Archive for October, 2013


The development of general practice as a provider of an extended range of services is welcomed by some and resisted by others.  The main barrier is the concern that some GPs have that any change will mean a requirement for them to specialise in some way. 

So it is helpful to consider the development of general practice into new service delivery areas separately to the development of general practice as the provider of core GMS/PMS services.  It is helpful because the development needs of each are different, because delivering new services is an optional not a necessary development, but primarily because it reduces resistance by clarifying the freedom that any GP has to continue to concentrate on the delivery of core general practice.

CCGs that are serious about whole system transformation require general practice to develop  in ways that enable provision outside of hospitals to be radically changed. 

So how might this development take place?  What stages might this consist of?  A route map at this point for those who are keen but don’t know how would be very helpful.  So here is an attempt to outline three key steps for the development of general practice provision. 

1. Practices form provider organisations.  The first step is the development of the basic infrastructure.  The current unit of general practice is too small to deliver an extended range of services at any sort of scale.  Practices need to find partners that they can work with.  This will primarily be other practices, but it could be a whole range of partners including other NHS organisations or even private providers.

Part of what is needed at this stage is investment.  This is required to set up governance structures, invest in any necessary capital, and to develop expertise in areas such as business case development.  This investment can come from the practices themselves, or can be part of any new partnership that the practices enter into. 

Initially these new provider organisations can hold a standard NHS contract for out of hospital services.  CCGs can help by consolidating the various LES’s into a single contract, which practices can then choose to deliver collectively through the new provider organisation.

2. Provider organisations offer an extended range of services.  The second step is for these new organisations to develop their service offering by incorporating new areas and skills, such as extending into the delivery of community services and building Consultants into their service offering.  Again this could be in partnership with other NHS organisations or by offering these services directly. 

At this point these provider organisations can start to demonstrate the value they can add beyond that of existing providers, by offering services across a whole pathway, e.g. for diabetes whereby the GPs and the consultants provide care as part of the overall service offering of the new provider organisation.  This allows CCGs to be able to commission pathways of care more effectively, and enables person centred care built around the core general practice offering to become more of a realistic possibility.

3. Provider organisations become ‘accountable care’ providers.  The third step is for these new organisations to really exploit the link between the list based care of the core general practice contract alongside the provision of extended services.  What this creates is the opportunity to take on responsibility for a budget for a specific population.  Innovative service delivery models will enable these organisations to improve the outcomes for a population, and for the organisations as businesses to generate a return on a capitation based budget.

At present general practice is getting lost in the ‘to federate, or not to federate’ question, as a largely defensive manoeuvre.  But in many ways this is the wrong question.  The right question is what is the vision for how the practice as a business will operate 5 years in the future, and what is required now to make this happen.  For CCGs the work is to help practices think these issues through, as an enabler of delivery models that can meet the financial and quality challenges ahead.  Practices do not have to change, but CCGs should give all the help they can to those who are up for the challenge.



A key responsibility of CCGs is to take a lead role in driving improvement in the quality of care and treatment through the contracts they hold with providers.  As part of this each CCG must put in place the type of contracts that they believe will enable them to fulfil this responsibility.

We have been on a journey of contracting in the NHS that started with block allocations.  Discontent with these contracts grew as commissioners were unable to identify exactly what they were getting for their money; there was no transparency and the situation worked against any form of meaningful and clear improvement.

And so we moved into the period of payment by results (PBR).  It brought transparency of activity and enabled real productivity gains (shift to daycases and outpatient procedures etc).  But when the outcome required is demand management, payment by results is not the solution.  We have seen this with the attempts to use PBR through MRET (marginal rate emergency threshold) to incentivise providers to manage demand (by only paying them 30% of any growth in emergency activity).  It does not work, and worse leads to dispute and tension between providers and commissioners, further distracting from whole system working.

So where next?  We recently discussed  the Porter and Lee Harvard Business Review Article ‘The Strategy that will fix Health Care’, and one of their key components of a successful strategy was a move to bundled payments for care cycles.  This marks a move towards a system that actually rewards payment for outcomes.  The issue they identify with both block contracts and activity based contracts (like PBR) is that neither reward improvements in quality.  A new model that does this is required.

Porter and Lee make a number of suggestions of what this might mean in practice, including commissioning full care cycles for a condition, and year of care tariffs for long term conditions.  CCGs are feeling their way into some of these new models, but they are unproven, and they are also being met with significant levels of resistance.  What is clear is that a wholesale move into this type of contracting is not going to be possible for next year.

So given the models available are either demonstrated not to be effective in tackling the problems that exist today, or are not ready to be implemented, what should a CCG do?  Contracting is not an end in itself; it is a means to an end.  The starting point for the CCG is to understand what its priorities are, and then to ensure the contracting model that is used is the one that can most effectively support delivery of those priorities.

