Developing a federated model of General Practice - CCGs and Co-commissioning
Following on from my recent post about commissioners and providers working in collaboration, and after a week where I have witnessed what the best and the worst CCGs have to offer newly emerging federations, I thought I should share a few more thoughts. It is also amazing what getting on the 05.40 train to London can do to sharpen your appetite to BLOG!
My first article of the day came from Dr Steve Kell; co-chair of NHS Clinical Commissioners, chair of NHS Bassetlaw CCG and a GP in Bassetlaw. The full article, which I recommend every CCG reads, is available via PULSE.
The section that drew my full attention, even before 06.00 and my first coffee, reads - "co-commissioning means creating joint responsibility and goals in order to improve outcomes. The ability for CCGs invest in new models of care for primary care and community services, for example, is crucial if we are to deliver the care needed for our patients out of hospital. There is little point in planning to reduce hospital capacity if GP services don't get the corresponding investment in new models of care". I couldn't agree more; however, in my experience many CCGs simply don't grasp this, or if they do are choosing to ignore it!
While I have one excellent example from my current workload where the CCG wants support from the new federation to improve Primary Care quality, in order to ensure high quality services are delivered consistently across all practices, reducing unwarranted and unexplained variation, the rest appear not to know what a federation is. This is further compounded by an apparent unwillingness to formally engage in understanding locally how the federation works, what it could support the CCG to achieve or vitally, that, as Steve Kell explains, without real investment in new models of Primary Care, which include General Practice (not simply dumping more work on an already overloaded system) the Practices will implode. We need to re-think the delivery model and increase capacity, which means working in a different way.
"Some men have thousands of reasons why they cannot do what they want to, when all they need is one reason why they can." Willis R. Whitney.
This week I had a federation meeting where the CCG has completely ignored all approaches from the Federation (a new model of Primary Care delivery for those who may not understand federated working), for formal engagement (means working to do something, not just meeting time and time again) and advised it doesn't want any "plans or proposals from the federation - only unworked ideas" (unpaid consultancy from the Federation) it might then develop and collaborate on! They managed to find 1001 reasons why engaging formally in doing something with the federation wasn't doable and couldn't find one why they could or would.
Keep in mind the Federation has been set up by local practices to represent them for service development beyond the scope of the core contract, and it makes this approach, which can only alienate the federation, and therefore by default the practices, beyond comprehension.
On top of that the CCG believes the federation can only help by bidding for any AQP it puts out or employing staff to help practices. It has ignored all other benefits of federating, primarily I sense because it doesn't understand what a federation is, while also ignoring any number of ideas and proposals from the federation. It has instead plumped for the sheer brilliance of asking practices for "ideas" - no limit on how many from each practice - to enable practices to create a temporary increase in workforce capacity. In return for the ideas the practices can bid for a % of the money available locally to implement those agreed.
This of course means that instead of working to drive sustainable and truly transformational change, and using scarce resource for maximum impact, with a clear clinical focus and added clinical value, they have chosen instead to implement in a way that has been has been done any number of previous times, within incentive schemes. If we get lucky we get outcomes BUT then find they are not scalable or replicable as they are specific to a practice. No scale, no pace and totally lacking in any real innovation or ambition. This is not what the NHS or General Practice needs in the current climate of austerity.
Turning back to the areas where federated working is being encouraged, welcomed and supported, I have a great example where the CCG is working with the board of the new federation, who are in turn working with the practices, to develop and then implement a standard approach across all member practices, focused on driving up the overall quality of General Practice and reducing unexplained/unwarranted variation. I will detail what is being done in future posts; however, what is clear is the CCG understands it needs to invest in General Practice, and is happy to do that in an appropriate way.
In working in genuine collaboration they are seeking to ensure the right balance between standardisation and consistency, while also allowing for local empowerment and flexibility across the federation membership, to address both the quality of Primary Medical Services and the Member Practice challenges. By taking a structured approach and putting in place a support team for Member Practices, the federation, with the support of the CCG, will create a win:win outcome for the CCG and the Member Practices, while also recognising the fine line between commissioning and providing.
I should add that in this particular federation we have also been highly successful in engaging with the local FT who are now working to subcontract services to the federation. This is also a great route for those with intransigent CCGs, and we have many examples of how this can work for you locally.
"When nothing seems to help, I go and look at a stonecutter hammering away at his rock perhaps a hundred times without as much as a crack showing in it. Yet at the hundred and first blow it will split in two, and I know it was not that blow that did it - but all that had gone before." Jacob Riis, Photographer and Journalist
For the time being it appears those in federations lacking formal engagement in "doing something" (other than having meetings) with their CCG are going to have to continue like the stonecutter did above, and keep hitting the rocks, knowing that at some point, perhaps when a practice simply tips over, the CCGs still stuck doing the same thing over and over again and hoping for a different outcome, will be forced to change, forced to formally engage and forced to accept that what hasn't worked before is not suddenly going to work today.