It may feel like the relationship with your CCG is one-way, but working closely to identify their needs, practices can access additional help and income
How would you describe the relationship between your practice and your clinical commissioning group (CCG)? When I asked this question recently, what was most interesting was the difference between those responses from CCG managers and those from practice managers. While CCG managers were generally optimistic about the relationship, practice managers felt that it worked one way, with them on the receiving end of new requests and requirements from the CCG, receiving little in return.
The heart of the issue is this. The strategy of nearly all CCGs is to shift activity out of hospital into the community. A key part of ‘into the community’ is into general practice. Practices experience this as ever-increasing requests for them to take on more work when they are busier than they have ever been. The CCG requests don’t take into account the pressures that the practice is under, and become another competing demand that the practice has to juggle.
It doesn’t have to be like this. CCGs present a huge opportunity for practices that by and large has not yet been exploited. In this article I will explore two strategies practices can use to make their CCG work for their practice: first getting help with here and now; and second developing a profitable business strategy for the practice.
Strategy 1: Get the CCG to help the practice with the here and now
CCGs want fewer referrals, lower A&E attendances, and better health outcomes for their population. This means they want each practice to have fewer referrals, lower A&E attendances, and to deliver better health outcomes. Currently CCGs ‘push’ actions onto practices to try and make this happen, such as referral management schemes, peer review, and protocols to be followed.
But if a practice understands what the CCG is trying to achieve, it can use this to make it work for itself. Rather than the CCG asking the practice to do things, the practice can be asking the CCG for things in order that the CCG goals can be met. This will work better for the practice, as they take control of the actions, and for the CCG, as it improves the chance of success.
So what might a practice ask for that the CCG is likely to support? Here are seven ideas to get you started:
1. Simplification of local enhanced services (LES).
Do we really need a new LES for every CCG scheme involving general practice? Wouldn’t it be better to have a single overarching LES, eg. an ‘out-of-hospital’ LES, where new elements could be added each time? This would reduce paperwork and returns. Because GPs form large parts of CCG boards, the common sense behind this type of request means they are generally favourably received.
2. Help with quality and productivity (QP) indicators
The quality and outcomes framework (QOF) quality and productivity (QP) indicators were set up to try to align the work of practices with the work of CCGs. It is very much in each CCG’s interest for its practices to be successful in delivering these indicators. The more practices tell the CCG what they need to be able to do this, whether it is clearer processes, sharing of actions, or support with measurement, the better the CCG will respond.
3. Training for practice nurses
Practice nurses play a critical role for practices, but also a critical role for the health economy as a whole. The more practice nurses can do and the more skilled they are, the better able they are going to be to support the practice to manage activity so that it doesn’t need to go to hospital. If a practice asks its CCG to fund (or even organise and deliver) training for its practice nurse, it may well say no. But if asked to do so in a way that outlines how it will prevent hospital activity, it is much more likely to say yes.
4. Support with patient participation groups
CCGs have a duty to involve patients and the public. If you want support with your practice participation group, your CCG is likely to want to help in terms of items for the agenda, publicising the group, or even support with facilitation.
5. Tackling issues with district nurses and community staff
Poor service from district nurses and other community staff can be a source of tremendous frustration for practices. CCGs can sort this out. Practices just need to be clear that this is what is needed to keep people out of hospital.
6. Improve systems of care
Individual practices suffer from different failures of care delivery systems. For example, one practice may struggle with a poor drug and alcohol service that really affects its population, while another may have really poor access to mental health services. It is in CCGs’ interests to sort these problems, so make sure these concerns are raised in a way that outlines the impact of the poor service, the changes that are required, and the improvements that will result.
7. Help with access
As the pressure on general practice grows, so waiting times for appointments are starting to get longer. Practices need a way of getting on top of access. One way is introducing telephone triage systems such as Dr First or Patient Access. While I understand this is not the route all practices want to go down, for those who do it is very much in the CCG’s interest to support you, as improvements in access are likely to reduce A&E attendances.
