A Double Blast From The Past

I found this in an old e-mail folder- its already 4 years old, but the trends are clear.

20 Years of Kirkby Primary Care: The Changing Numbers of Family Doctors

A nation that keeps one eye on the past is wise. A nation that keeps two eyes on the past is blind.

Introduction

The future of primary care is once again at a cross roads, this appears to happen every 10 years or so.   Changes such as locality purchasing, PCT, PBC, GPCC, CCG and now CCCs appear and mutate the very DNA of primary care.  It’s often said that General Practice remains a constant and that alterations in the delicate ecosystem will “destabilise” services. This belief, whilst comforting is not actually true. Primary Healthcare is a complex adaptive system, constantly changing and evolving to meet the demands of the system and the population it services.

This paper draws on simple demographic changes in the nature of practices and practitioners and attempts to pull out some threads for development which others may choose to fashion into a safety net or hangmans noose, depending on their preference.

Although as GPs we pride ourselves on continuity of care and accessibility the experience of patients based on their own experience does not always agree with perceived wisdom.

I recently came across some documentation from 1988, the year I qualified as a Doctor. This outlined some simple demographics for the GP population of Kirkby. The same information is available to day and perhaps the comparisons of the changes offer some insight into the changes we may expect or even create in the next twenty years, not for the patients but for ourselves as individual practitioners, the way we work and the people we are.  

As with all predictions there is a health warning. The more precise the prediction the less accurate it will become. So predicting the future demographic of primary care down to individual GP numbers is nonsensical, but broad strokes of strategic direction will for the most part be made real to greater or lesser extent.

The Population

Kirkby was developed in the 1950s as an overspill town for Liverpool, it reached its population maximum in the 1970s, 10,000 short of its predicted target and since then there has been a decline in the population numbers with a stabilisation and slight growth since the 1990s.

 

No data available for 1981 1991.

The ageing population demographic applies to Kirkby equally as to the rest of the county, however health needs are significant. NHS Knowsley Annual Report has full details.

The 1988 Position.

The St Helens and Knowsley Family Practitioner Committee document “A strategic statement for the development of Family Practitioner Services” provides basis demographics for the population of General Practitioners.

The document also outlined a number of challenges such as computerisation which would need to be addressed for primary care to develop. 

The data is not clear as to WTE figures simply stating GP numbers age and Gender. Aside from trainees there was no mention of salaried or long term locum posts.

This data would appear to be based on performers’ list details alone and so the 2011 data can be sampled in a similar blunt way.

Comparisons

Numbers of GPs. 

The table below illustrates a stark truth- the overall numbers of GPs have changed little since 1988. However the expansion of the primary health care teams has been massive.

	Drs	Trainees
1988	28	3
2011	33	3

 In 2011 all practices have some nurse support, the community teams have increased in size with new posts such as Community Matrons, Practice based pharmacists and Independent Nurse prescribes completely unpredicted by 1988 data.

The Options service has also been excluded from the data since the nature of that service is a pan Knowsley one and the model of employment means that actual WTE data vs. Individual Names not available.

Who are the Doctors?

In 1988 25% of the Medical body was female, this has increased to 33% by 2011, however this is still short of the current 42% national figure and the 50% Male: Female figure leaving Medical School. Given the increased uptake of part time work by GPs who are also main carers for children it should be expected that more of our population of Medics will be female in the next decade.

Have we aged well?

It would appear that with the notable exception of Dr Ford we have indeed aged well as a population. Although Dr Ford has since retired from practice the figures were generated at a time when Colin was still active.

 

Over the next 20 years we can expect 20% of or GP population to retire and be replaced and the figures do not appear to be a cause for concern regarding sudden departures. However the pension changes and external factors may simultaneously force retirement n some and prolonged working life on others. A solution may arise in practitioners “winding down” and becoming part time, at the same time as younger female medics are seeking part time employment.

What kind of Practices do we work in?

This data is the most interesting to note, given that the overall numbers appear to have changed little, has the nature of practice also changed little?

The answer would appear to be a significant shift, possibly to the extent of polarisation.

 

In 1988 the largest practice in Kirkby had 5 GPs whilst there were 8 who appear from the data to have been in single handed practice, a total of 16 separate medical facilities.

By 2011 there are no longer any lone practicing GPs in Kirkby with 16 GPs working in 5 2-4 doctor practices and 18 working in a brace of 9 doctor practices. This gives a total of seven medical practices.

This wholesale centralisation has multiple drivers, not least concerns over isolated practitioners, economies of scale and estates infrastructure development which have all conspired to develop the reduction in practice numbers and increase in practitioner team size which is clearly evident.

Where now?

As mentioned these are interesting times for the NHS and Kirkby and the vie of a world twenty years behind us does not predict the future, however it does show where we were, where we are and hence where we might go.

The NHS faces the Nicholson Challenge- a reduction of activity and expense to the tune of £20 Billion is required by the NHS. The coalition government strategy is forcing GPs to embrace a broader role in the commissioning of services, with subsequent impact on day to day care activity and for the Kirkby GPs questions remain about the viability of a commissioning unit with 50, 000 patients and 33 GPs.

The changes in the nature of practices observed might suggest development of a  co-ordinated approach, hub and spoke services, a collaborative environment. The reality is that we are not established in such a way at this time.

