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Fail or wither

"You cannot control what happens to you, but you can control your attitude toward what happens to you, and in that, you will be mastering change rather than allowing it to master you." Brian Tracy, Author 

I'm a long way from the first (and I'm fairly sure I won't be the last) to blog about the leaked briefing note from Paul Twomey, Medical Director of NHSE Yorkshire and Humber, who revealed the secret strategy to allow practices to "fail or wither".  In other words, transform or die; we won't be there with any resuscitation equipment if you don't sort yourselves out.

This on the back of reports in Pulse that hardly any of the transformation funding to support vulnerable practices has been spent, although apparently this is about to be rectified, as managers work to identify which practices might qualify.  Err, to a greater or lesser extent isn't that most of them?

However, for me of greater concern than the usual bureaucratically slow response by CCGs to the process of identification of vulnerable practices, is Paul Twomey's (and presumably his senior colleagues in NHSE Yorkshire and Humber), assertion that "we are no longer in a position to continue supporting practices irrespective of their willingness or ability as a provider to transform appropriately".

Add into this the news that Theresa May has decided that there’s no extra funding coming to the NHS, and things ain’t looking too great.

Granted, there are practices that undoubtedly have their heads in the sand, and appear to be unwilling or unable to help themselves out of the challenges they are facing, but my experience is that they are in the minority.  The vast majority of practices recognise that the world of primary care has changed and they want to do something about it.

Take, for example, the subject that I’ve blogged about many times: unfunded and unsafe work.  This is work either being dumped on general practice from other parts of the health and social care system, who themselves are unable to cope, or which CCGs have chosen not to commission.  This work, which is now at seriously unsafe levels in many parts of the country, is causing many practices to reach the tipping point of sustainability and viability.  They may be willing to provide the service, but are not able to do so because CCGs will not commission it.  How is this fair or reasonable?

I note as an interesting aside that one part of the country where I work, and where the majority of practices are struggling to deliver safe and sustainable 5-day a week services, and where the CCG were categorical that they had no funding, not a ha’penny left in the coffers to commission non core work, they’ve managed to find some pennies down the side of the sofa to continue the 7-day a week service run by one of the CCG’s clinical leads.  Hmm, interesting one.

However, I digress.

The transformation that Paul Twomey describes is largely around GPs working at scale, in federations, merged practices or super practices. 

Many practices have already risen to this challenge, putting their own money into forming federations, just as the GP Forward View describes, or becoming such as rapid tests sites for Primary Care Home, working in groups of 30,000 to 50,000 patients.  It is fair to say that in some parts of the country these are working well, with collaboration and transformation being the modus operandi of the health and social care system.  But equally there are as many, if not more areas, where GPs coming together to work at scale are failing.  CCGs, Foundation Trusts and other providers say all the right things – this is something they welcome, it’s the best thing since sliced bread, it’s fantastic, wonderful.  And then do everything they can to undermine the organisation; refusing to commission work, engage with the new at scale primary care provider, playing divide and rule games with the constituent practices and just generally being obstructive, to the point where the organisation fails.  How is this fair or reasonable?

But, here’s the thing: has the content of this leaked document come as any surprise to anyone working in General Practice?  The attitude to primary care from government, through NHS England, to CCGs and large provider organisations like FTs is no secret.  We have the press vilifying GPs (and more recently their Receptionists) on an almost daily basis, the removal of MPIG, PMS Reviews and the general all around crushing and disrespect of primary care.

Too often, I see and hear GPs complaining about this, but unwilling to take action.  I see them complaining about the strain put on their practices and staff around the volume of un-resourced work, but yet being prepared to continue to carry on doing the work for no remuneration (apparently, collapsing under the strain is good for patients).  I see federations forming and then failing, and yes, whilst this may well be in no small part due to the attitude towards them of CCGs, FTs and the like, I’ve also seen member practices undermining their board, their company and their colleagues.

Yes, the attitude of NHSE Yorkshire and Humber is reprehensible, but I would venture to bet that they are not the only Area Team with secret documents stating similar.

My view is that instead of complaining about it, wringing hands and having an outcry about how disgraceful this attitude is, general practice needs to genuinely engage with each other and their local health economies, collaborate, grow strength in that collaboration and do something about it.  By being willing to properly and genuinely work at scale, and unite together, general practice will gain the ability to transform in spite of this attitude, and not fail or wither.

My challenge to you is prove the likes of Paul Twomey wrong, demonstrate the art of the possible by working constructively at scale, do it for the survival of one of the best bits of the care system, and most importantly, do it for the communities in which you live and work.

If you are thinking of developing an at scale provider organisation, or about delivering any form of change, and are looking for a model to engage every stakeholder in that change, 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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