Federations – the story so far…
Does Simon Stevens (NHS England chief exec) know what really happens at grass roots level?
"In the confrontation between the stream and the rock, the stream always wins, not through strength but by perseverance." H. Jackson Brown, Author
I thought it may be time for some reflection, a look back over our work with the GP federations we supported from initial idea, to service delivery.
Most of those now hold contracts to provide services. Some of them of course don’t, and I’ve a couple of examples of what can be achieved in that category, where open hostility to the emergence of the federations is now occurring from the CCGs and local FT/hospital trust.
Newcastle GP Service lead the way in service delivery, where they hold a number of subcontracts from the local Foundation Trust, who quickly recognised the benefit of having General Practice working at scale to provide high quality, consistently delivered services across the whole population.
While the federation doesn’t include all GP Practices within the CCG, it delivers services across the whole of Newcastle. They’ve struggled to date to achieve meaningful engagement with the CCG, although that process is ongoing from their perspective and they remain focused upon achieving that.
It is a credit to the Board of Directors that they have been able to engage the practices in taking on new services at scale, which are properly resourced but which require a much more standardised approach to the delivery, with kit/equipment and pathways all formally included within the subcontract. They are clearly going from strength to strength.
What’s even more interesting is that the CCG could have bought all of the subcontracted services directly from the federation, making a significant saving in their budget; however, to date they have chosen not do that.
Turning to the flip side of the coin, where we have no engagement and no service delivery.
"Therefore, send not to know for whom the bell tolls, it tolls for thee."
From a poem by John Donne
The above quote is often viewed as a reference to our mortality, a reminder that we are nearer death each day and at some point the bell tolls for us all. For me the bell is nearer tolling today for CCGs, with the announcement this week that, “other bodies could take powers from failing CCGs”.
Add to this the emergence of the Vanguards, which are the new provider led care models, and also offer the hope of hard cash capitated budgets (a cash figure for each person in receipt of healthcare), and you really do wonder for the future of the CCGs, which in the main have failed to deliver the levels of service change and efficiency required.
I have no doubt whatsoever that a capitated budget across providers working at scale would deliver the levels of efficiency required. I see weekly in my work opportunity for efficiency that the CCGs simply get in the way of, or won’t support.
I have a CCG that’s part of an AHSN (Academic Health Science Network) bid for “test bed status”, where as part of the Five Year Forward View a small number of sites will “evaluate the real world impact of new technologies offering both better care and better value for taxpayers; testing them together with innovations in how NHS services are delivered”.
...and yet they have openly blocked the federation from implementing the remote monitoring of warfarin, which is now a NICE Quality Standard and would implement “technology at scale” across 34 Member Practices.
The CCG went as far as to deny any knowledge of being part of the test bed application, and only backed down from that position after a freedom of information request revealed they had indeed signed up to be part of it.
Yet they still refuse to remove the block on the federation implementing improved patient outcomes and reduced costs.
At the same time I have an area that has a PACS Vanguard, where the FT CEO has said:
“There is no need for the federation”.
In short, we have an FT out for health economy domination, as with no federation to work through, practices will in effect become part of a vertical integration with the FT; something they have long opposed.
The response from the CCG at face value is silence; however, keeping in mind it’s not what you say it’s what you do, can anyone explain why four of the federation Member Practices, where they have CCG Governing Body Members, all resigned from the Federation within a week of that being said by the FT CEO?
Nobody can locally, but it is pouring fuel on an already well lit fire. In time as that particular federation succeeds I sense it will be a long way back for those practices that resigned; people tend to have long memories in situations like this.
In both examples I sense the CCGs are frightened the federations will succeed and therefore must be undermined at every opportunity. This feels a bit like the pause in progress from PCT to CCG, which in effect allowed the old system to be recreated as the new system.
CCGs are PCTs renamed with a handful of GPs on the CCG governing body dominated by PCT managers with the same outlook they’ve always had.
Put simply, this is why there is no change.
The big difference this time of course is federations are legal entities, governed by company law and the articles of association for the company, which mean the directors have a legal duty to act in the best interest of their company and its shareholders. They cannot be bullied or threatened in to any course of action opposed to that duty.
Returning to the first question I posed; does Simon Stevens know what really happens at grass roots level?
I am certain he is aware, which is why imminently I anticipate an opportunity for the return of a hard cash capitated budget covering general practices working through a legal entity and with scale. What is clear is that we cannot continue as we are with CCGs if the efficiency required is ever to be achieved.
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