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The true cost of the levels of unfunded & underfunded work in General Practice

"You cannot control what happens to you, but you can control your attitude toward what happens to you, and in that, you will be mastering change rather than allowing it to master you." Brian Tracy, Author       

In my blog, I have revisited, a number of times, the issue of the levels of unfunded work that General Practice is expected to undertake. This time we lay bare the reality for a Practice within my current workload.

This Practice approached me having read the blog and told me that, having had their eyes opened, they were now going to work out the true cost of the levels of both unfunded and underfunded work. They have kindly shared the outcome of that, which has exposed total losses of £47,000 in this practice, across 6 service areas:

Table Mapping the Cost of Various Patient Services vs Cost and Volume of Service

This is not unique to them and I encourage all General Practices to take the time to understand the true implications for you and then act on what you find.

If you consider for a minute that many General Practices are now sinking under a completely unsustainable workload, you can quickly pinpoint why. As the income shrinks, few practices shrink their staffing levels to mitigate this. A small part of the reason for this is that general practices don’t tend to reduce staffing levels other than opportunisitically, but the large part of this is because the workload is increasing year on year and staff are still needed in order to deliver this. Add in that much of the unfunded work is being dumped on to practices by secondary care who are also being squeezed for income and you can see why the NHS is now in a parlous state, teetering on the brink of financial meltdown.

As I have stated many times; given the critical state that many General Practices find themselves in, my view is and remains, they need to take control of this, starting with a root and branch review of workload, where loss making services should be stopped, or you risk the viability of your Practice.

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 and recently updated: 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. It is 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? If they don’t have an interest, they should. 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?

Of course, this then ties in to the development of the New Models of Care (Primary and Acute Care System – PACS, Multispecialty Community Provider – MCP), which must first be established and then quickly achieve results and outcomes, as part of STP delivery.

Whether this happens becomes about how quickly CCGs and STP Leadership can engage the health economies in the changes required. To achieve this providers must be willing to take a small risk and a bit of a leap of faith that working in collaboration with each other, and across providers, is going to be to their advantage. This means engaging everyone right at the start and developing one organisation, with one vision that everyone involved then works to deliver.

Part of the overall STP solution is the goal of achieving one, high quality and standardised approach without unwarranted variation; this must become the reality. The transfer of services from in hospital care to out of hospital care provides an opportunity to create the platform for the larger and more complex system-wide changes envisaged in the list above.

My sense remains that if CCGs/STPS cannot quickly get basic services properly resourced and/or shifted from in hospital to out of hospital care as part of the development of a local MCP or PACS, I hold out little hope for delivering the large scale, complex changes that will ultimately be required in those models.

What these basic services achieve in that shift is properly resourced work being implemented by General Practice – where I know they will find the staff, the capacity and the skills to deliver it, if the work is properly resourced. These services start to build sustainability in to GP federations and General Practice. They also build a platform for changing the way practices work together, through hub and spoke models, with integrated and multidisciplinary teams, underpinned by inter practice referral. This is the start point for General Practice involvement and engagement in the MCP or PACS.

My confidence in saying that is down to one word – engagement. If CCGs/STPs cannot get everyone affected by the changes required to engage right at the start in the development of the MCP or PACS, and quickly get them working to transfer and then transform basic services, why would anyone buy in to the concept of large scale, wholesale change? In a PACS or MCP they are likely to need an evidence base of basic straightforward changes that provide confidence and underpin larger scale projects/changes, or they risk disengagement and complete failure.

The time is therefore here and now to take a low risk approach to resourcing and shifting basic services, that should sit in General Practice (with proper funding) and start to build the local PACS or MCP model from the font line, through formal engagement at the start. There are many basic services (if you want a list please email me) supporting the transfer of care from in to out of hospital and at the same time, underpining the development of the MCP or PACS.

What I know from my work is that where people own both the problem and the solution, you will see change being delivered. Where change often doesn’t work, is when it comes top down, leaving the frontline providers to implement an idea they would never have created had they been engaged right at the start. In that instance, what often happens is that no matter how good the idea, people simply don’t/won’t engage and the attempted change fails.

For an MCP or PACS to work change is not just necessary, it is an imperative, that they take a new approach to change, engage everyone affected right at the start allowing them to own the problem and develop the solution; A solution that will give them the results and the sustainability they need, whilst teaching them replicable skills they can use again and again.

If you are thinking of developing an at scale provider organisation, MCP, PACS or are about to deliver any form of change, and are looking for a model to engage every stakeholder in that change, 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 and we will do our best to answer these within the blog.

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