Ten years ago, when I was eight years into my consultancy role, the most common question I was asked by practices was: “How can we maximise income?”
Now the most commonly asked question I get is: “How can we reduce workload?” But practices are still keen to know how to increase their income, and what steps they can take to bring in more money.
Waiting lists are crippling, there’s a devastating lack of staff and GPs are completely overrun. So how on Earth can they find the time and energy to make more money?
Don’t agree to a £20,000 project that will cost you double that to deliver
Very often, the Integrated Care Board will turn to the practices and announce, with very little notice, that they have a pot of money to spend. For a share of it, the practice will need to quickly come up with a proposal for what they would do with, say, diabetics or mental health patients or wound care patients.
Then, with scarcely a thought, the practices, the Primary Care Networks (PCNs) and the federations will leap into action and start writing proposals because there’s some money on the table.
And that’s where things start to go wrong. Just recently, I’ve had instances of networks and federations coming to me because they’re drowning in work and struggling to function effectively.
When I dig into what’s going on, they will tell me they’ve got the opportunity to bid for £20,000, but nobody has bothered to work out if they can actually deliver the project in question for that amount of money.
They will have written a brilliant, detailed project outline and then when you read it, it emerges that it will cost them £30,000 or £40,000 to deliver all the work they’ve now committed to.
The needs of the patient must come first
I work really hard on maximising income. First and foremost, we want a good service for the patients that is easy to deliver but we want a small profit in the delivery of that service because we have to keep practices viable. There’s a lot of overheads and staff costs which need to be covered.
The first consideration when a network or federation is approached with any project or idea is does it significantly improve the patient outcome over where we are right now. Because if it doesn’t do that, there’s no point in proceeding.
The next thing I would want to know is, as a result of implementing this project, is it going to reduce GP and practice workload. Releasing pressure is the absolute holy grail right now. If it doesn’t, then again stop there.
If we’ve got two ticks in the box, the third consideration is what the project does for your income. Is it going to put it up, send it down or will it have no impact on income but might improve outcomes and reduce workload?
Ideally, the income wants to be going up but that doesn’t always have to be the case, especially if there’s a big workload release. That said, there is very little appetite for having less income because general practice is already struggling through a lack of investment.
The fourth and final consideration is the most important – have you got the workforce available to deliver the project? Or can you bring in a workforce that will be able to deliver this project?
Try to think of an innovative way to get the project done. Could it go into enhanced access? That’s Monday to Friday, 6.30pm to 8pm or a Saturday between 9am and 5pm. Would that make the project easier to deliver?
Could you use some of your access and capacity money – the £246million broken down into 12 monthly instalments to every PCN? Could you put on extra clinics and use some of that to entice a workforce to come and deliver a particular planned care project? But the project must fulfil those four criteria.
The ‘hidden’ patients who can come back to haunt you
There is a lot of opportunity in what I would describe as suboptimal treatment now. Let’s be clear, no healthcare professional sets out to deliver treatment that is not optimised. But we have to keep in mind that quite often, the evidence base changes and moves over time.
What was seen as gold standard treatment three or four years ago, could today be viewed as suboptimal and yet there are still lots of patients on it because their treatment has not been reviewed during that time.
If you go back to the pandemic, we had everybody rightly focused on dealing with it and getting people vaccinated so we could get back to what we would describe as normal life. During that time, lots of patients who would have been seen as a matter of routine, their treatment followed up as part of their annual quality and outcome framework review, were not seen.
These patients are hidden away – until they feel unwell and then they come back and start to fuel the workload. They have events, strokes and heart attacks that result in them being non-elective hospital admissions. If their care had been optimised that might have been avoided.
Four categories of patient – could your project help one of them?
I’m working on projects right between general practice and hospitals, where we’re looking at the patients who tend to fall into four categories:
- Diagnosed but not on any treatment. They might have started on treatment a long time ago but would have not taken to it, stopped taking it and were never followed up. That puts them at risk of having a potential event or their condition continues to decline, and they then need access to general practice and more care.
- Diagnosed but on the wrong treatment. They’re not up to date, they’re not optimised. They’re on treatment that was the gold standard previously but now isn’t.
- Diagnosed, on the right treatment, but only on the initiation. This group have not been titrated the way they should have been, hence suboptimal treatment.
- Should have been diagnosed but haven’t been. These people have never had any work done on their case and they’ve never been diagnosed or treated.
You can focus on these groups – which of them, particularly the long-term conditions groups, would it be good to work with, get reviews done and create projects and clinics around? As long as they pass the four filters, they’re worth following up.
I'm working with some wonderful projects right now in things like allergic rhinitis and suboptimal allergy treatment, where no diagnosis is the issue. I’ve got some great projects in heart failure, chronic kidney disease, diabetes, asthma, COPD, lipids, cholesterol treatment, oral anticoagulants, women’s health and wound care.
There’s a whole list of great projects in mental health, all of which improve the patient outcome and reduce the workload through fewer appointments, referrals, and admissions.
Most of them will do something to increase income and there are some great ways that we can create the workforce.
These projects are a fantastic way, not just of maximising your income, but making sure that the projects you take on do more than talk about income – they actually address the biggest issue that we have right now, which is the workload in general practice.
Scott McKenzie helps GPs, PCNs and GP federations build sustainable and resilient practices and organisations that thrive.
