NHS working at scale: Unfunded work in General Practice
- “Change before you have to.” Jack Welch, Businessman.
In my last post I raised the issue of unfunded work within General Practice. This time we go a step further and take a look at exactly what I mean.
You may recall the excellent document from the BMA, Quality first: Managing Workload to Deliver Safe Patient Care , which goes a long way to addressing the issue of unfunded work. Indeed, you could simply read this document and use the templates included, and you would immediately take steps to start addressing the issue.
Within my work I now have entire federations auditing the volume and resource implications of this type of work, and wanted to share the early results which, whilst perhaps unsurprising, are still startling.
However, before looking at this, I first want to address a question I was asked last week:
If the federation is successful in being directly contracted by the CCG, winning a bid, or securing a subcontract from the FT or Community Services, where is the capacity to deliver that work to be found when the Practices are already struggling?
The answer is: if you all stop delivering work that is unfunded you will have the capacity to deliver paid work. Additionally, General Practice might once again become an attractive place to work. At the present time the key challenge is that you are swamped, and generally speaking people do not find it attractive or motivating to work in an environment that is constantly swamped. It’s a vicious circle: you cannot attract the right people until the workload is manageable and you cannot get the workload manageable until you have more people. Consequently the answer lies in not doing work that you are not funded to do, and when you attract and secure
income, use this to recruit the right people.
The following list is far from exhaustive; it is a sample and it gives a flavour of what’s been unearthed in a very short space of time, whilst the audit continues:
- Patients having to be re-referred because of inadequate follow up arrangements
- Medication/prescriptions that should have been issued in the hospital
- Fit notes that should have been issued by the hospital
There was no particular specialty that stood out with any of the above; it was across all specialties.
- Pre-op assessment
- Clexane/warfarin (which really is part of the above)
- 24 Hour ABPM*
- 12 Lead ECG*
* Both of these services have just been tendered by a “high flying CCG” which is a clear indication to me that neither can be deemed to be core contract. I also have one federation delivering the 24 hour ABPM on subcontract from the local FT and two very close to securing subcontracts for that work.
Blood tests as follows:
- General requests
- Regular PSA checks
A real mix of things, but highlights include:
- Faxing CaB referrals because the hospital’s electronic system couldn’t transfer them to the outpatient clinic
- Arranging diagnostics
- Chasing up/arranging appointments because the patient had been told to ring the practice by the hospital
- Lots through medicines manager along the same lines as the GP – sorting out scripts that should have been issued by the hospital
When written like this it doesn’t look much, and indeed that was an argument put to me two weeks ago by a CCG: “the work takes very little time and is therefore of no value”.
As a result of unfunded audit work, I now have evidence to counter that argument, both in terms of time and in terms of value. Based simply on the time taken over a two-week period, this adds up to just under £100,000 per year, or about £8 per head of population IN ONE PRACTICE. Now imagine what you could do with the money in terms of buying in additional capacity (and I appreciate that assumes you can find the people).
In addition to this, this week I read an email from a Community Service provider, delivering anticoagulation services to the housebound, to a Practice, requesting the Practice purchases two new CoaguChek® machines for them to use, while also being asked to prescribe test strips in place of the Community provider buying them directly. Can you imagine the hospital asking the Practice to purchase and then send in the theatre equipment along with the patient? Neither can I, which makes this request even more ridiculous. It also shows the thinking elsewhere in the NHS; that General Practice will fund everything and anything, while also
delivering unfunded work.
Now it has been identified, the unfunded work will be sent back by all Practices within the federation to wherever it came from and/or to whomever has been commissioned, and is therefore being paid, to deliver the work.
It will also form the basis for local negotiations with the CCG and other providers, where we will be looking at how this work might be formally contracted/subcontracted through the federation, with proper resourcing; something we have already achieved in a number of areas.
This does not need to be a combative process, particularly where people are willing to engage in meaningful discussion, in pursuit of a new outcome.
Federated working offers a position where only those Practices willing to sign up to a legally binding Service Level Agreement (SLA)with the federation will be contracted to deliver services on behalf of all patients referred to them, for a fixed fee per patient.
Within the SLAs there will be minimum standards that will be monitored and any underperformance addressed. This immediately addresses the issue of variation, which is unexplained, unwarranted and currently unchallenged.
High quality and consistent delivery will run right through the services provided by federations, BUT the work needs to, and must, be properly resourced.
“Ingenuity - plus courage, plus work - equals miracles.” Bob Richards. Olympic Gold Medalist
The miracle here might just be if General Practices, through the Federations they have invested in, all stand together and refuse to deliver any unfunded work. The CCGs, Hospitals and Community Service providers might just get round the negotiating table and agree properly funded contracts for that work. If not the Practices should keep sending the unfunded work back. What they cannot afford to do is to continue to provide it, or we risk the very future of General Practice as we know it.
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