15
jul
0

How the CQC is Changing its approach to General Practice

Posted by Blogs, The General Practice BlogNo Comments

There have been some quite significant changes introduced by the CQC in recent months.  It can be hard to keep up with all them, so here is a quick summary of exactly what those changes are.

The background to the changes is an independent review of the CQC in 2024, which led to the then Health Secretary Wes Streeting declaring it as “not fit for purpose”.   The report highlighted a raft of failings including inspectors lacking the necessary experience, an inconsistency across visits and a huge backlog of assessments.

As a result, the CQC committed (amongst other things) to more sector-focussed regulation, more inspections and faster inspection outcomes.  The current raft of changes are these plans being put into action.

Disappointingly, the CQC has not introduced a general practice (or even primary care) specific focus.  Instead, the focus is on primary care and community services combined.  Professor Bola Owolabi has recently been appointed as Chief Inspector of Primary Care and Community Services.

In terms of practical changes the CQC is currently trying to do two things at the same time (which is leading to some of the confusion).  It is trying to increase the number of reviews it carries out, and it is also changing the assessment framework that it uses.  It is doing these two things in two different ways.

To increase the number of reviews it carries out it has introduced what it terms a “Return to Good and Outstanding” project.  This is a programme of visits that started in March and is specifically targeted at practices that hold a current rating of good or outstanding, had their last inspection report published between 2017 and 2022, are considered lower risk and have no ongoing regulatory activity.

These are slimmed down versions of a full visit.  They focus on the non-clinical aspects of care (there is no GP specialist advisor as part of the assessment team), and the primary person required for the visit is the practice manager.  On the latest podcast Ed Kennedy shares his experience as practice manager on the end of one of these visits.  The practice only receives 5 days notice of the visit, and the rating of the practice cannot be changed as a result – it can only trigger a full inspection.

At the same time the CQC is targeting practices for a full visit that that have been identified as high risk and not assessed, practices with previous enforcement action assessed for follow up, and practices with ratings older than 7 years.

These are the current inspections that are taking place.  At the same time, the CQC is changing its assessment framework.  It ran a consultation on the proposed new framework which ended on the 12th June.

This framework is long, and it tries to encompass practices, primary care organisations and community service providers which inevitably makes it unwieldy.  The focus on access, continuity, and partnership working across the system potentially opens the door for a wider range of assessments for practices in future than we have had in the past (nearly 90% of practices are currently rated as “good”), but we will have to wait and see how this plays out.

The CQC has stated that there will be a programme of pilots and testing of the new assessment system between June and October, with a final evaluation in November 2026. Pilot assessments will run alongside existing inspections. Participation in a pilot is voluntary, and the CQC has said if a practice chooses not to take part, there will be no regulatory consequence.

Whether all these changes will improve the effectiveness of the CQC remains to be seen.  At present the challenge is simply keeping up with all the changes the CQC is making at once!

1
jul
0

List Cleansing: An Abuse of the Population-Based Funding Model

Posted by Blogs, The General Practice BlogNo Comments

NHS England is undertaking what the BMA describes as an “aggressive” patient list cleansing exercise across the country.  According to some reports this has resulted in the removal of 450,000 patients from practice lists since November last year.

This list cleansing is clearly part of an NHS England cost saving plan.  It is no secret that the NHS is struggling to balance its books, and despite calls for any money generated by this exercise to be reinvested in general practice it is no surprise that these have fallen on deaf ears.

Most NHS cost saving or cost recovery plans try and find ways of reducing expenditure without making changes to how things work.  Rather than innovate to reduce costs, the NHS will more commonly try and find ways of reducing what it spends without changing anything.

A good example is how it has used capital funding to resolve revenue gaps.  It feels like a clever accounting trick that enables them to balance the books, but what it has actually resulted in is a crumbling and aging estate that is no longer fit for purpose.

Another example is high-cost care packages for patients.  Here the aim of the exercise is to reduce the amount the NHS pays for these packages.  The main outcome of this is that others, mainly social care but sometimes individual families, are left instead with the financial burden.

List cleansing is the same.  There is no change in the service provided, but the NHS ends up paying less for it.

NHS England justifies list cleansing by saying that they are ensuring value for taxpayer money by not paying for patients that do not exist.  But in reality it is an abuse of the population-based funding model.

General practice funding is population based.  Practices receive a weighted sum for every patient on their list.  This sum is regardless of the amount of activity generated by any individual patient.  The model has worked because even though the funding per patient is insufficient to cover the costs of the relatively small percentage of patients that generate the majority of work for practices, this is offset by the funding received for the majority of patients that generate relatively little work for practices.

The problem with list cleansing is that it skews this model.  Not only does it reduce the total amount of income that practices receive, it removes it with little or no reduction in activity (because by definition it is removing patients that have not been active with the practice).  Adding insult to injury, the process itself generates additional work for practices.

