Archive

Archive for June, 2013

Jun
30

Despite CCGs being membership organisations for general practice, so far practices have not seen commissioning as having any relevance to their core business.  In this post I will describe a way that can change forever.

The total turnover of an individual practice varies greatly, but for the sake of an example let’s take a practice with a list size of 8,000 generating income of £120 per patient, and so having a turnover in the order of £1 million.  If CCGs are offering schemes to ‘incentivise’ practices that pay 50 pence per patient, so for this practice £4,000, with a whole load of work to go with it, it is unsurprising that practices are not falling over themselves to participate.

Now, I am not saying that GPs or practices are only motivated by financial return.  Clearly that is not true.  But the reality is GPs do have businesses to run, and the more something impacts on the business as a whole, the more central it will become to the business of the practice.

So what some CCGs are doing now is exploring the possibility of devolving the budget for an individual surgical specialty to a practice, for a defined population.  Other practices would take on the budgets for other surgical specialties.  So for example in a population of 75,000 with 9 practices, one practice would take on the budget for urology, one would take on the budget for ophthalmology, one ENT, one for orthopaedics etc etc.

If you take urology, in this example the total budget for urology for such a population is going to be in the order of £1m, the same size as that of our practice.  The ambition would be to give the £1m to the practice and anything it saves on the budget it can keep, but at the same time it takes the risk on the overspend.  As a result the practice will change the way it operates.  Internally it will ensure it has urology expertise and that it is delivering extended urology services.  Externally with other practices it will ensure that referrals to secondary care are appropriate, and that GPs are properly trained and have as high a skill level as possible.

The reason the practice will do this is because the potential risk and reward is so significant in relation to the total turnover of the practice.  The practice over time is likely to redefine itself as a specialist practice, one that carries out core general practice and provides enhanced urology services.   The total turnover of the practice moves from £1m to £2m, and the CCG has finally made significant progress in shifting activity out of hospital.

Because each practice is dependent on the others (i.e. the urology budget could be blown by one practice referring at a much higher level than other practices), the model is much more likely to work if each practice has a specialty that they are responsible for.  The practices are then inter-dependent on each other.  One practice needs high quality urology referrals, one needs high quality ENT referrals, and so they will work hard at finding ways of ensuring that they find mechanisms of holding each other to account.

The reason surgical specialties are chosen is because the budgets are much more defined and easy to disentangle.  Any CCG that has tried to establish the budget for a long term condition like diabetes will know the difficulties in determining what activity should be included, and so in providing a concrete budget.

There are a whole host of issues that this proposal raises.  I have picked out three.  First, what if the practice is so small (or the budget so large) that the budget it is taking on dwarfs the turnover of the practice?  In this scenario practices would need to group together and take this on together.  This model is unlikely to work for small single handed practices.

Second, what right-minded practice would take on this level of risk to its business?  There needs to be a journey into this model where there is a risk/gain share agreement with the CCG.  So in the first year the practices may take indicative budgets where the majority of the risk sits with the CCG.  Here the practice may only take 10% of any saving generated.   Over time the practice and the CCG would work to shift this whereby the totality of the funds are actually transferred to the practice and the totality of the risk and reward sits with the practice.

Third, what about procurement?  The CCG cannot just give huge quantities of funding to its practices.  There will need to be a procurement route set up that enables all potential providers to bid to carry out this service for the CCG in line with procurement rules.  I do not think this presents an insurmountable barrier.

This is the type of ‘game-changer’ that we need.  CCGs are increasingly clear on the need to transform general practice, and that NHS England is not going to do this for them.  This model allows CCGs to drive this transformation at pace and at scale.

What is your view?  Do you think this model will work?  How could it be made even stronger?  Are you doing anything locally along these lines, and is it working?  We will collate all views and thoughts so that we can work together on creating a practical model that can drive real change.

Jun
21

We are at a crossroads.  April 1st has passed, and now Clinical Commissioning Groups (CCGs) are free to procure commissioning support from whomever they choose.  But once it’s gone, it’s gone.

Many CCGs harbour a strong desire to bring commissioning support in house.  They are frustrated with the service they are receiving from their Commissioning Support Unit (CSU).  They believe they could do a much better job by either hosting services themselves or jointly with other CCGs.

It is undoubtedly true that there are problems with CSUs.  They are in the early stages of development.  They have had to manage a difficult transition of staff from PCT roles into service supplier roles, that many were not suited for.  They are having to learn how to function as they go.  The information capabilities are taking time to develop, and are often built on a weak inheritance of what existed before.  The national information governance issues are making progress in this area even slower and even more frustrating.

But here is the dilemma.  The ability of CCGs to partner with a large commissioning support provider is most likely a once only opportunity.  And it is right now.  Some PCTs tried to do it using FESC (remember that? For those who don’t it is the ‘Framework for External Support for Commissioning’).  Very expensive, very difficult to procure, even more difficult to make work. 

Nearly all CCGs on the other hand have started life in partnership with a large commissioning support provider.  It is relatively easy to break these partnerships.  But once they have been broken, it will be incredibly difficult (and expensive) to bring these partnerships back.  Once it’s gone, it’s gone.

