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Birmingham and Solihull STP

You may be aware that the Birmingham and Solihull “Sustainability and Transformation Plan” (STP) was published on Monday and is attached. I am sending this to all Birmingham practices. Whilst I appreciate that Birmingham practices in Sandwell and West Birmingham CCG are officially in the Black Country and West Birmingham STP footprint (who’s plan has yet to be formally published) nevertheless I am advised that West Birmingham practices are “associate members” of the Birmingham and Solihull (BSol) STP and of course whatever happens in the rest of Birmingham is bound also to impinge massively on SWB CCG GPs and practices.

I would urge you all to look at the key sections of the document very carefully, in particular the sections on the “Community Care First” and “enhanced general practice” programmes. The headline intentions of the BSol STP are to achieve the twin aims of both improving health and improving the quality of care over the next five years, whilst achieving savings in excess of £700 million. This is to be delivered inter alia through failing to provide an extra 430 hospital beds that it is otherwise estimated would be required. Needless to say this will also involve reducing admissions, reducing GP referrals, reducing A and E attendances and shifting a massive additional amount of new work and responsibility onto general practice.

These key principles and aims of the STP were drafted without any initial input from representatives of GP providers. It is only laterally, when the plans were well advanced, that GP provider representation has been obtained, both through the GP provider alliance (this is a grouping of the Birmingham and Solihull super- partnerships and federations together with representation by the Birmingham “unaligned” practices led by Dr Olav Van Loon) and through the LMC. On behalf of the LMC I have over the last few weeks (by which time it has been too late to exert any significant influence over the STP content) been attending meetings of the Community First Board and general practice workstreams. I have also been attending meetings of the GP provider alliance.

The STP aims to shift care out of hospitals and into the community. Plans for this include ensuring transformation of general practice to work at scale, delivering “place-based care” through a number of integrated care hubs and “hublets” across Birmingham and Solihull, as stated in the STP document. The details of how this is actually going to be achieved and operate are yet to be worked out.

I have clearly stated to the STP leadership that I believe the STP, in particular the plans to massively increase the delivery of out of hospital care, to transform general practice, to massively increase access to GP appointments (the plan says a great deal about the quantity of access , failing to recognise the trade-off between quantity and quality) and to give it far greater responsibilities across a range of areas are simply undeliverable within the scope of the meagre additional investment, the unambitious plans to increase primary care workforce and the woefully inadequate intentions to support general practice sustainability and viability contained within the STP submission. My view is that the STP allows the transformation tail to wag the GP sustainability dog. There is no recognition either of the extent of the crisis within general practice or of the scale of additional investment, support and transfer of workforce required to enable core general practice viability let alone the grand plans to transform general practice and massively increase its delivery of out of hospital care.

I have also stated my concerns that the only explicit criterion mentioned within the STP to assess success in ensuring the sustainability and resilience of general practice is based achieving good or outstanding CQC ratings! Whilst not dismissing the importance of reducing variation and increasing the quality of general practice (and I shall refrain from any comment here on whether or not CQC and its process are a fit for purpose mechanism for determining this) I have suggested that far better markers here would be related to eliminating practice closures and stabilisation/increase in the number of GP partners and GP partner WTEs.

I have also made the point that whilst appreciating that the process is sadly wedded to inadequate GP Forward View Targets which fail to recognise the true under-capacity of general practice, the plan for just a 114 WTE increase in GPs across BSol by 2021 is just woefully unambitious and fails to go anywhere near addressing the workforce needs required simply to safely stand still to deliver core essential GP services, let alone the grand plans in the STP for general practice to deliver more in every area. I have also stressed that the increase in GP numbers should explicitly include increasing the number of GP partners who provide enormous value added not just in terms of the work they contribute but the central role they play in the system as the owners and leaders of their practice businesses, this being the key issue for practice resilience/sustainability/viability, as well as, of course, for transformation.

Further specific areas of concern relate to sections in the STP on child health/paediatrics, maternity and mental health, again all of which would suggest a massive shift of activity into general practice. These plans appear to have been developed without any GP provider input and again would seem undeliverable without the required increase in resources, support and transfer of secondary care staff into primary care.

The publication of the STP document is, of course, just the beginning, and a considerable amount of work is under way putting flesh upon the bones. The LMC will continue to engage with this as much as it possibly can, as will the GP provider alliance, in order to ensure that the interests of general practice and its patients are best safeguarded. Any unaligned practices who are still to get involved with Olav Van Loon’s group are encouraged to contact him on olav.vanloon@nhs.net. The STP for its part, does commit in its document to engage with and consult general practice, the GP provider alliance and the LMC.

Whilst I’m sure that we all accept that transformation of general practice to embrace new ways of working and new models of delivering care is both desirable and inevitable (and the LMC has long been a champion of practices working together in new business models) it has to be made clear to the STP leadership that the vision of transformation and delivery of enhanced GP services as set out in the STP can only be achieved if it goes hand in glove with ensuring the sustainability and viability of general practices to deliver current core work and this must be through ensuring adequate additional funding, workforce and support for this before any consideration be given to massively increasing the scope of what general practice is expected to provide and before delivering the transformation into new models of care that are proposed in the STP.

It goes without saying that the changes in general practice which the STP wishes to see can only be delivered with the full consent of GPs and their practices. It is impossible to envisage any of the STP’s aspirations being achieved without this.

Click here to download the document "Birmingham and Solihull STP 21102016".

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