If you consider this in the context of the (unfunded) additional demands placed on practices to provide same day responses to urgent requests and operate systems that do not cap online submissions, then the problem of the population-based funding model is simply exacerbated.

If general practice was operating an activity-based funding model you can guarantee NHS England would not be carrying out the list-cleansing exercise, and would have thought twice about the urgent care changes because of the price tag it would have brought with it.

If NHS England continues to abuse the population-based funding model, something will have to give, and at present that is most likely practices being unable to continue.  While the main argument against list cleansing appears to be the impact it can have on vulnerable patients groups (that I haven’t even covered here), it also presents a very real threat to the viability of the way that general practice is funded.

17
jun
0

5 Things to Look Out for in the Review of the Carr-Hill Funding Formula

Posted by Blogs, The General Practice BlogNo Comments

In October last year the government announced that it was reviewing the Carr-Hill funding formula for general practice, which is used to calculate the payments GP practices receive.  But what should we be looking out for once this review from the National Institute for Health and Care Research (NIHR) lands?  How will we know whether what is proposed will make the situation any better?

I had a fascinating conversation on the podcast recently with Dr Matt Jones about the Carr-Hill formula and why it does not work.  What is clear is that very few people understand the formula and the impact it has, even on their own practices.  If we don’t understand the problem, it will be very hard to work out what changes will improve things.

I took away five key issues that we need to look out for when the new recommendations finally land:

  1. Is there an up to date, meaningful marker of deprivation?

It turns out deprivation is one of the markers used within the Carr-Hill formula, termed the practice additional needs index.  However, astonishingly, this is based on survey data carried out before 2000. This has the double problem of one not being very accurate to start off with, and two being at least 26 years out of date.

The new formula will need to use a better marker for deprivation, and some mechanism for ensuring it is updated on a regular basis as the characteristics of local communities can change extremely rapidly.

  1. Are fixed costs adequately taken into account?

Dr Jones very eloquently points out on the podcast that even though practices might only be receiving 80% of the global sum as a result of the Carr-Hill formula, they are not able to pay for only 80% of their electricity bill.

Whatever the practice, wherever it is, there are some costs that are fixed, regardless of deprivation, rurality or the age and sex profile of the local population.   The current formula does not take this into account, which means the impact of the formula is amplified as practices that lose out through it have first to cover their fixed costs and are then left with an even lower proportion of funding every year to cover their variable costs.  This in turn affects their ability to provide sufficient clinical capacity, a problem that is now being exacerbated with the new access requirements.

The new formula must provide some recognition of the fixed costs facing all practices.

  1. Is there a commitment to regularly review the formula?

One of the key problems with the Carr-Hill formula is that is has not been reviewed or updated in over 20 years.  In 2004/05 the global sum was £54.72 per patient, but this year it is £130.07 per patient.  This means the impact on practices being underfunded as a result of the formula has more than doubled over the last 20 years.

It is highly unlikely that whatever new funding formula is generated will be perfect.  Many practices could tell immediately that there were problems with Carr-Hill when it first came out.  Regular checks and reviews should be put in place up front to allow issues to be addressed quickly, rather than allowing them to compound and result in the same situation we are in now.

  1. Will there be transparency over funding at an individual practice level?

The result of any funding formula will mean some practices will receive more money than others.  The situation with Carr-Hill, however, is that many practices do not understand these differences, let alone the patients.

If one equal-sized practice is receiving over a million pounds more funding than another, albeit for justifiable reasons, then there needs to be transparency with patients, practices and commissioners, so that expectations can be adjusted accordingly.

  1. Will a manageable transition plan be put in place from the existing to the new formula?

If the new formula is not accompanied by any form of cash injection then the big risk with the change is that money will simply end up being moved from some practices to others.  No practices are finding life easy at the moment, so there needs to be a realistic, thought-out plan (i.e. not an MPIG) put in place that will enable those practices requiring more funding to be able to receive it without destabilising others.

3
jun
0

What does the Introduction of Local Variations into the PCN DES Mean for general practice?

Posted by Blogs, The General Practice BlogNo Comments

The publication of the PCN DES specification for 2026/27 includes an opportunity for ICBs to introduce what is termed a “local variation agreement”.  What does this mean and what are the implications for general practice?

Essentially the change allows ICBs to alter the PCN DES locally.  It has to be agreed by NHS England, but one assumes there is a willingness nationally for this to happen or else they would not have been introduced.

The document states that the change is limited to sections 7, 8 and 10.1-10.5.  But when you understand that these sections encompass the ARRS roles, the core service requirements of PCNs and the network financial entitlements it pretty much means the whole lot can be changed.

