that situation? It's a long term treatment. But I don't think that's happened. We haven't had as many switches over the past five or 10 years. We used to switch every year, there'd be something else to change to because it became off patent. Drugs are obviously terrible until whilst they're on patent. And as soon as they're generic, they're the best thing ever. And so we saw a massive increase in particularly to lipid management medication or anti-platelet stuff. It was suddenly the best thing ever once it was cheap. So, and that's probably down to cost modelling and economics, but I'm sure there's less subtle reasons why that might happen. But yeah, I think working as a team, this is a team project, the NHS needs to work more together so that the savings that are released from this come back into support practices, support pharmacists, and support the wider team. Medicines are a massive cost, a massive part of it, but they're a massive necessity as well. You know, there's not, we take even for granted that there's the solution to somebody's problem and often there is and that is, as a result of the money spent through pharmaceutical research. So yeah, I don't think I have anything much more about that. I mean, to make a difference to that, you would need to have some input into the advisory boards for the prescribing guidelines and things, but I'd imagine that that is, Zafran knows better about that, how they make the choice about what is the optimum product range to choose for certain things.- Yeah. Just, Jack, just, I don't want to not include you in that. I know you were saying that obviously these sorts of, you know, the discussions around medicines, things fall to the likes of Zafran and Neil. Do medicines conversations cross your desk? Is that something you ever talk about?- Yeah, I think it. So in terms of how the business cycle works, so I would normally work with our chief pharmacist in terms of setting the annual plan. So, yeah, look at the budgets, look at the areas where we gain efficiencies, the new investment areas we need to make if there are technology appraisals coming down or other stuff. So there's definitely that initial business planning bit. I think we do get involved, so certainly I get involved with our pharmacists on some of the elements that Neil talks about, which I think are really important around how you develop a better model to drive efficiency and improvement in practise that gets a share of benefit back into the teams that are doing it. I think that's really important, because otherwise you are just bludgeoning people every year to say, oh, spend less, be more productive, do more work, be, you know, for less resource and so and so on and so on. So that's how we develop that model of gain share is something that we would definitely be sort of worked on throughout the organisation. And then there'll only be really specific high risk or high gain areas would normally be more addressed at a board level. So recently some of the biosimilar switching in more in acute care has been very, very, very high value clinically contentious in some areas, legally contentious in some areas. And there's quite variability in pace of uptake across hospitals, you know, even within a relatively small geography, so those sorts of things would sort of make it to board level and we'd have debate about that or intervene with different trusts and so on and so on. Or need to bring different clinical teams together to debate the merits of things like that. So when it gets to a certain threshold really, and it's one particular problem, diabetic technology and new monitoring and stuff coming through. There again is a massive investment area. And again it's an area where the centre may make a decision to say, oh, everybody should be entitled to this. And then quietly they'll say to you, well there's no much money to pay for that. So, yeah, be prepared to absorb that massive cost pressure in that year. And then you have to find a way of doing that within and which means other stuff will lose out. So in some of those really big trade off conversations, does it sort of get to organisational level, I think?- Okay. That's really interesting. Okay, let's-- I was also going to say, sorry Karen, I was also going to say apologies. I was also going to say there's something around population health management as well, health inequalities. So there's always, I mean, look at prescribing you look at what's not being prescribed or what's not being picked up. So for example, for us there's hypertension case finding and a lot of that kind of work, you can't do on your own. So you've got the public health consultants, the experts, you know, you've got data analysts, you've got all that in integral telling you where the issues are, but then you are also going to need private providers, third party providers, PCNs, place, practices to work together, the voluntary sector, local authorities to help you to identify those and treat those patients. So there is something about, yes, prescribing is important, but, and there is a, you know, always people talk about de-prescribing, but there's lots of areas as Neil's alluded to that actually we need to upskill to be more around secondary prevention as well and also initial diagnosis. So wasting a lot more of that work coming through as well now.- Yeah, and that's a really important thing because that's an open market really in sort of third parties being involved in providing for detection services or looking at providing focused long-term condition management. There's a whole lot of non-pharmaceuticals, but they're actually a service that teams would be able to provide. It's a business opportunity, isn't it?- Yeah, and not only that. If you think about that on a wider scale, a lot of that kind of case finding stuff, et cetera, might be coming through pharmacies, for example, where they're helping to find those patients. Well, well how could they do it? Or 'cause they've also got issues with resources, how could they use different technology? What could that look like? So some of this work, I mean a lot of this work is actually quite exciting, because it's about health innovation, it's about, you know, using different things, different models. It's about trying and testing and not being afraid of trying something and then not working. But as long as you learn something from that and you share that across the system, and you do start getting some wonderful pockets of experience of how that works. I'm very good to that being adaptive.