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How to survive a sudden drop in income

Business expert Dr Junaid Bajwa explains the checklist of advice he gave to a PMS practice facing a shortfall of £80,000 after their contract was renegotiated

A PMS practice with 8000 patients has had its PMS contract renegotiated along with other PMS practices in the PCT. They were told this was to improve quality standards within the contract and add value for money, but equated to a loss of £80,000 of core and additional service funding.

The practice wanted help in looking at ways to maximise income and reduce expenditure – this is the checklist of potential areas we gave them.

1. Register more patients

It may sound obvious, but many practices are hesitant to actively pursue new patients due to the fears this will impact on existing patients and stretch resources. However, most recent PMS contract renegotiations have meant you are paid equally for new and existing patients.

With new Darzi centres/polyclinics opening on your doorstep and the government's proposal of abolishing practice boundaries, competition will only increase. Also, the future polysystem commissioning agenda raises the thorny issue over practices list size making a financial difference. If you start losing patients on top of a reduction in your PMS baseline funding, a perfect storm may be brewing.

Think about extending your practice boundaries and maybe keeping on patients that are moving out of your boundaries.

Points to consider:

  • Review your registration process – could you be more flexible and make it easier for patients to register?
  • Market your practice - is your website fit for purpose?
  • Put adverts in the local newspapers, form relationships with your local estate agents leaving practice leaflets with them to give to incoming house owners or tenants.

2. Maximise QOF income

I am sure most practices try hard to achieve as many points as they can, but often the same is not true about improving the prevalence rates in the disease indicators.

QOF payments are now adjusted according to true prevalence. Some practices have increased their QOF income by up to 20% purely by aiming to get disease prevalence to national levels.

Make sure all clinical and administrative staff have had the appropriate read code training. It is shocking how bad practice can become the norm, it is often best to get an outside view with external trainers such as insight solutions ( or in-house EMIS or INPS Vision trainers. It is also important to carry out appropriate searches and audits using CHART or MiQuest ( to improve the yield of patients that should be on disease registers.

3. Sign up for appropriate LESs and DESs

Make sure you have a full list of all enhanced services. Some may not be appropriately funded or may require too much work for what the potential rewards may be.

4. Make sure your are claiming for all work carried out

If you carry out minor surgery, or carry out IUCD or contraceptive implant insertion, make sure there is an appropriate paper trail to account for all work done.

Many PCTs give bulk payments to practices on a monthly basis without any obvious breakdown. When helping one practice we found that they had not been paid for their extended hours, DES or MMR catch-up LES.

Be absolutely clear about payments due and do not be afraid to phone the PCT finance department on a daily basis until you get answers.

5. Maximise private fees and income

Many practices we have worked with have had either no or very minimal charges for even quite complex medical insurance reports and in some cases such charging was inconsistent.

Check out the latest fees' guidance from the BMA and also ask what other local practices are doing. Make you have a strict system for checking that payments have been made and done so in good time.

6. Use your premises more efficiently

It is not actually illegal to use your walls for advertising for private companies, ideally use companies that may benefit your patient's health in some way.

If you own your property think about subletting your rooms to other health professionals.

7. Review partners' drawings

Partners' drawings and the make up of the partnership must be reviewed. I would encourage partners to set up ‘away days' to have transparent discussions regarding any partner specific issues.

Points to consider:

  • Are any partners about to retire?
  • Do any partners want to cut down their sessions?
  • If the whole time equivalent (WTE) will remain roughly the same, think about reducing drawings, think about keeping PGEA - post graduate education allowance -(if you still get it) within the practice accounts
  • Do not draw current accounts down to £0, but leave the money in the practice
  • Think about temporarily stopping sabbaticals and cutting annual leave if entitlements are generous.

8. Review clinical staff costs

Staff costs are the single biggest drain on practice profit. The number and skill mix of clinical staff is a tricky issue - you want your staff to work smarter and more efficiently with the minimum number of staff required but you need to maintain patient satisfaction in a competitive market.

One practice we worked with had an HCA leave. Instead of a replacement, they invested in a ‘surgery pod' - a computer suite that allows patients to record biometrics such as weight, height and BP and fill in surveys such as new patient health checks, pill checks, asthma reviews.

The system was linked to EMIS/INPS Vision to store the information and they found much of the work of an HCA or nurse and QOF work could be done by this machine and money was saved.

Points to consider:

  • Look at what kind of service you want to provide, then decide on how you are going to do it
  • If a salaried GP is leaving do you replace them? If so, do you replace them with a nurse practitioner? Which is cheaper?
  • Do you have to make redundancies? How do you decide who goes?

9. Review use of receptionists and backroom staff

You need to be absolutely clear on what the roles and responsibilities are of admin staff and what they are actually doing on a day to day basis.

A practice we worked with had to let go of two receptionists - they installed software called ‘Patient Partner' ( which allowed patients to book appointments via an automated telephone system 24 hours a day.

They also set up ‘EMIS access' ( which allowed patients to book appointments and to request repeat prescriptions online 24 hours a day. Despite less faces on the front desk, patient satisfaction went up and the practice saved money.

10. Outsource HR and payroll

There are many companies who could do this for you for a reasonable rate including local acute trusts. Does this make sense from an economies of scale point of view?

11. Review utilities and suppliers

A systemic approach to reviewing this can lead to thousands of pounds worth of savings.

Try to get a better deal with existing providers, change provider or think about joining up with other practices to bulk buy supplies and achieve economies of scale.

12. Utilise other organisations or businesses

If you think about refreshing your practice leaflet or website professionally, think about having sponsors to make up some of the funding. This can be from local businesses, but some practices we work with had contributions from local charities and third sector organisations.

Dr Junaid Bajwa is a GP in Greenwich, south-east London, and healthcare consultant at Prospect Health –

How to survive a sudden drop in income