1 News and analysis from Primary Care CIC May 2018 At the table or on the menu: the choice for primary care The recently published planning guidance gives sustainability and transformation partnerships (STPs) a prominent role in planning and managing system wide efforts to improve care. STPs are expected to evolve to become integrated care systems (ICS). The guidance also refers to STPs roles as brokers of primary care networks and creators of system wide resilience. All of this sends a clear signal to general practices that if they don t start working together of their own accord, a solution may be imposed on them, possibly by people with no understanding of or interest in general practice. The need to work at scale was written large in the general practice forward view (GPFV). Simon Stevens enthusiasm for the primary care home and other early signs of scale and the subsequent adoption and frequent repetition of the magic number (30,000 to 50,000 population) should leave it in no doubt where this is going. It may not feel like it, but primary care has a strong hand, partly because it holds the first point of contact card. What happens in primary care, and particularly in general practice, has a very big effect on what happens in the rest of the system. There is also a window of opportunity created by the move to new care models. Continued page 2 4 LEICESTER REFERRALS SYSTEM SETS STAGE FOR COLLABORATION 5ROTATING PARAMEDICS: A WIN-WIN FOR GENERAL PRACTICE AND A&E Secrets of successful practice mergers What makes a successful merger? Paul Burns, PCC s lead for practice mergers, pauses: Meeting the aspirations you had at the start of the journey, he says. It s not the answer you might expect because the merger process is complex, time-consuming and often fraught with hidden obstacles. So much so that the process can start to get confused with the outcome. Once you make the decision to start, you re getting into a process that could take months and more energy that most GPs and practice managers have to spare. It s not surprising that some may lose sight of why they started and will judge the success of the merger on whether or not they got to the end of the process with the will to live intact, says Burns. But, he adds, a merger is more than the sum of its contractual parts. In the successful mergers that we ve supported, all parties appreciate that the work goes on long after the ink dries on the deal. You re putting together two or more businesses with different ways of working and often different ways of thinking. So when we ask Did you achieve what you set out to do? we don t just mean did it go without a hitch, we also mean Did everyone get what they hoped for? and crucially Can we keep it going? 6NICE LOGO, PITY THE FEDERATION NEVER GOT OFF THE GROUND Last year, according to NHS Digital, there were 254 mergers or closures of general practices in England (the figures don t differentiate the two). In many cases, the driver is necessity and the merger is really a takeover of a weaker practice by a stronger one. In other cases, the driver is capacity. According to Burns, Some practices may be tiring of all the rhetoric about the need for collaboration and scale, but it s true that smaller practices will struggle to survive and that there s strength in numbers. Mergers are one of the ways to make the business sustainable. As Simon Stevens memorably said, if general practice fails, the NHS fails. Some commentators and GP leaders appear to equate both mergers and closures with failure but, says Burns, a merger should be the opposite it s what you do to avoid failure, yours or your merger partner s, or it s what you do when you want to turn two small successes into a bigger success. Even when necessity is the main driver, practices should be looking for an outcome bigger than the merging of two lists and an expanded workforce. We encourage people to hope for something more than survival. Ideally a merger will benefit all stakeholders partners, practice staff and patients, Burns says. Continued page 2 7CONTRACT MANAGEMENT: DO YOU KNOW WHAT YOU RE PAYING FOR? 8TAKING STOCK: WHY PRIMARY MEDICAL CONTRACTS MATTER
2 2 Secrets of successful practice mergers Continued from page 1 The process starts with some preliminary work to check that a merger is the right solution. PCC runs workshops, usually funded by CCGs, to explain what s involved, outline the success factors and describe the process. It includes presentations from people who have project managed mergers and can talk with authority about the experience of the practices involved. We start by asking them why they want to merge. At the end of the workshop, which we think of as phase zero, some practices will leave more interested and others will go away clear that it s not for them. That s fine because practices that are really clear what they want, and who understand why it matters that their intended partner wants the same thing, are more likely to end up in a successful relationship, says Burns. PCC s support for mergers covers the process from end to end, starting with the workshop and progressing through the stages outlined (right). Not every project involves support for every phase or the entire menu of options within each phase. We flex the support depending on the expertise and resources the practices already have at their disposal. We can help you do it all or just provide the missing pieces, Burns says. Find out more: Phase 1 Due diligence helping you explore/clarify why you are merging Facilitation sessions to explore and clarify what you have and what you need