- Now that's something. I'm sorry. You hit the nail on the head there, trying and accepting failing, because that's something that in clinical world, that's a big no, isn't it, trying and accepting failing? So it's a whole mind shift to entrepreneurialism and actually looking at opportunities. And making a change if it doesn't work, you know, switch to a different opportunity. But there are a lot of opportunities in that market.- Yeah, there's lots of areas of work that suffer. Just mentioned that aren't overtly badged as medicine strategically or in documents you read, but actually are quite, you know, the medication interventions are quite critical in the preventative agenda, Karen, that you've absolutely mentioned across the board that has to be highly, highly targeted. A real focus on detection, a real focus on some of the data and intelligence infrastructure that goes around there. But they are often medication based solutions, and in fact I think that's the health service I think has got to really target its role much more specifically on some of those things. So I think my personal view is that we are a bit too woolly in terms of that we want to do prevention or address health inequality. And when you look at health inequality, so I'm sitting in Ashford hospital, which is under Heathrow Airport. And if I drive 20 minutes that way, by the time I got there, the life expectancy would've gone up for every one and a half minutes, I've been in the car by a year. The people live that far down the road live 14 years longer than the people in this community. I could throw the entire health spend at that problem in this area and I wouldn't make a dent in it because the driver of that is the economic prosperity of the area around Heathrow Airport compared to a leafy affluent town down the road. So if we we're talking about intervening health inequalities, we have to be really specific in terms of the samples of the communities want to influence and what are the factors we're trying to move, because at the end of the day, most of your health outcome is not determined by your healthcare. It's determined by your standard of living and equality of your housing and the quality of your education and the amount you take home every month and all the rest of it. So we have to be really quite specific and quite targeted in how we build those interventions from a health inequality point of view.- Absolutely. Okay.- And I'll say- Sorry.- Yeah. So, Zafran, again.- Sorry. Thanks Karen. And I would say that's where population health management really helps you do that,'cause you've got data set upon data set that allows you to look at it. So for example, one area of learning for us has been that there's an assumption that because you're in very deprived areas, you don't have high opioid prescribing, you know, deprivation, lack of opportunity, et cetera, but then you get pockets of high opioid use in very affluent areas as well. So what's going on there? So the data allows you to map out the areas that you need to work in and sometimes the areas that you think there's an assumption generally that would be aren't the only areas. So data's really important and really powerful. And the reason why I've interjected with Jack, so my apologies, is not everyone's got a handle on data. We haven't all got a handle on data. So the reality of it is there's some real opportunity there around how data is really captured, managed, and what that may look like across a landscape because that's really powerful.- Completely agree with that. The variability in the intelligence landscape is, you know, is massive, massive really. And, again, that's an area I think where in terms of working with industry and areas of mutual benefit where actually you can sometimes access expertise and infrastructure that is a lot better than the public sector can access and there's just an opportunity there. Go ahead.- Just getting a bit excited. And above my station there, I was just going to say, you all heard of the ARSS funding. Well, as part of the ARSS funding, now you can actually fund for data analysts. So again, where would they come from? Where would they have the expertise from? Who could bring them in? How could they co-create, co-locate, co-production? What could that look like? So there's a real kind of opportunity as PCNs really develop around their resourcing and what they've got. There's also opportunity for them to actually then take and shape that kind of working as well. So there's lots of opportunities out there that people probably don't think about when they think about journeying data, population health management, the public health policy, you know, et cetera, et cetera. It's huge.- That is really interesting, Jack, when you're talking about health inequalities and it's conversations we have quite a lot and it's quite interesting'cause when objectives are set around certain areas, they're really specific, and then in others it says things like address health inequalities and deliver the Core20PLUS5 approach. So I'd be really interested. Have any of you got any examples of initiatives within your area where you are delivering, you know, "delivering the Core20PLUS5 approach"?- Yeah, Karen, we've got an example from our PCN well up north. Obviously Northumberland's a very rural sort of area, a lot of farmers and we know that they're ones that don't access services very often. And so we've got a local initiative run through our staff funding that is based in the livestock markets and does outreach work there and does CBD assessments like an NHS health tech type offer. And that's had a great uptake and been really welcome by the community.- Brilliant. Anybody else got any?