In manufacturing the days of going it alone have long gone.  So writes Jill Jusko in an article in Industry Week entitled, ‘How to Build a Better Supplier Relationship’.  You can find it here .  Please read this article.  What is clear is that building these partnerships is difficult.  But the best companies, such as Toyota and Proctor and Gamble, have found ways of doing it.

The article provides the Institute for Supply Management’s definition of customer-supplier partnership, ’A commitment over an extended time to work together to the mutual benefit of both parties, sharing relevant information and the risks and rewards of the relationship. These relationships require a clear understanding of expectations, open communication and information exchange, mutual trust and a common direction for the future.

The main actions needed to make the partnership work, it would seem, belong as much to the customer as to the supplier.  Customers (in our case CCGs) need to listen to suppliers rather than think they are firms needing to be managed.  The CEO has to set the tone and be clear that the customer organisation (CCG) will work as hard to make the supplier successful as they expect the CSU to work to make the CCG successful.  Partnership is more than sharing information.  It involves joint decision making.  How many CCGs genuinely allow their CSU to be part of their decision making processes?

We need to be honest and recognise that as CCGs we are not yet fully mature organisations.  Hardly surprising, as we are less than 100 days old!  We have more to do to make the partnerships with CSUs successful.  It is going to take time.  Bob Ricketts, however, is set on a timescale of full procurement within 18 months. 

This is far too soon.  We need longer to make these partnerships work.  We need longer for CSUs to develop as effective suppliers.  We need longer to learn how to be an effective customer.  Giving up now is a big mistake.  It will be an opportunity lost that we will not get back.  If our ambition is to be as effective as we possibly can as commissioners, we at least need to give these relationships a chance of success.

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Jun
16

Most Clinical Commissioning Groups (CCGs) are extremely wary of direct involvement with changes to general practice because of fears of conflict of interest.  This needs to be tackled head on.

In this series of posts we are considering how CCGs can most effectively support the transformation of primary care.  So far we have established that we need to start with a small number of practices that are keen to change.  Next is the CCG making the bold statement that it will be leading this transformation.  The question that follows is how are we going to do this in a way that is clearly in the public interest?

CCGs must be 100% clear why they want to change general practice.  It is not because workload is rising, drawings are falling, or morale is low.  These issues, even though they impact on CCGs, are the individual practice’s concern.  The role of the CCG is to improve quality and outcomes for the populations they serve.

The medium term strategy of most CCGs is to improve quality and outcomes for their local population by shifting care out of hospitals and delivering it closer to home.  So the aims of the programme need to follow on from this.

There are three aims to any improvement programme based in general practice that CCGs should use.

The first is to, ‘Ensure the delivery of a high quality first point of contact for patients’.  If general practice does not provide a high quality, consistent intervention when patients first present, and pathways and services set up by the CCG are not used, then quality and outcomes will be affected. 

There are two major obstacles to this aim being delivered.  The first is what happens at nights and at the weekends.  Ensuring high quality out of hours service delivery is a clear CCG responsibility.  The second is the workforce crisis facing general practice.  A recent poll identified that 9% of GPs actively intend to retire within the next five years.  It is the responsibility of CCGs to acknowledge these challenges and to work to resolve them.

The second aim is to, ‘Enable the delivery of high quality care closer to home’.  Many attempts have been made to shift care from a hospital to a community setting, but without the active involvement of general practice these services often end up at higher cost and lower quality. 

To be successful, CCGs must find ways of making real shifts of activity happen at pace and at scale.  They need to find a way of linking the delivery of community based services with a high quality point of first contact.  This starts with the transformation of general practice.  Without a general practice that can operate at scale, build effective system partnerships, and take on new services quickly, the required movement of services will not happen.

The third aim is to, ‘Provide an integrated service around the needs of patients’.  The demographic changes of a growing elderly population and an explosion in the prevalence of long term conditions are well understood.  To meet this challenge patients with much more complex health and social care needs need to be managed in the community. 

Services within the community are not currently configured to deliver care around the needs of patients.  No one is better placed to coordinate this care than general practice.  But to take this on general practice needs to change.

Yes CCGs need to manage conflicts of interest between the member practices and the work of the CCG as a whole.  But to be successful CCGs must actively seek to support the transformation of general practice.  This starts with an improvement programme built around these three aims:

  1. To ensure the delivery of a high quality first point of contact for patients
  2. To enable the delivery of high quality care closer to home
  3. To provide an integrated service around the needs of patients

Jun
10

Jeremy Hunt did not mention Clinical Commissioning Groups (CCGs) once during his speech to the NHS Confederation last week.  He was however keen to make an argument that the GP contract is not fit for purpose and needs to change.

Many GPs have put their heads above the parapet and given up a great deal to make CCGs as successful as they currently are.  At the same time GP workload has massively increased, vacancy rates have skyrocketed, but even so remains the envy of the western world. 

Hunt’s logic is that since the introduction of the 2004 GP contract and the removal of the responsibility for out of hours, no one clinician is accountable for the care of anyone who is sick outside of hospital. 