Financial analysis and re-framing definitions, eg what is a session? Premises analysis making the most of what you have Contractual forms and which contract vehicle to select to meet future needs Patient engagement or consultation which route do we need to follow? Partnership agreement comparison/redrafting Exploring what the new partnership will pursue re new services/ways of working Horizon scanning Identification/application of available funding (commissioner liaison) Phase 2 Post due diligence pre-merger date Project management support from due diligence decision to merger date 1. Project plans 2. Risk registers 3. High level timelines 4. Document storage on NHS Networks 5. Teleconferencing facilities 6. Terms of reference 7. Regular update reports to partners and third parties 8. Support for practice managers 9. Lead for the project team Phase 3 Post merger date Leadership development for partners and managers of larger organisations Blending diverse practice cultures Blending reception teams Organisational development Business planning your first year When patient lists exceed 30,000 what opportunities can flow from this cohort? Team building/bonding Moving/amalgamating premises solutions
3 3 At the table or on the menu: the choice for primary care Continued from page 1 Plans for integrated care systems seem a very long way off. The multispecialty community provider contract under which some of the first ACO-style systems were to be given life has suffered setbacks. The contractual options for participation designed to attract GPs (virtual, partial and full) have created confusion and inevitably, as GPs tend towards the least binding option, give the contract a watered down appearance. Meanwhile legal challenges to existing plans by campaign groups worried about the intentions behinds ICS add to the impression that one of the Five Year Forward View s basic assumptions of a formal scaling up and coming together of commissioning and provision is stalling. Many in general practice have been alarmed by rhetoric about moving care out of hospitals at a time when general practice is under enormous strain. There may even be satisfaction in some corners about the bumpy ride given to ACOs, NHS England s nervous fiddling with terminology and the legal skirmishes that are delaying progress. But anyone hoping that life will soon return to normal, that STPs will be quietly disbanded and ICSs shelved is likely to be disappointed. The same financial and demand pressures that were present in 2014, when the Five Year Forward View was published, are even more acute today. For general practice, the arguments for working together, regardless of the needs of the rest of the system are also as strong as ever. Practices hoping to employ a workforce with the range of skills needed to expand their business beyond core contracts, and looking to be taken seriously by commissioners need to reach critical mass. They need to modernise their IT, premises and their business processes. So with or without the pressure to meet the demands of Simon Stevens grand design, practices need to work at scale for their own sake. They also need to recognise that the current lull in development of ICSs is an opportunity to get themselves in a stronger position. It is very clear that the GP element of the MCP contract and the more general failure to engage GPs in STP plans have slowed the FYFV bandwagon. What GPs choose to do next is the question. Some will use the next 12 months to get their act together locally. Many will opt for mergers and other vehicles for formal collaboration. Others will take the ultimately more challenging route of less formal working arrangements. The latter group will typically need the support of well-run federations. Any and all of the above will give local practices a more effective voice in local plans, whether for the purpose of negotiating their own contracts or for setting the direction of the ICS. Primary care should not undersell itself but for those not already working with others, it is now time to create links with other practices. Reaching the mandated optimal population size of 30,000 to 50,000 is a start but not an end in itself. Working out how to work in a larger organisation of whatever kind is the far bigger challenge. At the same time as they are dealing with the internals, practices will also need to keep an eye on the outside world. This is the time to claim a place at the planning table with the STP. The do-nothing option is of course still available. Survival is not compulsory. Tips for general practices 1 If you are not already working in a group that covers 30,000 to 50,000 minimum take steps to do so now 2 If you are in some form of federation or alliance, ask yourself if the group is fit for purpose 3 If you don t take part in the integration agenda, you risk being run by it 4 What can you do together that will benefit the group can you share workforce, rationalise back office functions or find new ways to bring in income? 5 Bring others with you communicate what the group can do, how it will benefit every practice, particularly bearing in mind the resilience and sustainability of individual practices. Leave the door open for practices even if they are initially reluctant to get involved 6 Engage with other groups of practices working together and where it is sensible to share functions or deliver services across a larger footprint, start these discussions 7 Share the vision for primary care in your local area is it in line with the STP? If not, sit down with the STP and agree a vision you can all support 8 Identify who is leading the STP in your area, and find out who is representing general practice at the planning discussions. Engage with the STP and get primary care seen as a key partner with a clear direction and vision that is owned across the groups of practices The resilience funding in the GPFV is only partly about shoring up struggling practices. It s also about finding ways to work together that benefit practices and their patients. It can help to have a neutral third party involved in leading these discussions, helping you map out the options and alternatives, the risks and opportunities, and the hurdles you need to overcome. PCC has helped many groups of practices to work together. For further information contact
