Once you have effectively evaluated the ‘day job' of providing NHS primary-care services, you can start planning other work. It is my opinion that more than seven clinical sessions of face-to-face GP work per week creates burn out – although this is not true for everyone, of course. In most partnerships, nine sessions gives the normal ‘full-time' share of profits. If partners agree on a core of seven sessions, they can choose to do up to nine clinical sessions or provide something else in those two ‘free' sessions. If GPs know the cost of each session, they can evaluate whether alternative activities are worthwhile. And before developing any new income streams, it is worth considering whether you can more efficiently provide your current services.
There are lots of opportunities to generate additional income in general practice, but the reason some partnerships do not develop these are complex.
The first is perceived lack of time. To develop, you have make time to plan and carry those plans through. Making time is a key step.
Second is lack of motivation – if you are already working nine clinical sessions each week, you are unlikely to be motivated to do anything else. You may also be someone who believes that doing your ‘day job' is enough. While there is nothing wrong with this attitude, you may have to accept the downside of increasing workload, falling income and the possibility that your partners feel differently.
Third is the pervading attitude that other activities might be selling out to the ‘dark side' – such as work that is commercial, non-NHS or even a ‘little dodgy'. This Government is very keen to see clinicians develop new services, so it is not going to be prescriptive and issue reams of guidance for every service you and your partners may think could be beneficial.
Seek the views of your patients. Ask them what they want from your practice beyond the obvious instant appointments with the GP of their choice. Ask them about additional services they might be interested in – you can do this easily through your patient participation group – and ask them to design and distribute a questionnaire or design your own.
You can also ask your staff and discuss ideas with your colleagues. You may find there is a service that isn't being provided but is needed. Or there may be a gap in the market or a way to improve a service with cost benefits that you can share in.
The GP contract does not reward practices that currently provide lots of in-house care, but this situation is likely to change. I predict CCGs are going to be looking at prescribing and referral rates – peer scrutiny with increasingly sharper teeth. It is also likely the GP contract will be redrawn, and the Government is interested in rewarding those that provide high-quality outcomes.
Keeping list sizes high and staff costs down, giving patients whatever they ask for, making a lot of referrals, and allowing the overspill from lack of appointments to go to A+E and walk-in centres all produce higher profits. But not only are they demoralising to general practice, they are also unsustainable.
With a generalised rise in costs, practices need to evaluate the most effective way to provide quality care. For example, pharmacists working in local medicines management teams can perform hypertension clinics on behalf of GPs, funded by PCTs – cutting costs to practices.
Likewise, voluntary agencies and PCTs sometimes provide a counsellor, sexual health or health promotion adviser at no cost. I am surprised at the resistance of some practices to take up these opportunities. There should be little complication involved in inviting third-party providers to your practice, as long as you make sure they comply with your practice's health and safety guidelines. The costs are those of servicing an often empty room.
Developing a truly new NHS-funded service in your practice is hard work, but can be interesting and could provide valuable enhanced care as well as a profit. Once you have decided on an idea, discuss it with colleagues in your CCG. I suspect most will be surprised that a practice is proactive. There is a risk that someone may steal your idea, but I suspect most will not have the motivation to do so. It is also worth identifying a leading manager in the CCG structure – someone who gets things done and gets other people enthused.
Most CCGs have not yet seen the potential of using any qualified provider (AQP) as a means of commissioning a service, nor have many got their head around redesigning services. This provides an opportunity for you to develop an idea, although you will have to be determined and patient. There are steps to go through to get a service accredited, and they are outlined in the guidance documentation that can be found in my earlier article on AQP.
In the early stages, it is about being proactive in encouraging the CCG to look at your idea and consider it. Alternatively, you could wait until CCGs put services out to tender through AQP or other commissioned service and bid for them. Unlike AQP, succeeding in a competitive tendering process is quite difficult for GP practices that, in the main, will not be used to writing bids and have no track record. However, partnering with an experienced organisation – a large private provider or a foundation trust – is a excellent idea, as this combines their experience with your local links. If you the bid is backed by your patient
CCG-commissioned services are rarely going to be ‘quick wins', but they do represent an opportunity to develop a useful and sustainable service with a potential long-term income stream.
Action points
· Get rid of obstacles to pursuing new opportunities to provide NHS services.
· Consult patients and staff on what ideas they have for new or improved local services.
· Share your ideas with the CCG or prepare to tender for commissioned services.
Click here to read the third article in the series, 'Setting up non-NHS services'.
Dr Paul Charlson is a GP in Cumbria