The new town centre development offers a potential catalyst, with the co-location of walk in services, practices and the facilities associated with St Chads and the Kirkby health suite there is a golden opportunity to develop a different healthcare system for the population. One which maximises the potential of collaboration between practices, uses the demographics of our General Practice environment to the fullest and as a result provides a new deal for the Kirkby population.

As one local GP suggested we should “Consider ourselves as mid size company with 8 practices [inc options], £75m turnover and lots of employees and 50k customers.”

Dr Chris Mimnagh June 2011

Applitivity

Ok, it is a made up word. 

However recently I met a colleague at a commissioning group event. He is a true entrepreneur, always looking for the next source of potential gain. He was keen to tell me that new ideas were all well and good, but what mattered was making them work, putting them into action. He is particulaerly good at that, the implementation, not the creation. It got me thinking- what is his adjective? What is his preferred thought process?

So my suggestion goes like this:

Innovation equals ideation plus implementation. 

It's easy to describe someone who is good at ideation, generating de novo concepts or taking various problems and solutions and creating a new concept. 

We call them creative, they have creativity. 

So what is the descriptive term for an implementer? Someone who takes that idea and makes it reality? Someone who sees a place where the words first nano watch can be read? 

Can I suggest the are applitive, they have

applivity (adj.) the ability to apply novel solutions to unique situations.

It's a Big Data World After All

I recently had the opportunity to mix with some really smart people at a Big Data Seminar. There is a lot of interest right now in the topic, althpough along side the interest there is a lot of Hype. 

The best comment which cut through the hype and described the situation came from a Professor who said "Big Data is like teenage sex- everybody wants it, everybodys talking about it, but nobodys really sure whose doing it!"

My job was to present a Health Perspective and suggest what was missing from the current landscap that could be a target for further development. 

Perhaps not surprisingly given my love of the strategic, my observations suggested that in terms of big data we have three axis along which any "big data" activity can be plotted. 

Operational Vs Strategic Uses

Single Vs Multiple Locations 

Personal Vs Population Perspective

In the three dimensional cube of the data we have applications which occupy all, bar two, areas within the domain of health. 

The two remaining holy grails are Strategic Population Multiple based systems and Strategic Personal Multiple based systems. Both of these two domains should have systems but as yet these systems do not exist.

I can collect my own health data, record it in an app, but much more interesting stuff could be gleaned from multiple sources including analysis of unstructured, perhaps socially generated data.

Similarly if we are to know whether a citys health will be suffering in two years time our best guess might be supported by data gathered from across a wide range  of media. 

All in all, my brain was hurting, but there is definately something in this big data lark. 

Who Trains the trainers?

There is a way to describe learning styles as a balance between pragmatic and theoretical, reflector and activist. I am it would appear an activist and learn best by "getting stuck in".
I've been getting stuck in to becoming a trainer in general practice and recently enjoyed the experience of taking part in the initial trainers course.
So who is it who trains the trainers?
The team I have met so far are a blend of all the above learning styles, but in addition they all share an ability to inspire. Each one of them is unique, but common traits emerge.
They are all enthusiastic about primary care. They are all committed to empowering the future trainers to create the best environment for new trainees.
Combining the opposites of ambition with practical achievements, inspiration with governance and reality with motivation is not easy. The breadth of sessions covered has already been significant.
But in answer to the question- who trains the trainers? - it's easy- bloody good GPs do the training.

Big Data, small issue.

I've been doing some thinking about BIG DATA recently. If you're not familiar with the concept the idea is that we are now at a time when technology is not confined to taking a "random sample" for study.
In the old paradigm it was impossible to know and analyse all the data in one topic, example customer preferences, so we asked a randomised or stratified sample. Now we have sufficient computing power to not just ask the customer, but to track their data, triangulate with other data sources and arrive at an answer which is based not on what the customers said but in what they did.
Making this computopia a reality is a matter of fusing certain existing systems and technologies together to fit the purpose.

And there is the issue.

All our current paradigm thinking is based on a model of science; asking a question to get an answer takes the form of a hypothesis. "What is the impact of neuropathy on life expectancies of diabetic patients?" The parameters create a defined subset, a population, a sample and controls out the variables, creating a baseline against which our sample group is compared.
Taking a big data approach is an alien one. Casting the data net widely across a population produces a population image, one in which the paintbrush consists of intelligent analytical algorithms and the appearance of the picture, like most modern art is a matter of interpretation.
The role of the artist could be defined as selection of the paints and canvas, with the inherent properties of the paint, it's colour or texture interacting with the brush to produce the final image.
Examples of biggish data include school results, ofsted and family income comparisons, biggish because the picture created used limited colours and a couple of brushes on a small canvas.
Big Data is a big leap on and in the case of school results would include additions of social media, travel patterns, benefits data, health records etc. More colours to create a more vibrant picture, one which may better suit the complex adaptive systems of our lives and when studied, like a work of art, small details may attract our eye, requiring the microscope of standard scientific method.

Given this fundamental change in analysis paradigm Big Data may find it hard to gain traction with those steeped in scientific method. Those who value complexity and chaos may feel equally uneasy, but ultimately until the practicalities of access and the mechanics of governance are the first hurdles for big data, with the dissemination challenges of acceptance and adoption further away.

Fad or Future? - to early to say.