4 4 Leicester referrals system shows collaboration at work When NHS Leicester Health Informatics Service (LHIS) was approached by local GPs to develop a referral management system, the idea was enthusiastically backed by the area s three CCGs, who provided the funding to get the project off the ground. Four years later, the system is used by all 138 GP practices in the Leicester, Leicestershire and Rutland (LLR) area and in 2017/18 supported 110,000 referrals across 130 conditions. The system, PRISM, ensures that the GP is provided with the relevant referral criteria and service information to create the referral and the consultant receives the appropriate baseline information. PRISM guides GPs through the referral process with a questionnaire for each condition. It uses the responses to populate referral letters in a consistent manner that can be attached to bookings made through the electronic referral system (ers) system. GPs like the system because it reduces the time taken to make referrals and cuts bureaucracy, but also because it provides other resources to enable them to make confident decisions and support their patients. These include clinical information, the latest NICE guidance and information to support patients to manage their own conditions. Local service directories are being added too, so that when GPs don t refer they can advise the patient what other healthcare or support services are available. Dr Nick Pulman, IM&T GP lead at West Leicestershire CCG, said PRISM helps the clinicians understand what they need to do prior to referral. I use it fifteen to twenty times a day. Referral processes and criteria are constantly changing. PRISM puts all that information in one place and allows it to be completed straight away, or if the information is not immediately available it guides the clinician to get the information required, reducing bounce backs. Quality referrals benefit patients too. With a shorter, more reliable pathway from the GP to the appropriate specialist in secondary care, they experience fewer delays. This is particularly important for patients referred for suspected cancer, who are entitled to be seen by a consultant within two weeks of the referral. Dr Tony Bentley, co-chair, GP and clinical IM&T lead Leicester City CCG, said: Having access to PRISM has streamlined my referrals in the twoweek wait pathway. I know I m sending the patient to the right service with the right information. As we put more resources onto PRISM, I am confident that this will make the life of the busy GP easier, and patient care will benefit as a result. The patient will be seen in the right clinic by the right clinician first time and everyone will benefit. Referral pathways go through a rigorous process which sees them agreed, tested, clinically checked by GPs and service leads and finally signed off for publishing by the PRISM clinical safety officer. CCGs like the system because it provides them with consistent referral information for every condition, better enabling them to monitor referral patterns. They also have the assurance that all practices are working with the latest guidance and resources. By working together, the Leicester CCGs are conscious of how these benefits could also be enjoyed at STP scale. The local STP appears to agree, recognising that good referrals data and improved referral quality are big factors in its planned care strategy. The system s growing use as a repository for self-care and signposting resources also appeals to commissioners, who can see its potential contribution to implementation of the GP Forward View. The Leicester, Leicestershire and Rutland planned care workstream clearly see the value of PRISM aligned with their own five year plans and have invested in a programme of builds for PRISM pathways. Managers at the local trust are also enthusiastic. Claire Brennan, operational manager at the University Hospitals of Leicester cancer centre, credits PRISM with helping improve efficiency, including the achievement of paperless running targets. In allowing us to ask GPs to collect a minimum dataset by way of questionnaire which feeds into a PRISM two week wait (2ww) referral letter we are quickly able to view and respond to key information that is presented in a consistent format and therefore easy to process - recognising that our 2ww team processes over 650 referrals a week, she says. In 2017 the three clinical commissioning groups mandated the use of PRISM alongside ers to send 2ww letters. As a result over 96% of our 2ww referrals are received on PRISM referral letters, providing us with a great platform for our wider consultant led paper switch off later this year. To put this into context we were only receiving 14% of our 2ww s as PRISM referrals two years ago so this clearly illustrates GP engagement and buy-in. There are lots of reasons why NHS organisations