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NHS working at scale: Diesel is good for my car but unfortunately Sainsbury’s expect me to pay for it!

“The great creators-the thinkers, the artists, the scientists, the inventors-stood alone against the men of their time. ” Ayn Rand,Writer

“Yes Scott, but it’s good for the patient!”  How many times have I had that fired at me across the negotiating table, when I am asking for proper funding for a service? I have lost count, but my response remains as it always has: if it’s that good for the patient then there should be acceptance and understanding that the work needs to be funded.

As was said to me many years ago by an LMC Secretary, “One area’s core contract is usually next door’s Enhanced Service.”

To put this in context, I am staggered at how much work is undertaken daily in General Practice which is clearly not funded.  Care that is “good for the patient”, but remains unfunded is ultimately terrible for the long-term viability of General Practice, and indeed the wider NHS.

I accept that much of this work often takes up very little time on an individual basis, but when aggregated it adds up to full time roles in some Practices. In essence, people working in those Practices are delivering services but not generating income, which ultimately means the partners are paying to deliver the services. This is a recipe for disaster in the long term, as eventually these Practices will tip over due to reduced profitability, in turn making it difficult to recruit and retain staff due to an inability to pay competitive salaries in comparison with practices that are properly resourced. This of course means it’s not actually “good for patients”. 

I continue to hammer the message that General Practice has less than 8% of the budget for 90% of the contacts. I get an inbox full of emails and tweets asking if it’s spurious data day etc; however, what none of those who email can ever answer is which % is wrong?  If it is spurious show us the data that proves that General Practice gets more than 8% of the budget or handles less than 90% of the contacts.

The excellent document from the BMA, Quality first: Managing Workload to Deliver Safe Patient Care [1], goes a long way to addressing the issue of unfunded work, and within my workload I now have entire federations auditing the level of this type of work. Once identified and agreed, this work will then be sent back by all Practices within the federation to wherever it came from and/or whoever has been commissioned, and is therefore being paid, to deliver the work. It will also form the basis for local negotiations with CCGs and other providers, where we will be looking at how this work might be formally contracted/subcontracted through the federation, with proper resourcing; something we have already achieved in a number of areas.  This is not a combative process, particularly where people are willing to engage in meaningful discussion, in pursuit of a new outcome. 

On this basis, I could not agree more with the comment from prominent NHS blogger Roy Lilley, who this week openly stated a key point I have been emphasising with the federations we support for a number of months now -  “population based, capitated budgets are urgently needed to replace a tariff system that is all but redundant.”  This is the future: providers collaborating and then working together to agree how best to deliver the required outcomes within a capitated budget. Proper incentives will ensure providers quickly change outcomes. 

What is clear is the current commissioning process is not working; it is not radical enough, is overly bureaucratic and completely lacks accountability, yet costs around £5,000,000,000 a year to run.  These commissioning structures could be stripped back, merged with the Local Authority into organisations that cover a much larger geography, and then oversee the provider-led system of delivery.  Some of the resources freed up could then be ploughed into front line services, with absolute accountability for the money and the outcomes.

For those providers who are successful and deliver agreed outcomes within the budgets allocated, there would be a renewal of their contracts, along with the offer to take over those who have failed. I suspect there will be very few failures, as the providers will pull together in a way commissioners have been unable to achieve. I can demonstrate this now within our work, where we have federations being subcontracted work as part of a wider redesign of services, and where there has been no CCG input.

“If you think of yourselves as helpless and ineffectual, it is certain that you will create a despotic government to be your master.  The wise despot, therefore, maintains among his subjects a popular sense that they are helpless and  ineffectual”.
Frank Herbert, Author of Dune

The quote above is where we are now. “The system” maintains a sense that commissioners know best and providers know little or nothing about “how difficult it is to commission services”. We can, of course, stick there and continue with demand outstripping resources, or we can enter a brave new world of capitated budgets, which brings providers together to radically deconstruct and reconstruct services which are responsive to local patient need, and deliver fantastic outcomes within the available resources. As a patient, I know which I would prefer.

If you are still thinking about federating or want to know how we can help support in order to drive your federation forward, arrange to speak to one of our experts please contact rachael.mackay@bw-medical.co.uk or call 0191 653 1022.

Additionally, if you should have questions for us please email rachael.mackay@bw-medical.co.uk and we will do our best to answer these within the blog. 


Scott Mckenzie

Scott Mckenzie

NHS Management Consultant

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