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Developing a federated model of General Practice: PMS Reviews

“You cannot be serious" John McEnroe. Philosopher, tennis player, angry man

PMS Review - “You really cannot be serious” Scott McKenzie, Change management specialist, health analyst, angry man

How many emails does it take to get a response to a question from your NHSE Area Team (AT) or Clinical Commissioning Group (CCG) about your PMS review?  If one of my clients is anything to go by, we are at a count of five now and no response, not even an acknowledgement.

This is a Practice under threat of losing £175,000, which will literally destabilise the Practice.  If that isn’t enough they are also being threatened with the draconian measure of having the money withdrawn over 4 years if they “raise any objection” and don’t sign a contract by 28th February, to allow the withdrawal over 7 years. I find that staggering. 

They are not alone.  I have an inbox full of people asking for help and advice on what to do when the PMS money is removed without any room for discussion or negotiation.

What nobody can explain is why the deadline has to be 28th February when there is a further 12 months before any deductions are to be made? As we cannot get any form of response from anyone, there appears no hope of ever getting to the bottom of this.  It is though noticeable that some areas are being more engaging and are actively pushing the dates back.  You can only assume the 28th February deadline is therefore yet another bullying tactic to back the Practice into a corner and actively discourage any form of challenge, debate or opportunity for negotiation.

The PMS review is bad news for Practices, which in turn also means it’s bad news for patients, only they are unaware of it. Inexplicably, while the NHS has to consult on commissioning decisions, CCGs and ATs are clearly unwilling and uninterested in consulting on something as key as the possibility of destabilising local Practices. This does not portend well for their plans for co commissioning.

Surely the fine details of any decision of this magnitude should be fully explored and debated, with a professional negotiation, which concludes in a decision, for which people are then held fully accountable. There will inevitably be Practices that haven’t delivered the value or the letter of their contract, and they must now face the consequences. There will though be those who have, and yet they are now about to be penalised to the detriment of the patients and the practices.

I suspect the reason we are not getting the opportunity to negotiate the finer details is due to the loss of corporate memory around the complexity of the financial arrangements that underpinned the earlier waves of PMS, in both the CCG and AT, whereas at Practice level they have the contracts right back to the day they were signed. It is easier to hide behind “the system” and without any accountability simply enforce the changes to PMS contracts, than to sit down and review everything with a view to negotiating and agreement.

Furthermore we need to keep in mind that these practices took risks and many were pioneers in developing innovative solutions for the benefit of patients. Those services being delivered now will not be continued, as to do so, would be financial suicide for the Practices involved, and at the same time if the work is then referred back to Secondary Care the CCG and AT will want to complain and blame the Practices. Where is the accountability for those in CCGs and AT making the decisions?  

While the example sighted is one of the worst, I am aware there are many others who will now teeter on the brink of collapse, and some will undoubtedly be unable to continue.  What happens then when the Practice is the only practice in the town, serving a population of around 15,000, many of them vulnerable (30% of which don’t have access to a car), which the PMS weighting only goes some way to address? What happens when the practice becomes unviable, which it is likely to do given the amount of money being taken away from their budget, when there is nowhere else for the patients to go? Who picks up the healthcare at that point? Is A&E ready for the consultations? Can Secondary Care and the local CCG budget cope when work ends up being referred and costing three or four times as much? 

As part of my work I then made some enquires across a variety of contacts to see what the view right at the top was, and was advised, there is “little interest” from the Dept. of Health. Where then is there any accountability, certainly not at CCG or AT level, and apparently not at NHS England or Dept. of Health either. In effect it appears there is a significant lack of concern for the future of general practice in “the system”, despite the rhetoric about investment in primary care.

Can you imagine the patient outcry if these Practices close, I can; however, would any patient even notice or care if the AT or CCG didn’t open for a day, a week, a month or possibly a year?  Perhaps the money being spent making decisions such as this would be better being slashed and invested in front line services, with accountability passed to the providers for their budget management – the Accountable Care Model from the USA?

One last thought. Please keep in mind the cost of the AT and CCGs is about 5% of the total NHS budget, give or take £5,000,000,000.  To give that some context you need to consider that in a million days there are 114 years; however, in a billion days there are 114,000 years.  Perhaps after that you might then question is £5 billion being well spent on CCGs and ATs, when this is the type of decision making, with no accountability for what follows, is going on?

This is why I continue to believe the time is right for Practices to federate and provide a united front, working with their LMC to protect and then grow General Practice.

“Let me tell you, life is not fun when you're banging your head against a brick wall all the time” You know who………….John McEnroe 

For more information on how BW Medical Accountants can support you in forming a federation, or for accountancy/tax/NHS Pension advice, contact or call 0191 653 1022.

Additionally, if you should have questions for us please email and we will do our best to answer these within the blog.  

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