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NHS working at scale: A tale of two mindsets

"The snake which cannot cast its skin has to die. As well the minds which are prevented from changing their opinions; they cease to be mind." Friedrich Nietzsche, German philosopher of the late 19th Century.

Last week I read in amazement an email from a Director of one of the GP Federations I work directly with. It was a communication where the CCG has decided to completely ignore the Federation and instead press on with creating “mini clusters” of Practices within the CCG. Sadly, it wasn’t a surprise on any level, as this CCG does top down dictatorship like no other I have come across; this one even comes with a cash incentive to Practices! 

The reason for my amazement is the openness of the CCG in undermining the Federation and their continued unwillingness to even contemplate working with the Federation. This is a Federation that Member Practices invested their own money to form, and yet the CCG has failed on every level to spot the message this sends. In their minds there is only one way: mini clusters of Practices, and they appear blind to any other option.  Member Practices are therefore gearing up to send some strong messages, which I have no doubt will also be ignored, and which is only going to increase the risks for the CCG.

I should also add that the federation has no relationship of any sort, on any level, with this particular CCG, and they are almost unique in my experience. Indeed, as was put to me last week by one of the Member Practices: “If we had formed mini clusters the CCG would have wanted a federation”. This sums up the CCG approach entirely.

Consequently, the Federation has instead focused on joint / collaborative working with the local FT, where the FT has subcontracted work to them.  The subcontracting is now about to go up a significant gear with a new subcontract agreed this week and a number of new services close to being finalised. Without doubt, this is a valuable income source and vital given the lack of investment from the CCG in General Practice.  However, more importantly it allows the Practices to start work on rethinking their delivery model, while tackling unwarranted and unexplained variation, which of course is crucial for the future of General Practice.  

If the CCG continues in the current vein it is quickly going to become an irrelevance.   The FT also runs Community Services, so if, as expected, closer and more formal arrangements are developed with the Federation, with services which could be provided on a CCG wide footprint, there will never be any need for Federation engagement with the CCG. Worse can only follow for the CCG, when the Federation engages patients to highlight what’s going on; something the Federation has declined to do to date, but that’s unlikely to last much longer.

With this backdrop nothing will change and my view remains that the CCG is playing fast and loose with the very future of the Practices, some of whom are already talking with the Federation and FT about takeover of the core contract, as they simply cannot go on as they are.  It is therefore hard to argue the CCG is representing its Members. 

“Those who cannot change their minds cannot change anything” George Bernard Shaw, Irish playwright.

At the same time as working on the above, I have also had contact from another of the directly supported Federations, where the CCG has taken entirely the opposite approach, and gone from trying to dictate to Practices to listening to, and engaging with Practices and the Federation. The CCG here confirmed they understand that there are options and are looking for collaboration and negotiation to reach an agreed end.

They also confirmed they cannot see a way to deliver 7-day opening without federated working, and local Practices fully engaged on that basis.  The CCG recognises that Practices have invested their money in a federated model and it consequently makes no sense trying to impose anything else; it will quickly be a layer of bureaucracy that
nobody wants or requires.

This change of mind from the CCG has fully engaged the Practices and the Federation, as it’s a first for the CCG and this point hasn’t been missed.  There is now a real willingness on the part of the Practices and Federation to negotiate, collaborate and compromise with the CCG in order to find the right way forward.

My instructions from the board of the federation are clear: find a way forward that meets everyone’s desired outcome and supports the development of new models of care, new ways of working and supports the CCG, wider health economy, and of course the Practice and Federation.  The 7-day working for General Practice will be the test bed for this new approach; however, my sense is they will all find a way to make this work.  Indeed, the CCG made the point to me that they want to “find a way to collaborate with all providers and make this work”. 

"You can't stop the future, You can't rewind the past, The only way to learn the to press play.” Jay Asher, Writer.

The following headline grabbed my attention immediately it landed in my inbox “Manifestos “missed opportunity” to support commissioners”. The full article is here: click

I do however wonder if the “missed opportunity” was in fact a deliberate omission? Are CCGs now dead men walking after the Election?

It cannot have escaped national leaders and political party advisers that CCGs simply don’t work. The outcomes, in terms of change and efficiency, are not being achieved. Anyone in any doubt should simply download the last 3 years worth of commissioning intentions and commissioning plans and look at what has actually been achieved in return for £5,000,000,000 in costs per year.

Consequently my view remains that we now require capitated budgets for integrated service providers to work with, particularly where CCGs are unwilling and/or unable to engage with providers in leading clinical change, which is the only way the NHS can hope to deliver the £22,000,000,000 efficiency required by 2020 – just to stand still. This will not be achieved by CCGs and it’s time the political leaders woke up to this.

If you are still thinking about federating or if you have established a federation but need support to progress, and would like more information on how BW Medical Accountants can assist, please contact or call 0191 653 1022 to speak to one of our specialists. 

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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