shouldn t grow their own IT locally, including the potential for dozens of different solutions where one would have done. Sarah Ost, service delivery manager at LHIS, acknowledges this criticism but stands by the decision to continue to develop PRISM s functionality. We looked and the alternatives were expensive and didn t do the job we needed them to do. This GP support tool complements the national programmes of work and as far as we are aware in Leicestershire there is no alternative that offers the features found in this product with the additional facilitation and support that the pathway development service provides. She adds that there was a more basic reason why an off-the-shelf commercial solution would have fallen short. It was soon clear that the real work was not developing the technology but getting the referral pathways agreed. That meant sitting round a table with all the stakeholders including GPs, CCGs and secondary care. As part of the NHS family we re able to do that, but I find it hard to imagine the same level of collaboration from other IT partners. Ost recognises that locally developed solutions can hinder the way in which the NHS shares knowledge and best practice. This is why LHIS are keen to continue to talk to other CCGs about licensing the service. If other areas were developing and sharing their own pathways we could soon have a comprehensive library covering every condition, she says. To find out more about PRISM, contact
5 5 Rotating paramedics getting the right response, first time Providing the right response, first time to people in need of urgent care has the exciting prospect of improving patient care, whilst significantly reducing demand on ambulance and other NHS services. That s the aim of the Health Education England (HEE) rotating paramedic model, currently being piloted by four ambulance services in England, in collaboration with community and primary care colleagues. Developed with input from NHS organisations and individuals working in the urgent and emergency care sector, the rotating paramedic model offers a radically different approach to system working. Paramedics working in settings outside the ambulance service is certainly not new, but ambulance services and primary care together supporting a rotational model of working through each care setting, with central support is different and that s what s being piloted and evaluated in the HEE programme. The rotational model of working involves specialist or advanced paramedics rotating into, and contributing to, the following areas: Commenting on the results so far, Rhian Monteith, clinical lead for the rotating paramedic pilot, Health Education England said: Early case studies and data from the pilot sites show that the paramedics are reducing avoidable trips to A&E and associated admissions; and increasing capacity within primary care by undertaking acute home visits on behalf of GPs. There has been excellent engagement, commitment and enthusiasm from everyone involved, including the ambulance service, primary care colleagues and community providers, said Rhian. Once the evaluation is complete, we will be looking to see how the model could be commissioned and rolled out as part of an integrated urgent care system. Multidisciplinary Team see and treat - receiving calls that have been triaged by the specialist or advanced paramedic in the ambulance control room as being suitable for response by the most appropriate healthcare professional in the multi-disciplinary team. Ambulance Control Room hear and treat - triaging and assessing calls and managing onward referrals to the multidisciplinary team to ensure the right response, first time. The pilot is expected to produce the following results. More patients, many with multiple and complex conditions, receive the right care, first time - safely managed in their own homes or in the community The ambulance service has increased capacity to respond to calls that are life-threatening General practice has an extra resource to immediately relieve workload pressure and reduce impact on ambulance and secondary care The community team s workload is supported by an extra generalist resource in the form of a specialist or advanced paramedic increasing capacity to provide the most appropriate response, first time to 999 calls and to provide proactive care within their community Partnerships are built across the system with shared responsibility for population health. Primary Care see and treat - contributing to planned activities within a GP practice, such as acute home visiting and same day clinics. Increasing the skill mix, capability and capacity of primary care to reduce pressures on primary care, the ambulance service and A&E. Improving patient care and reducing demand a paramedic s view The new way of working is already benefitting patients, according to Angie, a specialist paramedic working within three GP practices. A recent visit to an elderly patient who had called 999 after falling brought it home how effective the service can be at reducing demand on the ambulance service, A&E and hospital services. Angie and her colleagues provided the care he needed to stay at home. Prior to working within the multidisciplinary team, I would have arranged a medical bed at hospital for this gentleman as he was at risk of falls. I wouldn t have thought the services he needed to stay safe at home could have been arranged so quickly. The look of relief on the couple s faces when they didn t need to be taken to A&E was priceless and it was then it really dawned on me what an impact I was having.
