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When a contract isn’t a contract

Imagine for a moment that you installed a premiumrate telephone number for patients. Or unilaterally closed your list because you simply couldn’t take on any more patients. How quickly would you expect a call from your local commissioner for breaching your contract?

Trusts in England, though, appear to be able to ignore their contractual requirements with impunity.

I’ll let you behind the curtain. I’m writing this on my phone as I have a hospital appointment on press day that I couldn’t change. I’ve waited months for this appointment. The letter from the hospital says: ‘If you fail to attend without providing any cancellation notification you are liable to be discharged from our service, in line with trust policy.’

This is not a one-off. The NHS standard contract prohibits trusts implementing such blanket policies on discharging patients but as our cover investigation shows, this contractual stipulation is being routinely flouted.

Our figures show contractual changes introduced in 2016 have made absolutely no difference. The percentage of patients being discharged after a single DNA is pretty much the same.

Similarly, there has been little change in approaches to sending timely discharge summaries, or increasing consultant-to-consultant referrals, despite various diktats.

Trusts appear to be able to ignore contractual rules with impunity

The reason is commissioners are simply not enforcing the contract. We reported in April 2017 that not a single CCG had applied a sanction to a hospital trust for breaching its contract in this way. Our survey this month reveals 51% of GPs in England have complained about trusts breaching their contract, and only one (an NHS commissioner) said the CCG took any action.

Of course, CCGs know only too well the immense pressure secondary care is under and I can understand why enforcing this part of the contract is not a hill they are willing to die on when the whole system is in a mess.

But, to me, it demonstrates that commissioners still see GPs as (ironically) their secondary priority. First, these contractual changes were not some empty gesture – they were brought in because GPs are being buried under the workload dump resulting from trusts’ policies. The changes were wholly necessary and must be enforced, as NHS England confirms in our cover story. The benefits for GPs would far outweigh the effort needed from trusts to comply. The only possible reason not to enforce these requirements is that GPs’ time is valued less than that of trusts.

Second, we know that commissioners would go by the letter of the GP contract (even when those letters are unclear). As we approach Christmas, who can forget the commissioners’ heavy-handedness in telling practices they must open on Christmas and New Year’s eves.

Presumably, they are more concerned with GPs and practice staff getting those crosswords finished before Santa arrives than they are in relieving workload during the busier periods.

There is a lot of talk about integration and the system working together. Making sure trusts stop this unnecessary workload dump would be a signal that commissioners are taking this seriously.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at