Agree or disagree with the Secretary of State, the fact remains that he has nailed his colours to reforming the GP contract.  He tries to say that it is because of the contract (not because of the GPs) that the service is not providing what is required, and that is why the contract needs to change.

I am very disappointed that the self-proclaimed ‘pilot’ of the NHS could not find time to thank GPs for the hard work they have put into setting up CCGs, for the courage already shown by many GPs in making tough decisions and standing up publicly for those decisions, and for the tireless work carried out every day in general practice.  I do not agree that the GP contract requires wholesale reform.  But I do concur that modern general practice is not providing the service that the NHS going forward.

So what are our options?  Sit and wait for the battle over the GP contract and sift through the fallout?  Primary care is the jewel in the NHS crown, and that has the feel of cutting off our nose to spite our face. 

Wait for NHS England and the Area Teams to develop a primary care strategy?  Well we have had those (GP systems of choice, minimum practice sizes etc), very few of which changed anything.  By their own admission the Area Teams do not have capacity to even engage with anything beyond serious practice concerns, and any new national strategy will take at least a year to produce.

Or do we as CCGs take this on ourselves?  Is there any other real choice?  CCGs need a transformed primary care in order to be successful (click here for a post on how the fates of CCGs and primary care are intertwined).  The real threats to general practice income (click here for a post that spells these out), alongside any changes that Jeremy Hunt may introduce, mean that GPs need a new business model. 

There are lots of reasons why general practice will not change (click here for a full list), but there are those practices and those GPs who want to change, but just do not know how.  The key to effective change is to work with the willing.  Start with those who want to be at the front of the curve, the so-called ‘innovators’ and ‘early adopters’ in Everett Rogers seminal text, ‘The Diffusion of Innovation’. 

If we, as practices and CCGs, can show how a transformed primary care can operate and be effective and successful, we will inform any debate on changes to the GP contract or a national primary care strategy.  Torbay has demonstrated how a single community can become the model used to define a change (in their case ‘integrated care’).  What we need to do now is identify the willing, the volunteers, those practices ready for change, and work with them, put structure and support around them, and demonstrate to everyone how primary care should develop.

If Jeremy Hunt could start with the problem (‘how do I create the primary care that the NHS needs’) instead of starting with the solution (‘I am going to change the GP contract’), and if he could recognise the hard work and dedication of those working to implement his coalition government’s reforms, he probably could have persuaded primary care to reshape itself.  As it is we are going to have to do it despite him, not because of him, but regardless it is still the right thing to do.

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Jun
02

To deliver as much support as possible to Clinical Commissioning Groups (CCGs), we here at CCG Information are making some changes.  This site is dedicated to doing everything possible it can to enable CCGs to be successful, and the time has come to make some important changes.

The first is the address of the website.  It has changed from www.ccginformation.com to www.clinicalcommissioninggroups.info.  The site has grown much faster than we ever anticipated.  The new address will enable us to add value to a wider group of CCGs.  It is only the address that is changing, so email subscriptions etc won’t be affected.

The second is to focus much more on working with the community on this website from CCGs and elsewhere to develop practical solutions to the problems faced by CCGs.  Commentary can be illuminating, but is no substitute for practical support.

The way we are going to do this is spend the coming weeks focussing on tackling the issue that is coming out as the main challenge for the majority of CCGs: how to transform primary care. 

Whilst many have identified the need to transform primary care as the problem, there is as yet a real lack of information as to how this can practically be achieved.  The tools that do exist look at how practices can become more efficient, introduce techniques such as advanced access, and improve the coordination of care between different professionals. 

But these support changes that really only scratch the surface.  Practices need to find a way through the issues of declining profitability, rising workload and high vacancy levels, which require a transformation of the whole operating model of primary care.   

Other information relates specifically to forming federations, and federations, such as the newly announced 360,000 population federation in Ipswich and Suffolk (more here), are being established.  The danger is that federations are taking a life of their own rather than being the solution to the problems underpinning the need for primary care transformation.

The information available on federations focusses on things like legal structure, governance, and involving the patients and public.  This is great and really useful information.  But it has two major flaws.  One it starts from the premise that forming a federation is the goal, when largely it is not, it is transforming primary care.  The second is that it generally starts at the point of multi-stakeholder commitment to the idea in the first place.

Many practices understand the need for change.  But they do not know what to do next.  They set up talks with neighbouring practices, but it soon becomes clear that there are significant differences between the practices, in terms of earnings, workload, number of visits, patient populations, culture, willingness to change, estate – the list is endless.  So it gets put back in the ‘too difficult’ box. 

What we need is something to help these practices.  Something that will enable transformation of primary care to become the norm not the exception.  Something that starts with the problem not the solution.

And that is what we are going to work in the coming months to develop.  We will work through all of the issues in detail, and together.  Our ambition is to produce something that can genuinely add value to solving the problem of how to transform primary care.  We will look at not only what practices need to do, but what CCGs can be doing to support this change, and what role CCGs can have in enabling this transformation.

We don’t claim to have all the answers, but we do believe that there is more support that can be given to practices, that there is more that CCGs can do, and that by working together change will happen faster than by working in isolation.

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