Ok – what are the priorities?  While these will be different everywhere, two spring immediately to mind.  First to ensure we have an urgent care system that is safe and effective. Second to enable the reconfiguration of the health and social care system so that it can deliver high quality care within the resources available in future.  So if we take these two, which contracting model would best support their delivery, a block contract or an activity based contract?  When you think of it like this, the argument for a block contract is compelling, as it removes any incentive for growth in activity, creates shared incentives for effective management of demand, reduces transaction costs, moves the conversation away from who should be paying the bill to how can we work together to change the system, and creates a clear financial envelope for providers to understand the resources available.

Of course there is a downside.  Block contracts will be perceived by many as a retrograde step, a move back to the dark times of obscurity when contracts were amorphous masses with no clarity of what was contained within.  But a block contract today is not the same as one 15 years ago.  Payment by results has done its job in putting the systems in place to track activity, which are not going to stop immediately.  This problem would only come if block contracts were to be seen as a permanent solution.  The discussion here is really trying to identify the best solution for now while we progress towards and develop bundled payments for care cycles.  Block contracts over a long period may well take us backwards, but framed as an interim measure this risk is massively reduced and can be easily mitigated through information schedules. 

It can also be argued that block contracts are anti-competitive.  Monitor is reportedly to investigate a complaint from a private hospital in Blackpool that referrals dropped after the two local CCGs entered into a block contract with a local NHS hospital.  CCGs do after all have a duty to promote patient choice.  But choice happens at the point of referral, and so whether the contract is block or activity based is actually irrelevant; what is relevant is whether the GP at the point of referral is directing patients or promoting choice, and the CCGs concerned flatly deny that any direction of referrals has taken place.

Whilst I don’t believe that block contracts are anti-competitive, what they do is promote integration far better than activity based contracts such as PBR, because they encourage providers and commissioners to work together to find lower cost ways of working, and to reduce transaction costs. 

The final issue is the one of risk.  The immediate reaction of the board of a foundation trust may well be to reject any suggestion of a block contract, because of the perceived shift of risk from commissioner to provider.  If the activity goes up, there is no more money, and the hospital will be expected to manage the demand without any additional resource.  But if you look at what is happening to activity, elective activity is flat at best, and it is only emergency activity that continues to rise.  Providers already do not get reimbursed for this rise (because of MRET).  And if the block increases the chance of joint working across the system to manage urgent care demand (which everyone believes is necessary), is it really that much of a risk?

Clearly there does need to be a way of sharing risk between commissioners and providers.  Risk pools can be set up, and these can be put in place around an outline block structure.  But if the question the health economy is stuck at is ‘who is carrying the risk?’, then the chances of achieving any real integration or whole system redesign is minimal.

As the contracting round looms CCGs, conscious of their responsibility to improve quality and care and treatment, need to make sure they are using the best available contracting model as a mechanism to deliver this.  And for the first time in many years CCGs are having to think hard about whether the block contract, that for so many years we have been working hard to get away from, might just be the best answer.

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As we approach the precipice of the cliff, the pressure is on.  We look at the relentless tide of rising acute activity and everyone is clear, ‘something must be done!’.  In order for our hospitals to be able to restructure and organise services differently, experts and management consultants tell anyone who will listen that what we need is an ‘out of hospital strategy’.

But the NHS is changing. Out of hospital (as opposed to ‘in hospital’) is no longer the distinction that is helpful in framing the changes that clinical commissioning groups (CCGs) are striving to achieve.

Most CCGs are organised around some form of locality structure.  This is where groups of practices from the same area come together and operate as the underpinning infrastructure of the CCG.  In larger CCGs there may be up to 10 localities, and smaller CCGs may be made up of as few as one locality.  The principle however holds that practices are grouped in a rational way that makes meeting and decision making sensible and practical for the relevant practices.

A key question that many CCGs are grappling with is what exactly is the role of the locality in this post-authorisation world?  Initially the importance of localities was based on the engagement of practices in the CCG (which we have discussed on this site, for example here). 

But with the ‘call to action’ and the future of general practice becoming a live issue, the priority that CCGs are giving to the transformation of general practice, the introduction of the integrated transformation fund, and the murmurings about contracting general practice and community services together (here), the importance of localities is growing, and the role of localities is changing. 

Localities are now the focal point of the transformation of community based services around general practice.  The role of the locality is to bring the practices together into some coherent form of general practice provision.  This means a move away from, say, 6 practices operating in splendid isolation, to the 6 practices operating as one unit, and acting actively bringing together community services, social services and the voluntary sector.  There is no piece of NHS infrastructure better placed to support this change than the CCG locality.

This means the locality is no longer an arbitrary grouping of practices with collective responsibility for managing a budget, but is now the practical mechanism by which care for the local community will be organised and, dare I say it, integrated around local needs.  The crude separation of general practice as commissioner and general practice as provider is removed; the advantage of general practice as both is harnessed.

CCGs are redefining ‘out of hospital care’ as ‘locality-based care’.  It starts with the redesign of general practice.  It blends in community services and social care.  It adds any existing community estate.  It is all done in partnership with the local population.  And it can move at the pace of the quickest not the slowest; not all localities have to develop at the same rate.

