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Little evidence to support move to large-scale general practice, say researchers

There is little evidence to suggest that larger GP practices boost clinical outcomes or save money, researchers have warned.

Their paper, published in the journal Health Policy, found that trade-offs and unintended consequences meant that expected benefits from scaling up GP practices were hard to see on the ground.

The findings come as the NHS long-term plan has outlined plans to mandate GPs to work in primary care networks of 30-50,000 patients.

Researchers urged policymakers to move with caution before upscaling GP practice list sizes.

The academics at the London School of Hygiene and Tropical Medicine, Nuffield Trust and the University of Birmingham found that:

  • Economies of scale from larger organisations may not outweigh diseconomies of scale that may emerge due to new more complex governance and management processes;
  • Little evidence exists to suggest that integrated care initiatives have reduced the use of services or generated cost savings;
  • Improved clinical outcomes and cost savings do not automatically result from ‘scaling-up’.

If large-scale models were to succeed, ensuring GPs felt in control of the process was key, the report stated.

‘National and international experience underlines that the engagement of GPs is essential to increase the likelihood of collaborations succeeding. For this, GPs must feel they have sufficient autonomy and influence over any new groupings,’ it said.

The report noted that over the past decade, ‘new forms of "large-scale" GP-led provider collaborations’ have grown across England. By 2017, four-fifths of respondents to a survey of GPs and GP practice managers were working in some form of inter-practice collaboration.

However until now there has been ‘limited good quality research’ on the impact of upscaling general practice, the researchers said.

After reviewing the existing evidence in detail the researchers have concluded that the expected benefits, such as economies of scale, have not materialised.

The paper said: ‘While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size.

'Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.’

GP contract negotiations are ongoing but it is expected that GP practices in England will be mandated to join networks of 30,000-50,000 patients in return for a major funding boost.

NHS England said the decision to roll out the model across England came in response to the success of the vanguard trials of multispeciality community providers (MCPs) and primary and acute care systems (PACS).

In 2017, NHS England said that initial data showed that these collaborative care networks were effective in cutting emergency admissions. 

Dr Peter Swinyard, chairman of the Family Doctor Association, said that while no practice today ‘can remain an island’ there were problems with making practices ever larger.

He said: ‘It’s very difficult to provide good continuity of care in large organisations. And it’s interesting that [the report] says that cost savings don’t automatically result from scaling up.’ 

Stephanie Kumpunen, fellow in health policy at the Nuffield Trust and the report's co-author, said that while the study had not focosed on primary care networks specifically, evidence was still lacking that the long-term plan approach would be successful.

She said: 'There’s mixed evidence. I’m definitely cautious. There isn’t enough evidence in the UK to say these will definitely work as the Government envisages.'

However she added: 'But I wouldn’t say it can’t happen. There’s a lot to build on.'

Readers' comments (20)

  • Have been calling for research into this for some time. The move to larger groups is not a natural evolution but a consequence of deliberate starvation of the traditional model. Policy makers would do well to respect the views expressed on the ground as unfortunately they often seem to be backed by emerging evidence.

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  • So why are the BMA etc backing this in the new contract, reinventing the wheel is not always best look at PCG,PCT,CCG and now all the rest, no improvement one over the other

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  • Nhsfatcat

    Good primary care has always hinged on local knowledge of people and continuity of care. Bigger is not better or cheaper in healthcare, we know it, Nuffield are showing it but it doesn't suit the government as their mates cant make a buck out of it; but never let facts get in the way of profit

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  • Risk factors for poor practice are things like clinical isolation and lack of support, not simply working in a small practice where doctors are still engaged in local education and service development. Evidence plays second fiddle to policy though especially when juicy contracts for building health centres and large provider contracts are at stake.

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  • Once we are gone there is no going back,like the OOH debacle.They know the cost of everything but the value of nothing.

