Home » CCGs and Primary Care » £5 per head: Opportunity or Curse?
Feb
02

It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (http://ccginformation.com/a-3-step-guide-for-developing-general-practice/).  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.

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One Response to “£5 per head: Opportunity or Curse?”

  1. February 4th, 2014 at 17:54 | #1

    Very timely blog. How this is read by practices will be crucial – if £5 is added to all global sums, to give a named doctor for all over 75s, why would that be the same for a student practice and for one with twice the national rate of elderly and 5 care homes?

    If instead the CCG spends it on schemes to do good stuff, what is the evidence base? And how will they be evaluated? Does anyone care?

    Fudge indeed, sweet, creamy and crumbly all at the same time. Yum.

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