- Yeah, essentially I think this is one of the areas where we really leverage our partnerships across the different organisations. There's two sorts of types of project we would have, We would have, well ones that are highly medical in nature. So we have ones that are quite zoomed in on. Actually, we know there's a real higher prevalence of CBD or AF or hypertension in that area. And we need to really focus in on equalising that particular health outcome and getting people detected onto the right treatment,'cause we know that'll save x number of lives over the next five years. And so there's areas of communities that we've been able to use data intelligence to target very much like that. The ones that I think of were almost a little more interested in some ways are where we've tried to use NHS capital development quite differently. So one of our areas, we are looking at building a new health centre and, you know, getting rid of some of our old falling down GP practices and using that to build a new facility, but in a place that then has a leisure centre attached to it and creates footfall for business and regenerates a high street that then regenerates an area and creates more wealth in that area that over time will equalise outcomes for a community. And we have quite close partnerships with our boroughs or council authorities that are part of our alliance that now enables us to do that. So, and I almost think that's probably where the gain is on health inequalities. That's about regenerating towns really is where the gain is in that, I think. As I say, the health sector's role is probably really a lot smaller and in focusing on those areas where you've got health access inequality more than a health outcome inequality if you like. So yeah, we have two strands of projects on that and they both quite measurable in their results really.- Yeah. Brilliant. Okay.- Sorry. So I was going to say, so we had one with the hypertension case finding where we wanted to work within a quite a deprived inner city area and it was working with the GPs and pharmacies and we realised that they were as most of primary carers really up to the hill in terms of resourcing. So they came across with a really great idea of using the voluntary sector by training them up and mobilising them to go out to communities and to actually help find those hypertension cases, those patients. And so that was a very part but exceptionally successful and that's now been rolled out. So there is, you know, when you turn things on its head and you get partnerships involved and you get different ideas and creativity, it's amazing what you can actually achieve. And so then we've actually trained an army of people to become, you know, volunteers to go out and to scope and to find those patients. So then the community almost takes ownership for those health inequalities and then tries to move forward as to how they can do that better. And that's then has a spinoff of walking groups, people going for, you know, cups of teas, you know, there's people now looking to how they can lose weight. There's a whole campaign around, you know, staying healthy and that's been taken over by the voluntary sector. We said it has an impacted local communities. So I think yeah, there's different ways of working, but it could definitely have an impact.- I think we're pursuing a lot more devolution as well now. Now, Karen, I think that's so increasingly we're looking at an area and thinking actually, or what do we do in that town? What what's the population profile of that town? What's the need in a given area? And then we're devolving, you know, with the budgetary aspects, team composition, what whatever it is and lead clinical leaders in that town then shape the team for that neighbourhood. And it allows you to be much more targeted. So if you've got a higher prevalence of mental health, then you need mental health practitioners rather than heart failure specialist, nurses. You're able to to modify that team and tailor a professional skill mix that's a lot more specific to a community. And I think increasingly those sort of neighbourhood footprints are going to be the building block that we do our first sort of round of planning on really?- Yeah, there's a large drive to, oh yeah, sorry.- If I could just be controversially commercial. There's a lot of opportunity to help for inequalities and in terms of marketing. Brand awareness, brands could support these initiatives. There's potential for health service awards. there's all sorts of things that marketing opportunities with health inequalities because it's such a well loved area and there's such a priority, you know, and need to really think, well it's not, not direct marketing, but there's a lot of reputational gain from helping these projects. That's just my little commercial thing there.- I like that, Commercially controversial. Carry on. That's what we like to hear. Well, we'll stay with you Neil. Let's go onto the GP. We've got about 15 minutes left. Let's go onto the GP contract and the network contract DES. So obviously we know, I mean, BMA's publishing figures around 2/3 of GP practices are expressing concern about financial stability and longevity. It'd be really interesting to hear what it's like out there in terms of, you know, you've obviously had the 2% pay.- Yeah.- And there's different elements that have come across in the PCN DES in terms of some of the QOF indicators being financially protected and IIF reducing, you know, what's that looking like in general practice.