Consider the wider issues
In the current climate, practices often need to balance workload with financial viability by considering new services. Although evidence and ethics are pivotal to the services delivered by any healthcare system there are other issues to consider.
This LES may bring in patients for NHS health checks but will also provide a valuable opportunity to deliver other NHS services – from QOF reviews to flu vaccination in at-risk groups.
There needs to be a clear understanding of the position taken by each party and of both the potential benefits and the consequences of accepting or refusing a voluntary LES.
If there is any reference in the partnership agreement which clarifies decision making in such a situation then that should drive the next steps.
In the absence of a partnership agreement reference the practice will need to consider the dynamics within the partnership if decisions are made without unanimous consensus.
One compromise might be to retain the new funding for the partners that do engage with the LES but this could create issues around use of practice staff and premises which will be resourced by any partners that have opted out.
Ultimately the practice has to reflect on its ability to deliver the service, the revenue it generates, the benefits its patients and carers may get and how much stability in terms of finances, workforce and estates this opportunity will bring, and whether it may be commissioned elsewhere for the practice population if not accepted by the practice.
Dr Mohammed Jiva is a GP in Middleton, Manchester, and secretary of Rochdale and Bury LMC.
Consider an internal opt out clause
Conflict of interest problems are well recognised in clinical commissioning. However, this is ‘conflict of role’ situation and issues can become unduly polarised whenever ethics versus cash considerations arise.
The practice must address the request solely in its role as a provider. The services ethos that ‘the client may waste as much of my time as they can afford to buy’ applies.
As LESs have been offered at a remuneration level that does not match the input and expenses incurred by practices, an accurately-costed business case must determine the best interests of the practice by partnership/business law definition.
The practice could consider allowing an internal ‘opt out for ethical reasons’ clause. This might be already present in the practice agreement – or could be inserted by mutual agreement where a consensus exists that the dissenter´s view is a sincere decision of conscience.
Of course this has to be counterbalanced by the dissenter not participating in the distribution of the LES profit.
Where a majority in the practice does not agree that ethical principles apply to the proposal and the business case indicates the activity is financially beneficial, there may be grounds for formal sanction of the dissenter for failure to proceed in the business best interests of the practice as per the practice agreement.
Where internal discussion does not produce a consensus, external mediation of the discussion is advised in advance of any formal dispute process.
The local medical committee will be able to provide or recommend skilled negotiators to aid resolution – as well as access to GPC/BMA ethics committee guidance.
Finally, it is worth remembering that it is consistent to deliver the service as a provider yet also to lobby for its cessation as a commissioner – the ideal antidote to the ‘conflict of interests’ criticism.
Dr Andrew Mimnagh is a GP in Liverpool and former chair of Sefton LMC.
Set aside some protected time to explore the issue
It is a normal part of human relationships for matters of principle to emerge as a source of discord; handled well, this can actually help to improve relationships and future working, handled badly and there is the potential for disaster. The partners should try to disagree without being disagreeable, and the dissenting partner should be listened to with respect (even though her opinion has financial implications).
The practice may decide to set aside some protected time to explore the issue. As this matter involves money and workload (the commonest sources of partnership strife), it may be sensible to bring in a third party to facilitate – people are less likely to exhibit challenging behaviour in front of a stranger. Reasons for the partner’s stance should be explored and any evidence which would help her change her mind should be available. If she remains implacable, then it may be possible to look at a way of working which allows others to deal with this, while she contributes in a different area. If there is a deed of partnership, it may be necessary to refer to the clauses relating to dispute resolution.
If no agreement or compromise can be reached, then the partners will have to consider whether risking relationships within the practice, or even the very future of the partnership, is worth the additional income which the LES may offer. As with all LESs, the practice must look beyond the gross income which might be generated and make a careful calculation of the net profit after all expenses have been considered.
Dr Tony Grewal is medical director at Londonwide LMCs.