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NHS Working at Scale: Delivering the vision

In my last blog I highlighted the recently published document “multispecialty community provider (MCP) emerging care model and contract framework”, which describes a number of scenarios around General Practice at scale.

The document states:

“The MCP’s relationship with general practice must be at the heart of the MCP model. The fully integrated version includes all primary medical services within the contract. Indeed, general practice (working through networks and federations of practices) is a key driving force in developing the MCP model.”

Looking to the future, the following paragraphs make for very interesting reading; particularly if you are coming at this from a CCG perspective:

“Establishing an MCP requires local leadership, strong relationships and trust. No system of accountable care will get off the ground and be viable without the inclusion and active support of general practice, working with local partners. As expert generalists, with their registered lists of patients, general practitioners will always be the cornerstone of any system of accountable care provision.”

While I am frequently acused of being “too challenging towards CCGs”, who do you believe is more likely to deliver that vision? A CCG (which commissions services) or a GP federation (which provides services), which is owned and led by local General Practice as providers?
Additionally, the document goes on to state:

“General practice is experiencing unprecedented workload and workforce challenges. When general practice fails, the NHS fails. A big reason to develop an MCP is to provide practical help to sustain general practice right now. An MCP supports practices to work at scale and also to benefit from working with larger community based teams. It offers federations and super-practices the potential to combine with community services and create a broader, more holistic and resilient form of general practice. An MCP opens up new options for partners, clinicians and managers. Over time it should also help with managing demand for general practice, by building community networks, connecting with the voluntary sector, and supporting patient activation and self-care.”

Who do you believe is more likely to deliver that vision? A CCG or a GP federation, which is owned and led by local General Practice as providers?
Given that the vast majority of CCGs have not engaged with their local GP federation; not commissioned anything  from them in terms of the shift from in hospital to out of hospital care, rejected every proposal the federations have made, and show no signs of changing anything, how do they propose to meet the above requisites?

I continue to remind those working in federations that to get from where we are now as independent businesses, to delivering integrated care requires a stage of interdependence, and yet it continues to appear that the CCGs simply don’t understand this.  They appear to believe any change will happen in one leap. What evidence in their commissioning confirms they are capable of commissioning change in service delivery, driving efficiency, engaging practices and other prviders to provide one high quality and standardised approach across an entire population? What have they changed since authorisation? If in doubt go back and get the commissioning plan and the authorisation documentation from 2012 and review what they said they would do and then look at what has been done. That alone might shape your view of the questions I pose above.

If you are still in doubt, keep in mind that for any General Practice to invest in developing a federation is a major step, as the money is at risk in the same way it would be investing in any company. If the company fails, as many of these ventures look set to do through lack of income, the Practices and GPs who invested will lose their money. In looking at your GP federation is it delivering services now that provide the income to keep the company viable for the short, medium and long term? If not what is the Board of Directors doing to remedy that, and how much support and engagement in developing the federation, through service provision (interdependent service provision) are you getting from the CCG?
As a GP Practice are you genuinely concerned about the future, or do you believe the CCG will solve all the problems for you and there is nothing to worry about? Do you believe you can simply continue as you are and all will be fine? If you are concerned and you don’t believe your CCG will solve the challenges that you face, you need to start to look ahead and plan and then deliver your future, and you need to start now.
My sense remains that Practices need to up the pressure on their CCG, who in turn need to understand what’s at stake.  General Practice is now facing a real crisis unless it can operate a scale, start to share staff, federate back office functions, secure bigger and better contracts that allow GP Federations to start to develop as organisations, with a proper management structure that supports their Practices and the sustainability of General Practice. That infrastructure will then put the Federations in a place to be part of, and possibly lead, the development of the future. My worry is without that without this, General Practice remains at the mercy of a further political top down reorganisation; a further reincarnation of the PCT/CCG or a takeover by the local Foundation Trust or Hospital Trust, with the inevitable vertical integration that brings (the Primary and Acute Care System PACS model), leading to a salaried model where the Hospital will direct the Practices’ workload. 

For all those federations already formed but not providing services, I have many examples of subcontracts that keep the federations which hold them in business. If that is of interest, please use the details below to make contact, and we will work with you to keep you in business, and delivering services to your patients, to enable you to be part of the future, through at scale General Practice provision.

Whilst none of us has a crystal ball and can predict the future, one thing is clear: the status quo is not sustainable and that doing nothing is not an option if you want your practice to continue to be able to provide services for your patients. 

My advice is don’t wait for your  CCG to form yet another committee to decide how it might help you to work at scale in the ways detailed in the document; it will take at least half a dozen monthly meetings to decide the terms of reference and membership of the committee, let alone have anything like meaningful discussion.  While your CCG is busy rearranging the deck chairs, now is the time to seize control of your practice’s destiny while you still have the opportunity to make choices. My challenge to you is what choice will you make?

"Before you begin a thing, remind yourself that difficulties and delays quite impossible to foresee are ahead... You can only see one thing clearly, and that is your goal. Form a mental vision of that and cling to it through thick and thin." Kathleen Norris, Writer

If you are thinking about forming a super practice or 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 Rachael and we will do our best to answer these within the blog.

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