Herein lies the biggest challenge and opportunity for CCGs.  There is no question this is a hugely difficult task.  But as membership organisations of GP practices CCGs are uniquely placed to make this happen, and if successful have the chance to make more of an impact on the design and delivery of healthcare than any predecessor commissioning organisation in the history of the NHS.

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When I was 31 I went to see my GP about a mole on my right leg.  I had never met my GP before.  He looked at it, mumbled something about not worrying, but said you can never be too sure with these things and referred me to the hospital.  I never met that GP again.

A couple of weeks later I sat for 3 hours in a corridor in St John’s Institute for Dermatology at St Thomas’ Hospital.  Eventually my name was called, and I entered a large room with a consultant and 8 medical students.  The consultant largely addressed the students, who took it in turns to inspect and touch my mole.  Finally the consultant turned to me and said that it would be better to take it off and check for anything suspicious (we weren’t using the ‘c’ word at this point).

To receive the results of the biopsy I was to see the plastic surgeon.  I had done my research and, without being explicitly told, knew that a cancer diagnosis was on the cards.  If it was, it was all about the ‘Breslow thickness’.  Essentially the thinner the better.  I arrived, nervous.  An hour passed.  A second hour passed, and then a glimpse of the consultant as he left the clinic.  Half an hour later he returned, eating a sandwich.  A further hour later I was called.

‘Well it is what we thought it might be’, he started.  My heart jumped into my mouth.  What’s the thickness??  He told me.  Panic.  At first I thought he had said 3.3mm (5 year survival 60%-75%). But he hadn’t, it was 0.33mm (5 year survival virtually 100%). And breathe…

A week later I arrived at theatre reception for my surgery (I was having a skin flap) at 7.30am, as instructed in my letter.  The door was locked.  I banged on the door and eventually someone answered, annoyed.  ‘I am here for my operation’.  ‘Well we don’t open until 8am, so can you come back then?’.  ‘But the letter told me to be at here at 7.30?’.  ‘That’s because patients are always late’.

I hadn’t slept in a dormitory since I left school, and as I recovered from my operation I reflected that I didn’t much care for it now either.  The surgeon (different from the one who had given me the diagnosis) was keen to protect ‘his’ wound, and wanted me to stay over the weekend.  It was only by threatening to self-discharge that I managed to get out.

When the cast was removed the hospital told me to get the dressings I needed from my GP.  I rang the practice who insisted that I come in to receive the dressings.  I told them I couldn’t walk.  They told me that unfortunately those were the rules.  A friend ended up buying them for me from the local pharmacy.

For three years I went back to St John’s Institute for regular follow ups.  Each time I went I saw a different doctor, and would have to begin by explaining what had happened to me, while they furiously flicked through my notes to try and work it out for themselves.  Eventually I was told follow ups were no longer needed, but if I had any concerns to come straight back.  I am not sure even now whether I can call the hospital direct or need to go to my GP first.

In many ways the NHS provided me with great care.  I have been completely cured, I have a very tidy scar, and I have learnt which moles I need to worry about and which I don’t.  But at no point did I ever feel that the NHS was looking after me.  I was navigating my way through a system designed to serve itself rather than my needs.

A few years ago I bought a car.  I walked into the Audi showroom and was given a cup of coffee while I waited.  10 minutes later I was with one of the staff, a young man called Matthew.  I know he is called Matthew because from that point on he navigated me through choosing the model I wanted, arranging finance, and taking delivery.  He rings me every 6 months to check that I am happy with the car, and to see if there is anything else that I need.  Any problems he sorts out straight away.

For me it is not ok that the experience of buying a car is better than the experience of being treated for cancer.  The world around the NHS is changing.  Businesses work hard to ensure that what they do is built around the needs of the customer.  But in the NHS we are still lost in organising care around the needs of organisations and professional groups.  It has to change.

The HSJ reported criticism of the plans of CCGs to commission pathways of care for single clinical specialties.  The argument against is twofold.  First that focussing on a single specialty will reduce operational efficiencies, and second that patients often have more than one condition, and so focussing on a single specialty is not patient centred.  I fundamentally disagree.

The notion that commissioning whole pathways of care will reduce operational efficiency is based on the premise of ‘carve out’, which simply put is that if you take a lane on the motorway and make it a bus lane, the overall journey time for everyone goes up.  But of course what we are talking about doing here is creating roads that do not exist, roads that start with a visit to the GP and include diagnosis, treatment and follow up.  We must have a service designed around the needs of patients not the needs of organisations.

I know I was lucky because I only had one condition, and was not having to manage multiple conditions at the same time.  But the argument that organising care by pathways is not patient centred because patients often have multiple conditions massively overstates the effectiveness of the existing system, and totally underplays the fundamental shift to patient centred care that commissioning pathways of care rather than organisations represents.

I was not a mole, a biopsy, an operation, an inpatient, or a follow up.  I was a person with cancer.  But that was how the NHS treated me.  It has to change.  Commissioning pathways of care is not the end but the start of this journey.  Whatever the resistance, and whatever the complexities of implementation, it is the right path to be on, and one that CCGs must vigorously pursue.