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20 January 2020
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Dr John Allingham offers some general tips on how to ensure you get the most out of running a local enhanced service and ensure it remains value for money
1. Read the contract specification very carefully
Read the details of what exactly is being asked for in the contract, and consider all aspects before signing up to provide the service.
Be aware of any Key Performance Indicators (KPIs) and how they’re monitored, and consider the notice period that either commissioner or the provider GP, practice or primary care network (PCN) must give.
2. Maximise coverage
Some services have a limited group to whom a service may be provided, such as a wound care service, which may have tight criteria defining a small group of patients with gravitational leg ulcers.
Others offer opportunities, such as a community ECG service – this could be used to provide a baseline of left ventricular size for all new hypertensive patients, and thus offer a clinically legitimate income stream.
3. Deliver with staff working at the ‘top of their licences’.
In simple terms, it makes sound business sense to deliver a service using the lowest-qualified and hence cheapest staff.
The latest GMS contract talks about GPs working at the top of their licences, and this applies to all staff.
A phlebotomy service can be delivered by a phlebotomist or healthcare assistant (HCA) so to provide it with a registered general nurse (RGN) is an expensive profit-reducing luxury.
Similarly, a wound care service may be led by an RGN, but the time-consuming dressing application element of the service can be delivered by a HCA.
4. Be accurate with record-keeping
Contracts specify which Read or SNOMED codes must be used, so it’s important that all staff delivering any enhanced service are trained to use these.
Some services are being offered with computer templates, and system providers will help to write them. It’s worth getting this in place before commencing service delivery, so that ticking the right boxes becomes automatic.
Some services are moving to systems of automatic data extraction, while some still require submission of a manual claim.
It’s important to check regularly that the correct payment is received and that the correct activity is coded.
Some enhanced service contracts have a limit to how far back retrospective claims will be honoured in the event of a practice error, and this can be as little as six months.
With this in mind, it’s worth running a claim or payment reconciliation check every month.
5. Manage your appointments to minimise ‘Did Not Attends’
In routine surgery, a Did Not attend (DNA) may be tea-break or catch-up time. However, in the delivery of an enhanced service, it represents a loss.
It pays off to assess the benefits of a system to maximise attendance, which is especially important with services that require long appointments, such as wound care.
A pre-booked reminder phone call by an admin staff member the day before (not a clinician, as patients often find something else to ask, and clinicians’ time is more precious) or use of automated text message systems may help.
6. Review and analyse your costs and outcomes continually
Look at the time and resources that are actually being used to deliver a service factoring in elements for running the surgery (heat, light, rent and admin staff etc). Consider the DNA rate as a full cost.
Then calculate how much is actually being spent on delivering a service and if the payment offered is a realistic reflection of the cost.
Commissioners want value for money, so they’re looking at reductions elsewhere in the system. This might be prescriptions or hospital attendances – and keep in mind that evidence of this helps justification of money spent.
If a service is being delivered at a loss, don’t be afraid to serve notice in accordance with the contract.
The commissioners have a need to provide a service and if GPs refuse because the funding is too low, they often find that an alternative provider will be more expensive.
7. Prepare for threats
Planning for all eventualities is key, so ask whether the service is dependent on one member of staff, and if so, how the practice will survive in the event of them leaving. A good follow-up would be whether it’s worth developing a successor or organising cover.
Other points might be if sub-contracting within PCNs would work; whether the contract even allows for this; whether, if the commissioner served notice, the practice would be left with staff or equipment that it needed to sell or make redundant; and if there are any ways this can be mitigated for.
8. Talk to your Local Medical Committee
If a contract isn’t viable, ask your Local Medical Committee (LMC) how other providers are making ends meet, or whether there are any problems with the service.
The LMC can negotiate with the commissioner on behalf of many providers, and as such may be able to get contract amendments or higher fees to ensure the viability of the service.
Dr John Allingham is medical secretary at Kent LMC
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