Dr Michelle Drage highlights five areas where practices can take practical steps to secure their future between now and 2013.
If we fast-forward to 2013/14, we are likely to be operating in a very different environment, and it is key that practices prepare now for that change.
Whether you are in England – where the proposed changes to the NHS are likely to lead to radical change – or in other areas of the UK, GPs are and have to remain the advocates, gatekeepers and navigators for our patients.
However, we are likely to be doing this in an environment of even greater public scrutiny, reduced funds, potentially enhanced performance monitoring and, in England at least, growing private-sector competition.
This means that practices have to begin to ensure that they have the procedures in place to secure their future. Here, I will go through five of the most important areas for practices, or as I like to call them, the five ‘Ps'.
1) Partnership agreements
Do you have one, and is it up to date? Practices are highly vulnerable if they don't have a proper partnership agreement where there are two partners or more. This is particularly true when a partner joins or leaves, or there is a long-running dispute between partners.
At Londonwide LMCs we have seen a case where a partner was expelled from their partnership after taking 24-hour retirement – even though they had a verbal agreement from their partners that this was acceptable – all because there was no signed partnership agreement to provide for that.
Disputes may include perceived income differences, workload, ways of working, consultancy styles or simply personality clashes, and all of these situations can be exacerbated if you do not have a current partnership agreement.
In these situations, PMS practices are particularly at risk as legally their contract is with individual practitioners and not with the partnership as a whole, as is the case with GMS practices.
For any type of practice, unresolved disputes that prejudice services to patients may precipitate a performance investigation from your primary care organisation. This can place the practice contract at risk, potentially resulting in the patient list being procured by another practice or dispersed via any qualified provider.
Please don't leave yourself open to such a risk. It's not good for your patients and not good for general practice. Where there is a partnership agreement, it needs to be updated every time a partner joins or leaves the practice. The PCO should be made aware of those partnership changes so that they can be reflected in any appropriate contract variations. Your LMC can advise you, so do consider speaking to it.
2) Planning for succession
When it comes to securing your contract, does your practice have a succession plan for retiring partners? It is important that you have a plan in place to ensure that you maintain a stable team and can meet your obligations as a practice.
For many practices, the best option will be to arrange to fill that vacancy with a new partner instead of a salaried doctor.
While it might seem financially disadvantageous to go down this route, a partner will more than pay for themselves with increased commitment to the practice, greater ownership of achieving targets and by sharing management responsibilities.
Succession planning is particularly important for single-handed doctors considering full or 24-hour retirement. GPs in this position need to plan ahead, take advice from their LMC and consider all the options open to them, which include:
- doing nothing apart from giving the PCO notice of retirement, which would result in termination of their contract or agreement
- taking on a partner
- merging with a neighbouring practice
- negotiating an exit strategy with your PCO.
More detailed guidance on succession planning can be found on the Londonwide LMCs website.(1)
Even if retirement isn't around the corner, consider the benefits of developing and mentoring the local talent pool among salaried GPs and locums. This is part of good succession planning – you need someone capable around if you are going to consider taking on a new partner at some point – and will also help you to grow your business.
Consider offering partnership opportunities to those eager to take on the responsibilities, without requiring the financial investment up front (naturally, they wouldn't be entitled to notional rent payments). This way, you can secure additional commitment and talent to safeguard the future of your practice.
3) Premises
Acquiring funds to improve GP premises remains a problem. However, practices do need to ensure they are aware of and can meet their basic statutory and contractual requirements (2,3,4) – for example, those pertaining to disabled access.(5)
Often practices are not aware that they have to ensure patients with mobility problems can easily access a GP or nurse.
If there are steps to get into the practice, consider installing a ramp (ideally, consulting and treatment rooms should be on the ground floor). The test here is ‘reasonableness', and this is the key to understanding how the practice meets its obligations under disability-access legislation.
If you are a leaseholder or you and your partners don't own your premises, then you may be one of the many who have no formal agreement for the premises you rent. Although this may appear to be a positive thing at first – and many practices are cautious about signing on the dotted line when it comes to leases – it could be a serious mistake.
A lease is designed to protect both parties, and without one you could find yourself caught up in potentially expensive disputes or find you are paying over the odds for service charges – or worse, paying for services you don't even use.
If a practice finds themselves in a position where they are in dispute with the PCO about space allocation, service charges, rent evaluations and so on, do seek LMC support prior to approaching the PCO to negotiate a lease.
This can be complicated if the practice has been occupying the premises for a long time, or in cases where the landlord is a third party (such as the local authority) and the PCO holds the head lease. Taking legal advice is absolutely crucial in cases such as these, as leases are legally binding agreements and practices need to protect themselves.
4) Patient power
Patient participation groups (PPGs), or patient liaison groups (PLGs) can provide practices with an opportunity to showcase their services, be a useful ally in discussions with your local commissioners of care and hold them to account to ensure that there is true patient engagement around commissioning decisions. Engaged correctly, PLGs and PPGs can help raise your profile, support good patient communication and be a helpful sounding board when things get tough.
In England, at least, patients will have increased opportunities to publicly air their views about general practice at a practice and commissioning level, and at a wider community level, via health and wellbeing boards. We have a head start with the patient participation DES this year, which is designed to promote proactive patient engagement through patient reference groups and provides funding equivalent to £1.10 per registered patient.
Even if you are starting from scratch with proactive patient engagement, you don't have to reinvent the wheel. The BMA has some good advice about making your patient liaison group work (6) and a previous article from Dr Brian Fisher in Pulse also has some good advice.(7) Alternatively, the National Association for Patient Participation has a range of resources and examples of good practice.(8)
5) Provider protection
As budgets get tighter, GP practices are going to find that their costs will begin to come under even more scrutiny. Commissioners are going to want to performance-manage primary care more closely than ever before.
In England, the Health and Social Care Bill is going to present a real potential for conflict, as the GP's role as primary medical services provider is very different to that of commissioner. If the new clinical commissioning groups (CCGs) are involved in the performance management of your contract, just like PCOs in the rest of the UK, there needs to be a strong voice for the providers of care.
Remember that your LMC is the only statutory body representing general practice and is the honest broker between GP commissioners and GP providers. With LMC elections every two to four years, eligible members of your practice might like to consider standing for election to the LMC in their locality.
You could also contact the LMC in your area and find out if they have practice manager or nurse observers. The more your LMC can represent your views, the more powerful a voice you have for your patients, yourself and your practice.
Dr Michelle Drage is chief executive of Londonwide LMCs
References
1) Londonwide LMCs. Succession planning guidance. 2008. www.lmc.org.uk/uploads/files/guidance/issue2successionplanningoctober08.pdf
2) Department of Health. New GMS contract 2003 – investing in general practice. (NHS Confederation and BMA, London 2003). Annex B;contractual and statutory requirements:84
3) The National Health Service. General medical services contracts regulations 2004;s18(1)b, s18(3), schedule 6 part 1
4) The National Health Service. Personal medical services agreements regulations 2004; schedule 5 part 1, s2, s3, s6, s7
5) Disability Discrimination Act. 1995
6) BMA. Patient participation groups in primary care. 2009. www.bma.org.uk/patients_public/ppgintro.jsp?page=3
7) Pulse. Patient participation in your practice. www.pulse-learning.co.uk/practice-business-finance-modules/patient-participation-in-your-practice-cpd-module
8) National Association for Patient Participation. www.napp.org.uk