6 6 What next for GP federations? Going beyond the logo July 2014 A CCG event for all the member practices about general practice working at scale. All the attendees could claim backfill for the afternoon, so attendance was high. I had been asked by the CCG to try and push the GPs into seeing the benefits of working collaboratively at scale, having had experience of setting up a successful federation in north London. We need them to form a federation, said the director of primary care. We need them to come out of their practices and work together. Can you light the touch paper and show them some of the benefits? A simple enough brief. So, I did my talk. Cracked a few jokes. Did a Q&A session afterwards and stayed for the workshop. There was a real buzz in the room which reached fever pitch when the director of primary care announced that the federation would be funded to the tune of 50p per patient from transformation money. If any of the cynics in the room had needed convincing, that was the tipping point. What do we have to do to get the money? someone asked. You just have to demonstrate the will to work collaboratively under one umbrella, replied the CCG. The background volume of table discussions went up a notch. They came up with a name for the federation. December 2014 I m invited back to the board meeting of the new GP federation. The previous PEC chair has been appointed chair of the GP federation, although nobody is quite sure how. I look around the table. Eight people. All GPs. There is a practice manager taking minutes, but there is no agenda. In fact, there is nothing to review apart from a rather eager looking GP with a PowerPoint presentation. He has taken it upon himself to be the branding expert of the organisation. Twelve different logo designs are put up for the board to vote on. Tell us your first, second and third favourite and we will weigh the scores. They settle on a snake wrapped around a stick. Dr Mike Smith They then discuss their mission statement. High quality healthcare for all people through collaboration. Snappy. December 2015 Thanks for coming Mike, the new chair said. We are in a bit of pickle here. We haven t secured any contracts. The CCG won t talk to us anymore. They won t give us any contracts. A long chat. A look at the accounts and yet another difficult conversation about what to do next. Time to make this organisation dormant. So, what now for GP federations? I believe that many perhaps most GP federations have formed for the wrong reasons. When I speak to the boards, a lot of them view the federation as a contracting vehicle or a provider company rather than a federation of general practices. Winning contracts appears to be the main focus of some GP board meetings. Surely, we have missed the point. If we try and become a new private provider, compete with the big boys, we don t stand a chance. Commissioners won t be sentimental for long, just because we are GPs. The advent of integrated care systems will test this further. We need to play to our strengths.so, if you are a commissioner, a GP federation or anyone interested in general practice at scale, then please consider this list of questions to ask at your board meeting, quality meetings, patient meetings or on the train home. 1. Does your GP federation represent all practices within it? Be careful with the answer here. I often hear people say, Our federation represents all 34 practices in our CCG. But does it? Are you just reflecting the shareholding structure or membership (terms that are often conflated), or do you have a mandate to make decisions on behalf of the practices you claim to represent? Are you able to negotiate locally commissioned services or QOF on the practices behalf? Is the local medical committee happy about this arrangement? When federations turn up at STP meetings, CCG meetings or any public forum, I doubt that they represent the practices in the way that other stakeholders would like. Engagement with your own practices: do you have any? Get a mandate. Downsize if you have to. 2. Have you put any of your core, LCS, DES, QOF or private income into the federation to run? While federations are searching for new business and contracts, there is plenty of opportunity right under their nose if practices were creative in how they deliver their core contract. This ultimately comes down to trust, and it is staggering the number of GP practices that don t even trust their federation 3. Have you done any work on clinical governance, clinical quality and safety among your federation of practices? This is such an easy win. A standardised approach to governance is a simple task and one well within the expertise and resources of primary care. CQC inspection would be so much easier, less time would be spent on writing 34 needle stick injury policies even how we check the fridge temperatures could be standardised. 4. How are you engaging your local community and your patients? This doesn t mean creating a patient participation group. It means really empowering local businesses, groups, religious groups and volunteers to lead change supported by you. Not the other way around.
