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A faulty production line

CCG tells local GPs to federate or face loss of enhanced services contracts

Exclusive Practices in one CCG will be told they have to federate or face the removal of local enhanced services worth up to 15% of their practice income, Pulse can reveal.

Leaders from Newham CCG - which has one of the largest numbers of single or double-handed member practices among CCGs in London - told Pulse that providing extended primary care services ‘cannot be sustained by a small practice’, and that practices who do not federate will continue only with ‘shrinking resources’.

There is a push from the professional bodies and NHS managers to encourage practices to federate, but this is the first time a CCG leader has issued warnings that a failure to do so could lead to a loss of income from April.

GP leaders estimate that LESs account for around 15% of a practice’s income, and warned that practices will need to start to federate across the country if they want to provide LESs.

Under the new competition regulations, CCGs will need to procure LESs from April, unless they can prove that the services can only be provided by a single provider.

Speaking to Pulse at NHS England’s ‘Call to Action’ event, Newham CCG chair Dr Zuhair Zarifa said that the CCG has started to consider how it will commission the LESs, but added that the CCG felt the services cannot be sustained by a small practice.

He said: ‘I think primary care as it stands cannot carry on working under the current arrangement. We need to work together and we need to work very quickly. The message that will be going out from the CCG to the practices now, primary care now, is that you have to belong to a federation, some arrangement [of working together]. You have to start to talk.’

‘We are being asked to commission extended primary care services and that cannot be sustained by a small practice. That really has to be supplied by a bigger organisation, a bigger practice which can take care of bidding and have the infrastructure and the facilities to sustain this… Unless you federate you can carry on, but you will be doing so within a shrinking resource and your financial situation will continue going down - for you and your patients.’

The CCG will kick-start discussions between practices on the issue of federating in February, when it has enrolled the LMC to act as a neutral body to enable talks, Dr Zarifa added.

‘We are holding a meeting in February, where the LMC will be guiding the discussion as a neutral [entity], and we will be working to spread the idea that everybody should be working together in some form of federation. We hope to bring them all together to start to talk about commonalities, because I really think that our differences are very, very small compared to our commonalities.’

Dr Richard Vautrey, deputy chair of the GPC, said that LES income ‘amounts to around 15% of funding, but this may vary in some practices’, and added that it was looking increasingly likely that practices would need to federate if they want to start providing LESs.

He said: ‘If practices want to be able to win contracts to provide services over and above those currently provided by typical practices then working through bigger practices or groups of practices will make this more likely. However for many of the enhanced services currently delivered by practices, that depend on a registered lists to deliver them properly, both CCGs and local authorities should not fall in to the trap of assuming competitive tendering or AQP are the only options, or that big is automatically beautiful. Patients want services local to them and in their own practices.’

Dr Clare Gerada, former RCGP chair who is now chair of NHS England (London’s) primary care clinical board, said: ‘It´s very sad, but I do think small practices are unsustainable now. We need to relook at the general practice offering, particularly in London. It´s important for practices to come together under a single structure for reasons of economies of scale, rationalisation and so on. Let´s all start to talk to our neighbours. Its a massive opportunity for us. Tinkering at the edges of general practice is no longer an option.’

Note: This article was amended on 2 January to reflect accurate statistics regarding the number of single-handed practices in Newham. According to a spokesperson, the legacy Newham PCT was sixth highest in London for both the proportion of single (28.79%) and combined single or double handers (53.03%), and the 10th highest in London for the proportion of double handers (24.24%).

Readers' comments (31)

  • Russell Thorpe

    Is that legal?

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  • Economies of scale , rationalisation, ease of privatisation.

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  • If I was a GP in Newham I would be looking to get a vote of no confidence in the CCG board.

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  • @Russell Thorpe, Yes it is legal.

    I would imagine (as I am not local to the area, but am a commissioner elsewhere) that as the CCG will be undertaking a formal procurement for such services, they will construct the tender and weighting to score the tenders in such a way that gives higher scores to bids that can demonstrate such things as: their depth of coverage (either geographical or availability across the week), ability to manage peaks in demand or provide rapid access to services (depending on what service is being tendered), integration with other parts of the health and social care system as well as value for money.

    While not restricting single handers in bidding for services, it isn't too much of a stretch in imagination to see that federated or larger providers would have an advantage in demonstrating how they would achieve such requirements more easily, given economies of scale and the ability to pool resources to offer wider-reaching services and therefore score more highly at the tender stage.

    As long as the CCG is clear in its tender documententation as to how it will assess bids, the relative percentage of the overall score that each question / evidence will contribute and that it can demonstrate why it is assessing bidders on the particular questions, then it is all legal.

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  • According to their constitution they can't remove the chair directly, but can remove the other GP members of the board. Their replacements can then remove the chair.

    Actually looks quite easy, if there is a will.

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  • I am a commissionner elsewhere
    I think the whole concept of federating has been ill thought out for the services that are on offer ie current LESes /DEses .
    These are bolted onto already existing practice infrastructure ie premises, patient records and managing other health issues within essential additional services.
    With the money on offer it would be not worthwhile for new providers to take on these services- so i think the need to federate unless something big comes on horizon (perhaps 7 day access) is not necessary and the CCG chair is talking rubbish.
    If I were in newham- yes I would deselect him because clearly he is talking rubbish and appeasing his managers

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  • Federation! The latest brainwave (sic) of the great unwashed who come up with these ideas to justify themselves. If I was in Newham,I too would table a motion of no confidence, after all, we are all told that we are the members. If they could afford it they should withdraw from providing some enhanced services and see where that leaves the CCG - let them federate and provide services centrallly at another practice, cos' that would please the patients wouldn't it! Stupid politicians!

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  • how have the LMC responded to this? there are various options to this. just on a side note whilst we have commisioners in the forum, what do you all make of the concept that small practices are unsustainable. what options do you see around this matter?

    anonymous salaried!

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  • Small practices tend to be popular with patients. I just wonder why changes in the system are being accepted with the "very sad" result that small practices will be made non-viable rather than looking again at the implications and rethinking the changes instead of the practices.

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  • Largely negative comments above, but if the thinking is to try ensure practices are sustainable then surely this should be welcomed not attacked?

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