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  • As a single-handed practitioner in a remote practice I’m probably a bit biased in my views! However I knew all my patients for better or worse and had overall outcomes at least as good as those of bigger practices. Could it be that we are coming full circle when in my late fathers time (he was a single-handed GP) virtually all practices were of sole practitioners?!!
    I suppose not as most young GPs could not or would not manage the workload in the primary care workplace now. Brave New World!

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  • I suspect there is evidence to state that what is needed is more GPs [J Hunt certainly staked a claim on this] over bigger practices. This knee jerk policy is yet another reason why the NHS needs to be taken out of Political control. It can then concentrate on what is needed rather than what wanted and use evidence rather than whims to create policy. The policy here is the opposite. it enhances government control and anyone at the grass root level with any nouse of sense will simply be diluted and drummed out.

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  • These are solutions designed by accountants to enable politicians to gain even more control over the health care agenda. Bitter experience has demonstrated that none of their solutions has worked to date except in terms of enriching external consultancy advisors and spawning a mass of bureaucrats who have no understanding of the importance of the doctor/patient relationship in optimising patient outcomes. Poor (absent) manpower planning coupled with initiatives for "efficiency gains" have let us to where we are now: one of the worst health care systems in Europe, failing our patients with little or no chance of recovery.

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  • doh!, could have told you that for free, oh we did - years ago. history repeats. we go big, we go small, we learn nothing at all.

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  • AlanAlmond

    Dermot Ryan've got it spot on
    it's not done to improve heath care it's done for the benefit of administrators and politicians. it makes their task of continuous resource wasting reorganisation so much easier. every few years the politicians change jobs and as sure as night follows day this heralds the next 'bright idea' which needs to be implemented. so much easier for them to do across big units- that is the primary driving force here, everything else is after the fact spin and political wishful thinking

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  • Predictable!
    Announce policy in an evidence free vacuum and hope for the best!
    I'll just add Christopher Ho's comment as he must be busy now-
    More evidence to take health out of the public sector

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  • Some are in serious trouble with poor governance and lack of engagement. It seems that even in big combines the original practices still attempt to maintain their separateness. This is without all the problems of lack of continuity and poor working experience. NHS England is aware but chooses to ignore this growing scandal as this bandaid policy is too big to fail and too big to reverse.

    A curse on all those who recommend it.

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  • When have politicians ever allowed research to get in the way of political dogma?

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  • Spot on DermotRyan

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  • business has found that the franchisee model works best and general practice is an example of this. Over the last 60 years medium sized practices have been the most stable and successful. what idiot is going to throw this out...

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  • This is not new evidence. It has been collated to demonstrate that the 'big is best' policy is not self evident and may be wrong.

    It is in everyone's interest to look carefully at the report to learn how the dys-economies of scale work. Especially those who are already trying to cope with spiralling costs in big practices and practice groups.

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  • Vinci Ho

    We should consider that this is an ‘insult’ to our intelligence.
    The model we have been running on (GMS GP partnership)is clearly the most cost-effective , at least historically , with preservation of continuity of care .
    But in face of austerity, it would appear to be ‘easier’ for politicians to control and cut cost of there were only 20 humongous GP practices in the whole country .
    Today , they are talking about a size of 30,000 to 50,000. What will it be tomorrow? 100,000 to 500,000 , easily !
    Please , give us a break, we all know where politicians want to end up.

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  • I was single handed till I semiretired. I knew every one by name and their health problems. You will never get this is large organisation. Patient hate to tell same story to different doctors each time they visit.
    I have no doubt the decision is financial but that too they will not achieve.

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  • I suppose one thing that might help is with a large organisation like this you could pass on more management stuff to managers, and you could even form your own small "union" amongst the large group of salaried GP's there willing to strike or work to rule at a moments notice, forcing decent conditions. And I must admit that that being the best outcome for this possible scenario makes me depressed beyond belief....

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  • Does political management of the NHS often seek evidence for its reforms?

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