7 7 DO YOU KNOW WHERE YOUR PRIMARY CARE CONTRACTS ARE? Speak to the pharmacists, the dentists, the optometrists who also have primary care contracts. Hear their ideas of how they are making their businesses more resilient. Look for areas of duplication. Don t treat them like competition. 5. What exactly are you trying to achieve by federating? I take you back to the mission statement mentioned above by the federation I visited. Nobody can argue with vanilla statements about providing the best care for all, celebrating the role of primary care, and protecting general practice but what do these statements amount to? Be honest. You aren t on The Apprentice. Go back to why federations were originally introduced. There has to be something about sustainability in a federation s raison d etre. We know where we are struggling in general practice, so why not reflect this in your federation s organisational aims? How about these for a start? To help address the issues of workload in general practice To help address the issues of workforce in general practice To help address the issues of premises in general practice If we don t address these issues soon, then federations definitely won t be able to provide better care for all. Most CCGs are now delegated, which means they have inherited responsibility for primary medical care contracts from NHS England. Unfortunately they haven t all inherited an up-to-date schedule of contracts or complete paperwork for every provider. Your CCG may be paying for enhanced services that are not underpinned by a valid contract. In extreme cases, services may be out of contract before the commissioner is aware of a problem. PCC can undertake a comprehensive review to help you establish a schedule of core and supplementary contracts, ensure that all the right documentation is in place, and create a pipeline for procurement for contracts that are due to expire. Get on the front foot The following example, based on a project for a CCG in the north of England, is typical of the work we can do to support process improvement in contracting, though the detail of the task varies according to the needs of the organisation. A recently delegated CCG discovered that it had inherited incomplete records of existing contracts with primary care providers from NHS England. With a new primary care commissioning manager in post, the CCG set out to create an orderly pipeline of procurements for contracts that would soon to be up for renewal. With a small primary care team already under pressure and knowledge of primary care contracts in short supply the CCG approached PCC for help. We were tasked with: Establishing a register of all core (GMS/PMS/APMS) and supplementary contracts including an accurate uptake of enhanced services Ensuring a complete set of core and supplementary contract documentation was in place in both paper and electronic format Establishing a process and pipeline for procurements where contracts were due to expire Reviewing the contract with a local GP federation to ensure that all services had been contracted for correctly Work with NHS England to set a timeline for procurement of GP access funding Providing contractual support and a planning questionnaire for a premises relocation Drafting the contract for the GP out of hours service Working alongside the contracts support office and ensuring a robust handover. So, calling all surviving GP federations out there and their hosting CCGs and neighbouring acute trusts: you have a very limited amount of time to give your federation a spring clean, a clearer sense of direction and a real purpose. Otherwise all you will have left next year is an absolutely smashing logo. Contact PCC for information about how we support GP collaborations, including board development and help with business planning and strategy. Mike Smith is a GP in St Albans, a federation expert and a partner in MBI Community. The CCG s primary care commissioning manager said: When I started in my new role I discovered what many other colleagues in delegated CCGs know to their cost, which is that processes for monitoring essential primary care services were not fit for purpose and much of the documentation was incomplete. See also page 8. To find out more about support for contract reviews, PCC was the natural choice of partner to help us get on top of the situation. They brought much needed expertise and capacity to bear on the problem and we no longer feel that we re running to catch up.
