NHS working at Scale: "Nothing will ever be attempted, if all possible objections must first be overcome"
"Nothing will ever be attempted, if all possible objections must first be overcome.” Samuel Johnson, Essayist, lexicographer
On Sunday 16th July, I learned just how true the quote above is. I also learned a whole lot more about myself and my three other team members, and what it takes to complete a challenge when every fibre of your body is screaming at you to stop.
The challenge was to play four rounds of golf in one day to raise money for Macmillan Cancer https://www.justgiving.com/fundraising/Scott-McKenzie7. It may sound like an easy challenge; however, the day really was much harder than we ever imagined it could be. We all learned a lot about ourselves in the process. We just about survived, walking 26,358 steps (according to Fitbit) covering 4.6 miles per round (according to Strava x 4 rounds) playing roughly 340 golf shots each in total and each burning around 1000+ calories per round.
Towards the end of round two it was starting to hurt and we hadn’t yet reached half way. We knew it wasn’t going to get any less painful as we progressed. The debate then centred upon whether or not we could make it as a team. What mind games could we play that would keep our minds off the pain and on the outcome we wanted: to complete our four rounds and raise as much money as we could for the charity.
It came down to one word: control. The whole day was in our control, we could decide to complete the challenge or not to, we could pace ourselves, take breaks, or not, we could eat and drink as required and we could, of course, quit. The whole day was in our control.
As a team we chose to complete the challenge. We pulled together as one, supported each other when it got really tough and made sure everyone was in the right place to get through. Standing on the 72nd tee was an amazing feeling; knowing 4 or 5 more shots would complete the day. By then it was 20.30 and having started at 05.00 we had played golf for 15 hours, with only 30 minutes in breaks.
On reflecting upon the day I quickly concluded the control aspect applies to most things in life, but not all. This is where I started to apply the thoughts around controlling the controllable to my work life in supporting General Practice. It was quickly apparent the control aspect is often missed in deference to top down management, blocks, obstacles and sometimes bullying and threats.
Given the parlous state that many General Practices find themselves in, my view is they need to take control, starting with a root and branch review of workload. The first step is designed to stop doing work that is not funded. My advice is that Practices use the GPC list of non-core work, which was published in 2015: https://www.bma.org.uk/advice/employment/gp-practices/quality-first/quality-first-guidance and start to identify what you are being asked to deliver without resource, and stop doing it.
As highlighted by the GPC, “accepting inappropriate work from elsewhere risks undermining the quality of care for your patients. Practices which act to reduce this work must ensure that measures are in place to ensure patient safety”. It is the CCG as commissioner who has overall responsibility for ensuring services are appropriately commissioned to meet patient needs, not the role of the Practices.
Consequently, the start point for any negotiation is the CCG. What interest do they have in properly commissioning and appropriately resourcing the work? What should not happen is that the Practice becomes unviable and/or unsafe through the levels of inappropriate work. While offering services is often good for the patient, it cannot, and should not, be to the detriment or expense of the Practice.
If there is no interest in commissioning the services from General Practice, the next question is to understand where the CCG would like the work to be referred?
Beyond the step around inappropriate work, comes the next question over under-funded work, usually found under the banner of Local Enhanced Services, Quality Schemes, Local Incentive Schemes etc. You need to work out the costs associated with delivering that work and whether or not it contributes to the overall running costs associated with the Practice. I often hear that “the staff are there anyway”; however, that’s not an answer. If you bring in £20,000 in income and it costs you £30,000 to provide the service you have a £10,000 loss, despite the fact that the “staff are there anyway”. If you then find you have more staff than are required or can be afforded it will mean people being made redundant, or if possible redeployed, or perhaps shared with another Practice. This is perfectly normal and happens daily in many businesses. As you identify the under-funded work I encourage you to serve notice to the CCG and ask where they would like the work referred to or what advice they require being given to patients. It could be that the CCG decides it no longer commissions and funds particular services or treatments. However, that is a decision for the CCG.
Times are tough and not likely to get any easier anytime soon. While I keep hearing that Accountable Care Organisations (ACO) to deliver integrated care, are an “inevitable” replacement for CCGs and independent providers, unless the ACO can create new ways of engaging/working with General Practice, we are likely to find General Practice on the outside looking in. My sense remains that to get to “integrated” needs a step from where we are now as “independent” of each other. I call that stage “interdependent”. The key is the step from independent to integrated is unlikely to happen in one shift, which means the time for interdependency is upon us, except most CCGs and Hospital Trusts haven’t yet spotted this and therefore don’t commission for it. There are some examples of CCGs and Hospitals contracting with GP Practices individually and at scale; however, they are very few and very far between.
All of this is in the control of the GP Practice. In essence, you control your workload by deciding what you will and won’t take on, and will and won’t provide. It will need a degree of mental toughness and willingness to become unpopular; however, I know I’d rather be unpopular than out of business and in a position where I am not able to deliver care to my patients.
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