There will inevitably be some nervousness about this change within general practice.  While individual practices are small and relatively weak compared to NHS England or even an ICB, their strength has always historically come from acting collectively as one.  The national GP contract is the biggest symbol of this, and by negotiating it collectively their position is far stronger.

The shift to enabling ICBs to essentially create their own version of the PCN DES, which constitutes a large percentage of GP practice income, potentially undermines this position.

However, the benefits could well outweigh the risks.  For a start NHS England is no longer negotiating the contract with general practice, and is instead simply imposing it year on year instead.  We will have to wait and see whether the new round of collective action is able to influence this.

There are also significant safeguards in place for practices when it comes to any local variation.  First of all, the ICB has to evidence each practice has agreed to participate in the Local Variation Agreement (4.10.6).  The PCN DES part B guidance makes it clear that ICBs have to ensure that “the total investment available to the participating PCN(s) is greater than that provided under the relevant Network Contract DES Specification entitlements” (B.2.1).  On top of that, the ICB has to engage with the local LMC in making any changes (in contrast to NHSE who do not believe they have to engage with the GPC at all).

The other question that the change raises is what its relationship to the forthcoming Single Neighbourhood Provider (SNP) contract will be.  NHS England states that this is separate from the SNP contract, which we know a consultation is planned on later in the year.  But there does seem to be considerable overlap between the two considering the SNP contract once it arrives is expected to incorporate the PCN DES.

For general practice the option of an upgraded PCN DES with more resources attached as opposed to a whole new SNP contract feels much more attractive.  This is because the PCN DES is a contract for general practice and is held by practices.  The big risk with the SNP contract is that it could be held by organisations outside of general practice, and as a result move resources away.

So more resources, retaining control within general practice, and in a deal that all practices have to be happy with seems like a lot of upside.  Indeed, if general practice can make this work maybe we can get to a position where the SNP contract is not even needed (and there have been a lot of delays when it comes to any guidance or documentation linked to neighbourhoods to date), which might end up being the best result of all.

20
may
1

Are the Right People Representing General Practice in System Discussions?

Posted by Blogs, The General Practice Blog1 Comment

As the shift to neighbourhood working accelerates there is an important question that is emerging: where does the legitimacy of those talking on behalf of general practice come from, both with the GP practices themselves, and with the leaders of the other organisations across the partnership?

Practices and PCNs ideally want a say in which individual or individuals should take on these roles.  But as many of these roles are (or at least were) funded by ICBs, it often ends up being a direct appointment by them.  This lack of an obvious link back to practices and PCNs can create problems when it comes to legitimacy, which then in turn can make it difficult for these leaders to be effective.

For partner organisations the legitimacy of these leaders comes from their ability to convert conversations and agreements that are made into tangible action, rather than a clearly defined route back to practices.  They are far less interested in the process by which leaders came into post than effective services being put in place when agreements are reached.  The most common complaint from acute and even community trusts is that they invest time with GP leaders and nothing tangible happens as a result.  Instead, what they more commonly experience is a list of issues and complaints about their own services.

I recently spoke to Dr Sian Stanley on the podcast about this very issue.  She is very clear that legitimacy comes from delivery, not from representation.  If she as a general practice leader is able to work within the new provider partnerships developing within the changing NHS landscape and turn those conversations into the practical delivery of new services and new ways of working then her legitimacy will come from that.

This works with the practices, because they are happy with the tangible changes in service delivery, the opportunities to work within these services should they want them, and the financial returns these generate for the practice.

And it works for the partner organisations, who can see the result of their own investment of time and energy into partnership working in actual service delivery.

The impact in West Essex has been tangible, with general practice playing a leading role in the running of the urgent treatment centre and developing further services to change the model of care, all of which are generating a return for the local practices.

But this is in stark contrast to many parts of the country where place-based partnerships and system working feels more like a lot of meetings and a drain on leadership time than an enabler of actual change.

The really important take away for general practice, then, is to consider whether they have the right people representing them in system discussions.  The right people are those GP leaders who can make change happen, who can set up new services from scratch and who have a track record of delivery.  Often they are the people who set up shared assessment and treatment sites during covid, or got the immunisation sites up and running, or who have set up system wide delivery models through federations or other such organisations.

The point is they will have a track record of delivery and of setting up services at-scale.  People who will be able to deliver within the emerging integrated care system will already have experience of doing it.  These are the people general practice needs to be in leadership positions within the new system, because these are the ones who have the best chance of making the left shift a reality.

Equally, what won’t work for general practice is having leaders in place who understand the role as attending meetings, and of giving a general practice point of view, rather than of making change happen.  Sooner or later the system will get frustrated with these individuals and the most likely result will be general practice being bypassed when changes are made.

The neighbourhood system presents real opportunities for general practice to re-shape the system of care and to strengthen the role of general practice and community services within that.  But the first step to grasping this opportunity is ensuring that it has the right leaders in place.

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