- It's looking terrible really, to be honest, Karen. I don't want to deal with doom and gloom because this is opportunity. So yeah, there's blood on the streets, it's an opportunity. And the, the actual funding has gone from per capita patient was what, 152 in 2016 pounds per year per patient to 164 pounds per patient per year in 2022. So there's not a lot of increase for such a long time, and we all know inflationary costs, staff costs, staff pressures are a real big concern both in terms of the unaffordability of pay increases, you know, that aren't reflected in the contract and also the workload, I supposed it's maxed out the headlines are a lot of funding is coming to primary care, but it's maybe coming to the PCN DES and the ARRS, but nothing's come into practices whatsoever. And even stuff that the digital, the digital monies has gone to commissioning support units rather than coming into practices. So yeah, there's a lot of concern. I think something like 3,500 GPs left last year and I think, what was it, one in five practices closed since 2013, sorry. And new GPs, they're leaving and one in four is leaving at the moment. Younger GPs plan to leave. And a lot of the GPs, a lot of doctors aren't planning to be in clinical training, clinical practise, they're leading to other sectors. So I mean that's an opportunity for other sectors that they've got some healthcare workforce for health tech companies, pharmaceutical companies, but it's a difficult time, challenging time, but that focuses people's investment. So, and looking for solutions. So I think primary care is looking for more solutions and willing to explore the edges of reasonableness. So yeah, what I mean by that, the edges. So I think you have to explore the edges of what you can do because we've got a contract and we can't over deliver that contract anymore. We have to really stick within our contract. We've seen workload coming from secondary care, which doesn't come with any resource to deliver it. And so there's been a big appetite to push back on that workload. But the opportunity there in terms of new IT systems, new solutions, I'm looking at robotic processes quite often. I'm looking at AI triage type systems, anything that will help us be more productive, more efficient and automate some of these repetitive tasks that don't need human intervention. So yeah, there's a lot of opportunities and, it is a difficult time, and I think there's kind of message-- There is a lot of change isn't there? There's a lot of change in primary care in the way- Change in terms of the staff. The staff mix is very different than it was 10 years ago. And that's a benefit, that's a real big benefit. We've got bigger teams now. I think that's really important.- Yeah, it's interesting. I know NHSE sent a letter out to all practices at the end of April talking about the fact there's been an additional 57 and a half million appointments since pre-pandemic, which is huge. But obviously with 3,500 GPs leaving, that's not GP appointments, is it? It's patient facing appointments.- It's quite hard to, unless you really dig. The data is captured through GPAD, so it's GP activity data and that. Because a lot of work was previously hidden, it's hard to know what the increase is.- Okay. Oh, we've just lost you there, Neil.- Schedule activity, that was a contact, but it wasn't a consultation. Yeah, sorry. Previously we didn't schedule all activity, but now all activity's on there, so that some of it might be that there's better recording of the information. But yeah, like I say, it's a massive increase.- Yeah. So from your perspective, Jack, with the PCN DES, what's happening in primary care, the changing way that primary care is now operating and the pressures that they're under, what sort of things are happening in your area or that you're aware of nationally to support primary care?- Yeah. It feels like a particularly unique ground, this one,'cause also I haven't been in just as an absolute experience of some of my colleagues. But every contracting round of it, no one's ever happy with the contracting round. I can't remember a time when anyone said, oh yes, it's a great contract. I can't remember it. I can't wait for it to come down. But this one was quite unique in that I had GP board members bring me up to, I want to bring something to board this next month about how bad the GP contract is and how out outraged the profession is and the impacts this is going to have. And we need to plan for the consequences of this through the year. And that was quite a step change of reaction to what we would normally see. Even in a contracting round, when people are quite dissatisfied. I think it is a change in landscape primary care. It's the variability that makes it really, really challenging,'cause I have some of the most inspirational top quality colleagues that I've ever worked with would be GPs who run excellent practices. But I could take a sample of any 50 practices and I'll see a threefold variation in any metric of your choice, a business metric, a quality metric or whatever. And in some areas, it's impossible to provide modern, good standard of healthcare if you are in a converted bungalow or a Portakabin in a park, and it's just you and no clinical backup, or you simply can't provide modern healthcare like that any anymore. So I think strategically in the next few years, there will be a shift to greater collaboration. I think you will see smaller practices either giving up contracts or people are choosing to retire who are single hands in practice and therefore a natural sort of consolidation of the primary care market. And then I do think the partnership model, I think is one that you're seeing less and less GPs choosing to be partners. And it's more and more difficult to recruit good partners. And I think newly qualified doctors want more portfolio careers across primary care. So I do think you will get to a point in the next sort of 10 years where there are more primary care organisations, whether they are limited companies or whether they are NHS trusts that develop a primary care arm. And there's a lot of models out there that do this very well and do this at a scale. And I think that'll become more and more prevalent and it'll become more and more sort of an employed arm of the health service rather than the partnership model that we have. I think that's probably the 10 year sort of trajectory that you can see a little bit. And I know some of my GP colleagues would find that incredibly depressing. others would see that as the natural next step. So I do think it's a really challenging time. I think the PCN contract and this sort of central, I think any time where you are forcing people to collaborate through a commercial lever, I think is never some sort. So it works in areas where people want to collaborate and they're a good mix of people and they get along quite well. But if you're in an area where you don't get on with the practises down the road and somebody's leveraged a contract over you that forces you to work together, that's not a recipe for high quality service delivery. So I don't like it as a principle. It's my personal view.