This list is not exhaustive. The key principle for a practice manager to understand is to learn how to couch the changes that are needed in terms of how they will reduce referrals, reduce A&E attendances or improve population outcomes. Talk to the CCG in these terms and the CCG will be much more enthusiastic to provide support for whatever it is you need help with.
Strategy 2: Use the CCG to develop a profitable business strategy for your practice
Don’t be misled by the fact that it is NHS England that the practice contracts with. The reality is that it is the CCG that needs to take activity out of hospital, and it needs you to do it. NHS England needs to spend less on general practice so that it can break even. CCGs, on the other hand, want to spend more on general practice, to enable delivery of their strategy to move care closer to home.
This means there is enormous potential benefit in practices working with CCGs to create a strategy for their business. Practices need to be clear what success in the medium term means for them. CCGs can then work with you to make this happen.
So what should a five-year strategy for your practice look like? In my view it should be built around two key elements: first, a reduced dependence on the core general medical services/personal medical services (GMS/PMS) contract; second, an increase in the earnings per patient.
Profitability in the future is not going to come from a core contract that will be squeezed year-on-year. Practices need to find ways of expanding the business model beyond core general practice, and CCGs are the partners who can help you to do it.
I have outlined three practical steps that practices can take to get support from their CCG to develop their business model.
1. Broaden your business base
The first step is to identify what extended areas of service provision the practice might provide. If a GP has a special interest in a certain area, eg. urology, you could develop a relevant service, such as a lower urinary tract service, for the local area. The CCG will work with you to set this up.
At first these will be ‘fee for service’ models that may have a limited margin and create a pressure by reducing the overall practice capacity. But don’t let this put you off. Think big. This has the potential to become a service whereby the practice takes on the entirety of the urology budget for the local population as a lead provider, and sub-contracts elements of it to other providers such as the local hospital. The CCG will work with you to make this type of ambitious goal a reality.
2. Joint working with other practices
Joint working is important as it enables new services to be developed at scale and allows risk to be shared. In our urology example, it is much easier for a group of practices working in partnership to identify and access the skills required to deliver the service, make the necessary changes in pathways, and share the risk on the budget, than it is for one individual practice to do this all on its own.
‘Federation’ is the most talked about version of joint working. CCGs can help with this, as part of their role in market development. CCGs need effective community-based providers that deliver high quality first contact care and manage demand. The most likely provider is a large GP practice/federation of practices, and so CCGs need to be doing everything they can to support their development.
But don’t get put off if your GPs already have antibodies to the idea of federation. The trap many practices fall into is thinking that if they do not merge or federate, then the limit to joint working with other practices is some shared back office procurement agreement.
There are however other mechanisms of joint working that are worth pursuing, such a joint ventures or even more informal agreements.
For example, a local hospital has sub-contracted with a local practice to provide GPs to staff a primary care stream within the A&E department. The practice has agreed a remuneration rate with a group of local GPs from across the patch, and by acting as co-ordinator has the beginnings a new income stream.
Close working with the CCG is what helped the practice identify the need, and as a result was able to exploit the business opportunity.
3. Developing premises
The reforms to the NHS have left practices not knowing where to turn when it comes to developing existing or new buildings. The funding for any existing or new rent sits with the Area Team of NHS England. However, these budgets are fixed, so new proposals are highly unlikely to be approved.
In the past, the additional rent for new developments mostly came from the commissioning savings that the new property would enable. So practices and CCGs need to
work together to understand these savings, and ensure that the conversation with NHS England involves all three parties. The relationship between practice managers and CCG leads does not have to be one where neither understands the other’s world. Practice managers and CCG leads can form a partnership, in which they focus on aligning the core business of the CCG with the core business of practices. This can create short-term benefits, as well as enabling a longer-term strategic change.
So how would I describe the relationship between a practice and a CCG? Currently, I would describe it as a missed opportunity. But in the future I hope I will be able to describe it as the relationship that enabled CCGs to be successful and that transformed general practice.