Practice resilience

Vulnerable practices need more than a quick fix

The project to create primary care at scale cannot hope to succeed while substantial parts of general practice are struggling with the basic problem of survival.

NHS England recognised this fact last December when Rosamond Roughton, director of commissioning, wrote to NHS England regional directors and CCGs setting out funding arrangements for support to failing or “vulnerable” practices. The letter provided details of a £10m rescue package announced six months earlier. It also set out the criteria for identifying vulnerable practices, including those with CQC ratings of “inadequate” or “needs improvement”, and those with below average QOF attainment. 

A freedom of information request this March by GP Online revealed the scale of the problem: 811 practices, more than 10% of all practices in England, were considered in need of support.

The money was originally intended as match funding, with the practices matching NHS England’s contribution pound for pound. This provision has already been relaxed in favour of a commitment of practice time in return for funding, partly as a pragmatic response to the fact that the poorest performing practices may often be struggling financially (a point underlined by a BMA report published in May), partly in recognition that unless practices invest their own time in remedial action, any financial assistance is unlikely to result in sustained improvement.

How PCC can help

PCC has developed a support programme for vulnerable practices and is in discussion with NHS England regions about rolling it out.

Other organisations are offering a basic diagnostic service only, but we believe that effective support demands a more robust approach. This should take into account all the issues affecting practices’ performance and the support they will need to develop their own capacity for self-reliance and sustainable improvement.

Sally Simmonds, lead adviser for PCC’s practice support programme, says: “CQC ratings and other measures provide a fair indicator where practices are having contractual problems or facing leadership and governance issues, but these often have deeper roots and may be symptoms rather than causes of the underlying problem.

“It’s easy to see where there are contractual issues, but the real issues are likely to be around softer skills, relationships, personalities and other factors that may not be obvious or easy to measure.”


PCC has developed its own diagnostic approach, which has been successfully trialled, covering:

  • Practice performance
  • Premises
  • Staffing
  • Patient care
  • Practice management
  • Contractual performance indicators.

The diagnostic includes a SWOT (strengths, weaknesses, opportunity, threats) analysis and recommendations for improvement.

“Our approach recognises that practices may need support in a range of different areas, and we would expect to find different problems in different practices so the support has to be able to flex accordingly,” says Simmonds.

“In some cases, we may be looking at weaknesses in administration, requiring practical, hands-on support. In others, we may need to look at recall rates or referrals and the clinical behaviours behind them.

“In all these cases, the diagnostic will provide important clues but the solution has to be to support the practice to make its own sustainable improvements.”

Recovery planning

Practices will be able to book further support visits to identify how their issues can be addressed. These will include agreeing plans to address weaknesses in leadership, workforce, training, clinical and administrative processes and resourcing, as appropriate.

But the emphasis will be on speedy, practical solutions, not theory, says Simmonds. “For many of these practices, the alternative is closure and the timescales were looking at may be a few months. Once those most at risk have been stabilised, we can help them to think about longer term improvements. For instance, are they making the most of existing sources of funding, such as QOF and locally commissioned services?

“Later we can also look at how they work with other practices to reduce costs, increase efficiency and improve the range and quality of care they provide. But to do that they have to be back on their feet. There is nothing to be gained from poor performance and still less to be gained from poor performance at scale.”

PCC is offering its support service to individual practices and to commissioners with responsibility for general practice.

For further information, contact