- Yeah, that's just totally correct, Jack. That's really is what happening. And I think what's going to happen further along is a private, like a two tier system of private general practice staff by GPs and a second NHS service that's GP supervised rather than being patient facing.- Yeah, I would also, sorry. I was going to say I would also add to that, Neil. You're probably going to get other providers, for example, community pharmacy now looking at point of care testing, so co-creating with clinicians. So you've actually got a whole different kind of way of how people are delivering healthcare that that may come about. However, I am rose tinted. I think there is something about, you know, what GPs bring, what primary care brings that other parties can't bring to the table and their ethos and their working and their hardship and their commitment. You, you're not going to get that at any kind of piece at, that kind of value. So whatever happens, it has to appreciate that that once that is taken away, then what you will get will not be as good as what it used to be. And that's been really honest because there's a huge amount of goodwill out there. I mean I've, you know, I've got to declare I've got friends and family who are doctors. I've got nurses in the family. I've got, you know, opticians. I get it, you know? I've got people in admin, you know, and it makes you appreciate the good amount of goodwill out there. And so if you try to build everything on a commercial model, which I know Jack was saying, you know, you can't really force people to work together and you lose that goodwill through either, you know, bad practise or actually not very good intentions. Once it's gone, it's really hard to replenish. And I think we've got to be really careful about that as well. You know, so the workforce issue is really, really important. That has got, you know, we've got to make sure that these people, and that's why everything that we try to do, we try to co-create, is really important and powerful that that decision making is there. And we're looking for opportunities and we are being honest and transparent about doing that because we want to hold onto the people that we've got. That's really important. So the heart of everything is the workforce. Without them, we can't deliver anything.- Yeah. We've got two minutes left. I'm going to throw one question out there that the audience have asked and just ask for kind of a one or two line answer from each of you to see your views on it. So, 'cause quite a few people have asked about funding. So obviously with ICS formation and consolidation of organisations and budgets. One question we had was, "Is there really just one budget?" and what's being seen quite a lot is that what potentially should be happening with budgets flowing through the system into the right place or for the patient isn't necessarily happening. So kind of in one or two sentences for each of you, what are your views on that? Are you seeing the benefits and the difference with the way budgets should be working within ICSs? So, Neil, come to you first. Have you noticed a difference?- No, I have not seen one budget. We have a very small budget and I don't see how that, the money doesn't follow a patient, it doesn't follow their condition. It is predetermined. That's all for me.- Okay.- My view.- Jack.- No, no, no. I've managed health economy budget for a number of years. I've never seen it go in any direction other than become more fragmented and often decrease in value. And it's the fragmentation that kills it, to be honest.'cause you get a budget for mental health and you get a budget for this and a budget for that and a capital budget, and actually it completely constrains your ability to plan strategically and use resource in totality. And that so it's fragmentation, that's a real challenge from a funding point view.- Zafran.- So I have come across where, I mean, so the prescribing budget normally is not within scope anyway. The financial envelope is really tight. If you look at economy, cost of inflation, cost of medicines, that's always far higher than what they're giving you, you know, a 2%, 3% growth. And actually you need a 10% growth to keep line with that. It means that we are already, you know, starting off the blocks, well behind the first few runners. So it's a race that, you know, you'd always try to play catch up. In terms of budgets and central procurement, that was quite interesting'cause there was this idea about, you know, making savings strategically and disseminate that down to ICBs and then using that pot of money to then go out and test and trace, you know, and treat and prevent patients. Did that really work? I think it could have been done a lot better. So I think there is some degree of it can work, but then that resource needs to follow all the way through. And sometimes you don't see that, that's the problem.- Yeah. Thank you. Perfect. So we're out of time, unfortunately, but thank you so much. I'd really like to thank all of you for joining us and for the invaluable insights you've shared. So as we bring the webinar to a close, just remains for me to remind everybody that we're here to help, should you wish to delve deeper into what the changes are and the challenges facing primary care mean for your business. So thank you once again for joining and we look forward to seeing you at our next webinar. And please sign up to the newsletter and then you'll see what's coming next.- [Presenter] Thank you for watching. If you'd like to find out more about our work with the NHS or how we could support your market access goals, please email info@mtechaccess.co.uk or visit our website at mtechaccess.co.uk.