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Enhanced Services Under Threat

Innovation without implementation is a waste of time!

"You can have everything in life you want, if you will just help enough other people get what they want."

Zig Ziglar,
Author, salesman, and motivational speaker

Without Enhanced Services there is no core contract; this is because, whilst optional, General Practices cannot survive on the current core contract alone. These Enhanced Services exist to plug the holes in the localised populations served by the primary care sector to ensure minimum standards of healthcare are maintained.

However the ongoing erosion of Enhanced Services continues unabated this week, with more CCGs opting to market test. This often results in the growth of private sector providers eating in to traditional general practice as the individual practices cannot hope to compete, unable to provide the scale to cover an entire CCG population.

Unless we halt the ongoing erosion, or General Practices gets itself in to a position to compete at scale, or we see significant levels of new investment, General Practice as we know it simply won’t exist. Practices will go out of business, particularly when PMS (Personal Medical Services contract) reviews and the withdrawal of MPIG (Minimum Practice Income Guarantee) take effect.

Consequently, the 5 Year Forward View challenges general practice, and the wider NHS provider landscape, to rethink the delivery models. General practice can respond in one of the following ways:

  1. Do nothing
  2. Develop a federated model
  3. Merge to form super practices

No matter the route to working at scale (options 2 and 3) you then need other providers, particularly the local hospital trust and community services, to engage. You also need the CCG to be part of any engagement. It is important to understand that engagement is not meetings; it is an arrangement to pursue an outcome, for example rethinking the delivery models and implementing change/projects/pathways.

This is often where progress breaks down, with entrenched views in hospitals and CCGs, coupled with a complete unwillingness to change, halting progress.

If I have heard once that it is “custom and practice”, I have heard it over a hundred times this month alone, meaning to provide work free of charge. Where general practice picks up work that is unfunded and dumped on them by the local hospital, or is not commissioned by the CCG, such as 12 lead ECG (electrocardiogram), 24 hour ABPM (ambulatory blood pressure monitoring), post op suture removal, vitamin B12 injections etc, and primary care is expected to provide it by default.

This free work consumes just as much time and practice resource as funded work, while being challenged by the whole health economy for not offering better access. In my work it often appears the local CCG and hospital simply expect this to continue and are completely affronted if challenged. Can you imagine the outcome for General Practice if it was vertically integrated with a local Foundation Trust?

Perhaps if General Practice declined to continue to provide the unfunded work – as advocated by the GPC (the British Medical Association’s General Practice Committee) in their excellent document “Quality First – Managing workload to deliver safe patient care” – they would have the capacity to offer better access.

If that’s not enough, even when federations do innovate and start to implement new ways of working, we have faced a level of undermining opposition in one CCG that nobody could have foreseen.

My example here is quite simply stunning, particularly when you consider the 5YFV (5 Year Forward Plan, NHS England) states: “using digital technology to rethink care delivery”.

Why then has a CCG undermined the use of technology in the NHS and is instead promoting the idea that a practice continues bringing patients back and forth to self-test without any financial compensation for the practice.

“The LES does not cover patients who self test”

In essence, where the patient exercises choice and prefers to self-test, the practice is expected to manage any dosing and further support along with the ongoing management/care planning for the patient, without payment.

Patients will therefore be removed from remote monitoring and brought back in to clinics; I trust the CCG communications department has been alerted to the deluge of complaint that is about to follow from patients, and questions about why this is routinely funded in other CCGs but not locally.

I heard yesterday that the idea of passing a hard cash budget to a group of practices comprising no fewer than 25,000 and no more than 50,000 patients is to be piloted imminently. This is excellent news as hard cash budgets with real accountability will have the desired effect. CCGs on the other hand have simply failed to change the delivery no matter how hard they have tried.

Therefore a time for fresh thinking and approaches; a chink of light at the end of the tunnel.

"Putting off an easy thing makes it hard. Putting off a hard thing makes it impossible."

Charles Wilson,

If you are thinking about federating, and would like more information on how BW Medical Accountants can support you, or to arrange to speak to one of our experts please 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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  • BW Medical Accountants have a good working knowledge of General Practice and are keenly aware of the challenges Practices face within the changing environment of the NHS.  We have been very impressed by the way BW Medical continue to deliver the range of services they provide from Accounts to Tax and NHS Pension advice. 

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    The James Street Family Practice, Lincolnshire
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