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Commissioning, competition and conflict

14 October 2011

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Rebecca Thornley
Associate Director, Primary Care Commissioning (PCC)

Rebecca has been with PCC Community Interest Company for the past three years, working in healthcare management for more than 20 years. Her MBA research focused on delivering quality services during transformational change. She is also business director to a team of GP providers in Plymouth

Sam Clay
Practice Manager, Plym River Practice, Plymouth
Chairman, Plymouth Practice Managers’ Forum

Sam has an eclectic commercial background that includes working as a disaster-planning consultant, a chambers’ director for a leading barristers’ firm as well as having worked previously in primary care management

The new landscape introduced into primary care with the publication of last year’s Health Bill will create new dynamic relationships between individual GP surgeries and clinical commissioning groups (CCGs) and between surgeries and any qualified providers (AQPs). This creates significant business challenges for GPs and in particular their practice managers. So will it increase significant inter-practice conflict as some anticipate?

It is a reasonable concern, and one that practice managers should think about, but there are good grounds for thinking that not only can dignity be maintained on all sides, but also that, by necessity, greater co-operation can arise.

All acknowledge that competition, though of a very limited nature, already exists. It is something all practices have lived with for some time given that they already compete locally for patients. With the exception of the introduction of outsider providers by primary care organisations, this has generally been ‘polite’ and rarely tips over into open and unseemly conflict.

However, there are – and have been – areas of significant conflict between practices under the current regime, particularly with the lack of transparency around the processes for allocating additional funding. This has applied to competing for funding for anything from clinical service pilots to premises upgrades.

Often, the more politically astute practices, helped by a nepotistic malaise, have won out over practices with greater need. Given the often-significant amounts of money involved this has been known to provoke strong feelings.

It is worth noting that a number of potential areas for local conflict, such as premises funding, are about to be removed from local decision-making, with responsibility for funding to be assumed by the NHS Commissioning Board (NCB).

None of this means we should be complacent: there is scope for potential tensions. GP practices are individual businesses, many of which will seek to grow as new opportunities arise through the movement of services from secondary to primary care and new services are developed in response to local priorities.

However, it is likely that these fields of conflict will migrate to a different arena, away from inter-practice rivalry, and be between practices and CCGs, CCGs and the NCB and, for those looking to develop services individually, between themselves and the AQPs entering the market.

However, any such changes and business development plans must be seen in context. Primary care is facing massive transitional and transformational change – with a sense that the manual for implementing that change is not only missing a few pages but is also still at the printers and subject to last-minute changes by its nervous authors.

People do fear change in any working environment, particularly ones as far-reaching as those proposed. This fear is being fuelled, almost daily, by the continued lack of information and certainty at a national level and is further compounded by poor communication by local commissioners and pathfinders. Lack of knowledge and an absence of clarity could itself breed conflict.

So how can practices minimise conflict to ensure service provision for the most important and frequently ignored individuals, the patients, is achieved?

Clear, open engagement
Some basic principles, which commissioners and practices should adhere to already, can minimise that risk and help local participants respond positively when tensions do arise.

First, and without doubt of most significance to commissioners, is transparency. All decisions involving resource allocation and the provision and development of clinical services must take into account the diverse capacity and populations of the practices within a CCG or cluster area.

Commissioners, whether CCGs, clusters or primary care trusts, must always allocate resources through transparent tendering processes that provide a level playing field for all those practices wishing to engage in the tendering process – and, in the new environment, AQPs. They need to set clear criteria based on the needs of the local community for allocating specific resources. This would apply to the migration of services previously provided in hospitals, new services and current provision.

Practice managers and networks should be insisting on this. CCGs, as developing commissioners, should swiftly develop clear strategies outlining how these arrangements will work.
Commissioners need to engage fully with their community. They should not focus their dialogue merely at the clinical audience. There is a need for inclusivity and it is vital that the experience and expertise of practice managers is used to communicate with the local population.

Develop a proactive communications system that ensures rapid and concise dissemination of information. Practice managers have a tendency to complain about the avalanche of emails they receive on a daily basis, but as the pace of change increases the need for robust communication networks grows.

Healthy debate
For practices and their managers, there are also significant considerations as the ‘brave new world’ develops and the process of migration towards it accelerates.

No practice can be an island in the new environment. All will need to know what the CCG, the NCB and the evolving Health and Wellbeing Boards expect of them. As a practice you need to be engaged, working in co-operation to ensure that service provision meets the need of locality populations.

Your local practice manager networks and forums need to be robust and should be involved in identifying and developing strategies as well as supporting operational priorities. In particular, practice manager networks will continue to play a vital role in developing agreement around the implementation of national and local initiatives such as the implementation of nationally negotiated directed enhanced service opportunities and the shaping of local enhanced services.

Remember, debate is healthy – no matter how heated. It is the outcome of that debate and its ability to provide influence and consensus that is most important.

As the level of commercially aware managers increases there will be tensions as cultures clash. We should recognise the risk that some people, intentionally or otherwise, could push too quickly and loudly new ways of working and initiatives brought from sectors where competition is pursued more aggressively. New arrivals filling new posts around business development in practices should respect the experience and achievements of local long-serving practice managers.

Make sure that information is disseminated rapidly. This can be via a simple comprehensive network newsletter or even detailed minutes of meetings. Several practice managers are already using NHS Networks (see Resource) to provide a free virtual network to disseminate information and host discussions.

Strategic planning
The outcomes of these meetings, together with communication with CCGs and other commissioners, should help you shape a clear business or strategic plan for the practice. This should also be based on a clear understanding of the needs of your practice population.

Given that the plan could be used to help secure locality-wide services, it should also reflect wider population needs and known local priorities. As the need for increased engagement with the new CCG and the NCB becomes apparent, this detailed understanding and planning will encourage you to see other practices as possible partners in either federating some activity or working together to tender for particular services.

While most practices will embrace the new environment in a spirit of co-operation and mutual respect, tensions and conflict are never going to be eliminated entirely. The human element cannot – and should not – be removed from practice management and relations with local partners, commissioners and, yes, commercial rivals.

A degree of independent scrutiny and arbitration is both inevitable and welcome.

Local medical committees (LMCs) are ideally placed to play the role of honest broker in disputes between practices or between an individual practice and the local CCG. As a practice manager you should ensure you have good links with your LMC and other organisations that could be involved in resolving any local tensions or disputes (see Box 1).

Challenging times lie ahead, which might well test all our management skills – including how we work with each other. With some work and thought on all sides, however, we could create local primary care providers based on positive competition rather than aggravated conflict.


NHS Networks