Taking stock: Why your primary medical contracts matter

10 May 2018
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hold for general practice services, the contracting portfolios they have inherited from NHS England may be incomplete, out of date and poorly documented.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 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 email enquiries@pcc-cic.org.uk
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