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Making the most of enhanced services

Dr Peter Joliffe, chief officer of Devon LMC, answers questions on getting legal advice, potential risks and when to consider making a loss

Dr Peter Joliffe, chief officer of Devon LMC, answers questions on getting legal advice, potential risks and when to consider making a loss

Do enhanced services have to benefit patients?

This is perhaps the most important question to ask, because unless the service is beneficial to patients it will seem wasteful and unethical to dedicate scarce resources to it. Most clinical services will be beneficial, but other, politically motivated enhanced services may be less obviously so. Just because a service appears to have clear benefits to patients doesn't mean a practice should necessarily provide it, but the corollary is not true – services that will not benefit patients should be resisted.

How do we know if we are in a position to provide a service effectively?

Your decision here should be based on an the skills of your staff and take into account the impact of not providing the service. Do you have the right skill mix or would you be using a more highly paid person to provide the service than is required? Is additional training needed and would you have to recruit new staff? And are you concerned that if you were not to provide the service, somebody else would be doing so in potential competition with you?

Will we generate a profit?

This is the question that seems to embarrass so many and yet shouldn't. Unless you are a registered charity, you should seek to make a profit from the services you provide. Not all services need to be profitable but as many as possible should be if you're going to maximise income.

You need to do the maths and to be careful you add in all the costs of provision: staff or partner pay, pensions and holiday entitlement, equipment purchase and replacement, disposables, and rent and rates (if using a part of your premises not covered by any PCO reimbursements).

Don't forget to add in the opportunity costs – what could you or your staff member be doing that would otherwise generate income that will not be done as a result of taking on the service? As long as your service breaks even, it may still be worth doing it if you wish to prevent others providing it or if it is something you or your staff will find professionally rewarding.

Should we be prepared to make a loss?

It may be worth making a loss on occasion, where it will improve your relationship with your PCO. Some matters are vital to PCOs as Government must-dos and non-achievement will cause them difficulty. So, for example, the ethnicity DES is of doubtful benefit to patients, the payments are minimal and you will make a loss if you pursue the required answers on an individual basis. Nevertheless, some LMCs have agreed a LES with PCOs to help managers meet their targets. If the questions are asked of all new patients in a routine screening questionnaire or during routine chronic disease checks, the loss may be mitigated and your PCO may consider that it owes you a favour.

As we are effectively forming a contract for services with the PCO, should we ask our lawyers for a view?

Most LMCs will advise you to avoid lawyers wherever possible. In the matter of enhanced services, remember most lawyers charge eye-watering hourly fees and only a couple of hours work could eat up all the profit many enhanced services will make.

It is important to remember enhanced services are by definition outside of your practice's core services and taking them on does not alter your contractual status. If funding is withdrawn by your PCO you are entitled to cease provision of the service.

What advice may the LMC give on enhanced services?

LMCs are not protected by union law and may not advise you to cease provision of a service. But before you take on a service, it is still sensible to check your LMC's view of it. In the case of Devon LMC, when we have agreed a specification and reasonable offer of resources for an enhanced service we say so, often in a joint PCO/LMC letter to practices. If we have been consulted and are unhappy with either the specification or the resources we merely ‘note' the proposal. A PCO is able to make any commissioning decisions it wishes but it is my experience that those enhanced services that work best have been fully agreed with the LMC.

If we develop and provide a service, what future risks are we exposing ourselves to?

The main risks occur when you have recruited specific staff to undertake a new service. Enhanced services are mainly commissioned on an annual basis and as financial pressures come on PCOs, they look to reduce costs in areas that are not must-dos. Local and national enhanced services are not compulsory for PCOs and so can come under pressure. If your staff do not have transferable skills that would allow them to take on a different role within the practice (and preferably one that is profitable) you could find yourself in the position of making them redundant, with the costs attached to that process.

You could also find yourself the target of discontented patients who do not understand how practices are funded and may take out any anger for the loss of a service on you rather than the PCO.

Your LMC can help by providing a poster pointing out that the service is not part of core general practice and that the PCO no longer wishes to purchase it. Giving the contact details of the PCO chief executive might be helpful so patients can pass their comments to the appropriate place.

How do we maximise the cost-effectiveness of services?

You should conduct a review of the service as part of your practice audit. The payment alone for an enhanced service will not be sufficient to maximise your income. You need to look at all your costs and determine whether they are necessary. It may be time to consider the cost-effectiveness of branch surgeries and outlying consultation facilities. You might consider using partner and employed GP time differently or exploring whether practice-based commissioning will allow you to set up new patient pathways that bring a profitable income stream to your practice.

How do we stop providing an enhanced service if we need to do so without falling foul of ethics or the law?

If you decide for any reason that you no longer wish to provide an enhanced service, you should give notice to your PCO before ceasing provision. Very few enhanced service specifications contain a notice period but the standard notice of three months should be acceptable, and a six-month period would be unarguable, since this is the period of notice to be given on ceasing the provision of a PMS contract. It would be unacceptable both contractually and ethically to just withdraw a service without due cause.

Making the most of enhanced services

You need to do the maths and be careful to add in all of the costs of provision.

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