M Word - Issue 22

I have three resilient and empowering things for you. The first is meant to be reassuring; the second is to urge you to hold fast to the values of general practice when you form your networks, federations or mergers; and the third is to inform you further about co-commissioning and to encourage you to seek as much clarification as possible when asked to decide on matters which can affect your contract and livelihood.

1. We are here for you in these toughest of times
2. We are here to see that general practice in London thrives
3. We are here to guide - essential information on Co-commissioning

You can find more resources on resilience and healthy challenge on www.gpresilience.org.uk. We have developed a set of proforma letters that you can download and use to challenge inappropriate requests and transfer of work to your practice. Don't forget that you can also download our patient-facing posters for your waiting rooms. As well as this you can be resilient and challenging in our Facebook group GP Resilience – Take Control or you can access all of these via our main website and our Londonwide LMCs' iOS app.

As always, any thoughts or comments you might have are very welcome and can be emailed to mword@lmc.org.uk or post them to our GP Resilience Facebook group.

Dr Michelle Drage MBBS FRCGP

Chief Executive

Londonwide LMCs

1. We are here for you in these toughest of times

If you've managed to find a few moments amongst all your frontline pressures to read this then I am full of admiration and hugely grateful to you for recognising that Londonwide LMCs’ communications are the ones worth opening amid the flotsam and jetsam of NHS and CCG bureaucracy. For no other organisation has your direct interests as GPs at its heart. 

We know exactly just how much pressure you are under, and we understand your daily frustrations with the unprecedented demands on your personal and practice resources. But we, above all others, also know precisely how much you give to your patients and to the NHS, both professionally and personally, and just how fragile that giving has become. 

And so, with even more uncertainty ahead, I wanted to make something really, really clear and certain: we in the Londonwide LMCs family are here for YOU. Here for you as GPs, whatever your contractual or employment status. And here for the practice teams you work with, the nurses and other staff on whom our vocation as expert generalists - yes I’m using the V-word in the M-word - depends. Please contact our GP Support team on gpsupport@lmc.org.uk if you need advice on any matter of concern to you as an individual or as a practice.

2. We are here to see that general practice in London thrives

General practice does not exist in isolation from the rest of the NHS, but our philosophy can be quite different to the rest of the NHS. We value whole-person care; we tend to take a ‘less is more’ approach to investigation and diagnosis, and we place high value on the social determinants of health. Above all, our patients value us for being the guardian of these things through our uniquely British registered list arrangements, and our independent role to be their advocates. 

If you, like me believe these are bottom-line values to be nurtured and cherished, then we all have a duty to make them visible and embed them in whatever new model of general practice we, or others, devise. 

We state these values very clearly in our Securing the Future of General Practice in London documents. They must not be lost in the new-found interest in integration from all comers and pretenders. We GPs and our teams, along with our patients and potential allies in the other under-resourced community-based services, know all about integration. Ask yourself and your patients which model of integrated care is more likely to protect these values – a hospital trust-led model (primary and acute care provider), a multi-specialty (the clue is in the S-word in the M-word) community provider, or if none of these, what else do we want to see happen? 

Meanwhile, ask yourself, "Are these values embedded and clearly stated in any network or federation I am involved in, or any vanguard bids?" and, make sure you know in which direction these are going, whether they protect your core funding, attract enhanced practice funding. Also, check how sustainable is any such funding and what the rules and workload are. Resilience is just as important when forming GP provider organisations as it is with commissioners.

3. We are here to guide - essential information on Co-commissioning

Co-commissioning means formal shared decision-making between your CCG and other commissioners. Your CCG will currently be asking you to vote on proposals to co-commission with the NHS England London Regional Area Team – the people that commission and manage your core contract. 

As all the levels (there are three) of co-commissioning involve some degree of shared management of your core contract by your own CCG with the Area Team, in voting you must ask yourself whether the level of co-commissioning proposed presents you and your contract with more or less risk and hassle than doing nothing. If your CCG is asking you to vote on level 3 co-commissioning with the Area Team, you must understand that this involves your CCG in full performance management of your core contract. 

All CCGs in London are different. Understand precisely what is being proposed to you, challenge where you are unclear, and vote wisely bearing in mind that co-commissioning might also enable your CCG to commission better things for you and your practice by opening up a semi-permeable membrane between secondary care and primary care resources – but make sure the ions diffuse across the membrane in the right direction. Co-commissioning can, in theory – this is all theory – also enable better integration across primary, community and social services. In this case the diffusion of the ions must be ‘facilitated’. If you haven’t the foggiest idea of what I am talking about, then shame on you! But this may help a wee bit - https://en.wikipedia.org/wiki/Semipermeable_membrane. 

At this time you are not being asked to vote on co-commissioning with social services, but watch this space. There is a government short consultation out there on this, involving ‘pooled budgets’ including your core funding. If you can spare the time, you can read my argument in my Huffington Post piece about listening to London's GPs! The intention may fit with our GP values on the social determinants of health, but would the pooling of the inadequately funded social care budget and the inadequately funded GP core contract monies herald a better future for us and our patients?