8 8 Taking stock: Why your primary medical contracts matter By Julian Patterson As of this April, 91% of CCGs now have delegated responsibility for primary medical care. It s doubtful whether a majority of them are fully prepared to discharge that responsibility, however. Not only will many lack the expertise and experience to take day to day decisions about the contracts they hold for general practice services, the contracting portfolios they have inherited from NHS England may be incomplete, out of date and poorly documented. Some CCGs have tackled the issue and instigated painstaking reviews to check that all of their practices have current contracts, that supplementary contracts covering locally commissioned services are also in place and that there is an established pipeline for procurements where contracts are due to expire. Others are aware that there s an issue but lack the resources to tackle it. Others still may simply assume that everything is fine. Does it matter that you don t know where all the paperwork is, whether the right contract has been issued or what s in every clause? Don t we have bigger fish to fry ensuring the sustainability of general practice and the long-term health of the NHS? Two fairly significant problems lie in wait for commissioners who take the view that what they don t know can t hurt them. One is that in the event of a dispute your organisation will be at risk. In any contract dispute, not having a copy of the contract or not understanding what it means may just put you on the back foot. The second is that even if relations between your CCG and member practices remain untroubled, not knowing exactly what services you re paying for makes it impossible to be sure that primary care funding is being used as well as it could be. For CCGs concerned with the sustainability and development of primary care, enabling the transformation of general practice envisaged by the GP Forward View is severely undermined if the baseline is Julian Patterson For CCGs concerned with the sustainability and development of primary care, enabling the transformation of general practice envisaged by the GP Forward View is severely undermined if the baseline is wrong. It s like trying to plan a journey without knowing where you re setting out from. As the old joke has it, you wouldn t start from here. wrong. It s like trying to plan a journey without knowing where you re setting out from. As the old joke has it, you wouldn t start from here. Not only is there huge variation in the rates paid for the same locally commissioned service depending where you are in the country, but there have even been cases where services that should be delivered under the core contract are being paid for twice. As with clinical variation, there may be good reasons for some of these disparities. The problem, without a clear paper trail, is being able to justify them. So what s to stop CCGs from sorting it out? One is that the same lack of skills and capacity that has historically hampered primary care commissioning exists today and after the lift and shift disruption of the Lansley reforms is arguably worse than ever. Another may be embarrassment unwillingness to acknowledge that they re not on top of the situation. Then of course there is the matter of resources: it s not just trusts that are struggling to maintain financial balance, CCGs are also running deficits. But the PR risks of a messy contract dispute far outweigh the risk of acknowledging that there s a problem and doing something about it. The do-nothing option incurs the much graver risk that funding is not spent fairly or well, creating ill-feeling among contractors and short-changing patients. There is also a governance issue. Primary care commissioning committees have been set up to ensure that commissioners make safe, well-informed decisions on contractual matters. It s difficult to see how these bodies can discharge their responsibilities if the underlying foundation understanding of contractual arrangements already in place is weak. Contracting does not drive transformation but it could slow it down. The scaling up of general practice, whether through mergers or more ambitious integrated care programmes, will be helped or hindered by the clarity or otherwise of existing contracting arrangements. What was brushed under the carpet isn t going away. Commissioners can choose to deal with it now or leave it to fester, but the latter course will only suit those who are happy to base primary care transformation plans on guesswork. Culture, they say, eats strategy for breakfast. Left unattended, your legacy contracts could be equally destructive. PCC can provide the expertise and capacity to get your contracting portfolio in order. To find out more Excellence is supported by PCC and NHS Networks. Contact or visit and