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NHS working at sacle: Can I play with madness?

  • 15th April 2015

NHS working at sacle: Can I play with madness?

The prophet looked at me and laughed at me (ha ha) He said: Can I play with madness?
He said you're blind, too blind to see” 
Writer(s): Bruce Dickinson, Stephen Percy Harris, Adrian Frederick Smith Copyright: Adrian Smith Ent. Ltd., Imagem London Ltd. 

In my last post I looked at the issue of unfunded work within General Practice, and the “issue” simply isn’t going to go away, no matter how much the CCGs I have dealt with in the last week wish it would.

What a week; hence the title to this blog – Can I Play with Madness? The Iron Maiden song is about a character pulled into a story but what the character doesn’t understand is that it may be their own end that unfolds in front of them.

In one week I have had:

  • GP Practices threatened with contract withdrawal if they send any unfunded work back to the local Hospital, which is funded to do the work within PbR Tariff, but prefers to have it carried out by General Practices free of charge. This is despite the BMA (nationally) and the LMC (locally) recommending this as a positive course of action for Practices.

    My question is why are the CCG unwilling to tackle the issue?  Surely as a membership organisation they should be acting on behalf of their members? Is it that they are unable or incapable of challenging a strong hospital trust? What appears inescapable is that weak commissioning leads to strong providers, who then dictate.
  • A CCG demanding that the Board of Directors for a Company Limited by Share ignore their legal duty to act in the best interest of shareholders and instead act in the best interest of the CCG.  Can you imagine the scenario if the Directors find themselves in court saying the company had gone out of business as they had ignored their legal duty because it was “at odds with the CCG’s philosophy”?
  • A Medical Director at a CCG emailing the Practices to advise they should be happy to continue to offer services free of charge and that, despite co-commissioning, the CCG is not in a position to address any of it. In this instance they quoted NICE Guidance at the federation without realising the guidance was to be used by commissioners to commission (purchase) the service.

If that’s not enough, the outstanding contribution came from one CCG, which doesn’t believe that the federation should see eradicating variation in service provision from Practices (beyond core contract) as something it should be addressing when it subcontracts work to Member Practices.  The CCG believe it is their role, which I assumes means that the CCG has failed, as the current 57 varieties have been around for many years and show no signs of improving.  

This CCG also doesn’t believe that the federation should be interested in generating income; it would appear from what they say that they believe the federation should be prepared to work for free. This is simply untenable as any company needs income, even those that are not for profit need turnover (income), profit and cashflow to stay in business, as Directors and staff need to be paid, the legal work and contracting will also cost money and of course the company will have overheads. 

The CCG instead believes the federation should be focused on improving core contract and nothing else, despite the Member Practices not delegating this role to the Company of Board of Directors. It is hard to understand the CCG preference when the Federation is offering to try to support the practices to remain viable through a rethinking of the current deliver model, and bringing in properly resourced service delivery opportunities that generate income to keep the company and Practices in business. There appears no concept that unviable Practices will eventually go out of business and no income for the federation will ultimately mean no federation!

Above all the other madness this week, the same CCG finished off by saying if the company couldn’t survive with no income “the CCG has no choice but to look at alternative methods of federating GP practices”.

This raises as number of questions:

1. How could they do that without a massive conflict of interest?
2. How would they persuade Practices that after one failure in such a short space of time, the next time would be any different?
3. How would they convince member Practices to invest their own money in a second company?
4. This also ignores the fact that with one failure locally where would they find Directors willing to step forwards and take on the risk of a second company going under?

I am very much looking forward to watching this one unfold in the coming weeks.

As a consequence of all of the above what has become clear is that unfunded work is clearly going to be the argument in many areas, and it will be very interesting to see CCGs’ response to this.  What will be of particular interest is where Member Practices make a request for a CCG view, and CCG assistance, to address this with acute trusts and community service providers in the coming weeks and months. How many will step up to the plate and do something about it, or at least start to work with Federations, Practices and LMCs to address it?

In all the federations we work with, we are using the excellent BMA document Quality first: Managing Workload to Deliver Safe Patient Care [1], as a start point for auditing this work.  I will continue to provide feedback on how different areas progress.  However, I emphasise that this is an argument that General Practice cannot afford to lose or you have to be concerned about what the future will look like.

My hope remains that Simon Stephens will see that Clinical  Commissioning in its current form simply doesn’t deliver the required outcomes.  The very people who didn’t commission great services in the times of plenty (PCGs, PCTs and PCT Clusters) have now, and having transferred their employment to CCGs, been given the responsibility for commissioning services in austere times.  Is it any wonder then that they are failing spectacularly to do that?

Anyone in any doubt should simply download the last 3 years worth of commissioning intentions and commissioning plans and look at what has actually been achieved in return for £5,000,000,000 in costs per year.

"When you innovate, you've got to be prepared for everyone telling you you're nuts."
Larry Ellison, Entrepreneur.

It is time for capitated budgets across integrated service providers, with CCGs reduced by two thirds in staff size, merged with Local Authority Commissioners and placed into nothing more than an oversight role. This is precisely why we need General Practice to be federated.  We need one voice to represent the General Practice view in contract negotiations, and that voice needs to have confidence that the membership can deliver.  

The General election is not suddenly going to fix the problems the NHS faces and therefore it is time for something radically different BUT not from commissioning, which has had its time; instead we need something radically different which is provider led.

If you are still thinking about federating, and would like more information on how BW Medical Accountants can support you in forming a federation, or if you require on-going support. Call 0191 653 1022 to arrange to speak to one of our experts.

Additionally, if you should have questions for us please email rachael.mackay@bw-medical.co.uk and we will do our best to answer these within the blog.


[1] http://bma.org.uk/practical-support-at-work/gp-practices/quality-first

Who writes this?

Scott Mckenzie

Scott Mckenzie

NHS Management Consultant / Working at Scale
Find out more about Scott
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