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Gold, incentives and meh

No practice to have fewer than 10,000 patients under radical local plans

Local commissioners are planning to ensure that no practice in North East London services fewer than 10,000-15,000 patients, and will be meeting with small practices who wish to remain independent.

NHS England and North and East London CCGs have said they expect GP numbers to reduce by a third over the next few years, and have set out radical plans to ensure general practice remains sustainable. 

As part of the plans, they will offer GPs ‘golden handshakes’ in a bid to alleviate the recruitment crisis, and offer funding to support the high cost of London living.

But they will also aim to ensure that all practices consolidate to cater for minimum list sizes of 10,000-15,000.

The proposals are part of its ‘Transforming Services Together’, which sets out how it will configure primary care over the next few years and will feed in to the wider region’s ‘sustainability and transformation plans’ - the secretive blueprints being drawn up by every region in England. 

The plan said:

  • GP practices should cater for 10,000-15,000 patients or be on the same site as other practices or work as part of a network of practices.
  • Primary care hubs for over 30,000 patients should have on-site minor surgery units, sexual health clinics, a greater range of test facilities, and learning areas with access to nutritionists.

The plan also addressed issues with GP workforce shortages, saying commissioners would:

  • Work with universities and other education providers to offer courses to qualify in new roles, e.g. physician associates and advanced nurse practitioners.
  • Encourage young people to work in the NHS by connecting with local schools and other education providers, as well as develop apprenticeships and internships.
  • Introduce flexible working options and financial incentives, which could include ‘golden hellos’ or ‘golden handcuffs’.
  • Support with the high cost of London living and transport; key-worker housing; bursaries or student loans to help fill hard-to-fill vacancies.

A spokesperson for the CCGs told Pulse: ’We hope that all GP practices will see the benefit of working in partnership with other practices. By joining forces GPs can offer better out of hours support, share knowledge and reduce back office costs.

’Their patients will be able to access services more quickly and at different places without going to hospital. Most practices are already working in this way. If small practices do not wish to work in this way we will seek to meet them in the first instance to understand their concerns.’

The plan said that by 2020 there would be 58 more pharmacists, 25 more physician associates, 49 more nurses and 46 more community health service staff working in surgeries in the area.

Dr Jackie Applebee, chair of Tower Hamlets LMC warned that failure to boost GP numbers in the area would badly impact on patient care

She said: ‘It is of great concern that the number of GPs across the TST area is projected to drop by up to a third while the population continues to rise rapidly. GPs are already struggling, due to lack of workforce, to provide the services that their patients need, such opposing changes in demographics.

’Decreased GP numbers on the one hand with an increasing population on the other is not sustainable. Simply relying on changing the skill mix will not address the problem and will adversely affect patient safety. There must be a concerted recruitment and retention initiative to avert crisis.’

Readers' comments (44)

  • and the reasoning is......??

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  • more flailing about in the lifeboat- come on - its time to eat the cabin boy

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  • The reasoning is that NHS London proposed that federation was the answer.

    This was some years ago and the question has been forgotten.

    But versions of federation are now the national answer to everything in general Practice. No matter what issue - mergers and federation and you see NHSE managers use terms such as 'working at scale'. Obviously trying in a rather pathetic way to draw a parallel towards 'economies of scale' found in manufacturing plants etc

    But the scary thing is that this is the aim of NHSE.

    The important thing to remember is that there is NO evidence that this improves care or reduces cost - probably does the opposite.

    This is an ideological mantra for NHSE

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  • accountants i have spoken to are reporting that these at scale federations are actually proving less profitable because of all the managers running around

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  • Change career. Only answer or retire. Worse is coming as the public get more disgruntled and complain.
    GMC visits for GPs will be yearly adventure.
    Good luck. I am leaving had enough

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  • I find it fascinating that we are all told to offer 'Choice'... but when the patients tell us, repeatedly, that they like small practices, suddenly the concept of 'choice' is nowhere to be seen.

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  • Choice is like "The free market","The weekend effect"etc, terms that are only used selectively when it suits politicians aims.

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  • "If small practices do not wish to work in this way we will seek to meet them in the first instance to understand their concerns"

    I find this sort of thing ominous and controlling. I am trying not to say Orwellian of course.

    How about "if small practices do not wish to work in this way then we will leave them the heck alone and let them get on with it and work to their own strengths and professional values"?

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  • Perhaps the other answer Anonymous GP Partner 11:44am is to leave them alone and just let them die out. The model of small independent practices ended with the last century. Its not sustainable and GP trainees have said they don't want it.

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  • NHS Manager 11:56 "Its not sustainable and GP trainees have said they don't want it".
    That's the sort of baseless bullshit that is managing us. My 5500 patient practice is one of the most cost effective practices in our CCG locality and we have had no problem replacing retiring partners or nurses in the last few years. So it is sustainable and GP trainees do want it.

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  • @Manager 1156:

    I wasn't necessarily saying I felt small practices were a good idea or a bad idea. My point is that it is for individual practices to decide what works for them and their patients, and to be allowed to keep their own house in order (as beautifully illustrated by GP Partner 1220). Interference is stressful and harmful. Support is good as long as it is a) optional and b) non-prejudicial. You should never set out to "support" someone to change their mind. That's not support, that's brainwashing.

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  • I have already left my partnership. I am salaried but ready to locum if even that gets too onerous.

    I have enough savings to fund a few years of gardening leave till I can take early retirement. Push me and I will go, along with quite a few others.

    When I left my partnership I wondered if I was doing the right thing, it seemed such a drastic leap. I now realise I was prescient in my action.

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  • CHEAPER CHEAPER CHEAPER
    THAT IS ALL TO IT. THAT WILL BE DONE UNDER PRETENCE OF IMPROVING PATIENT CARE. WHO CARES WHAT PATIENT THINKS OF SMALL PRACTICES

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  • The interesting thing will be how his will be funded.

    If it is a block contract - I would run a mile away. The costs will increase exponentially as he population get older and more demanding.

    This is where we are stuck at the moment - essentially a block contact for general practice - with ever increasing demand

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  • Shut down small practices so patients have to travel out of their community but if patients can't come out of area, then the friendly GP with a 'duty of care' will simply do a home visit across town....

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  • The crisis cannot be averted because there are not enough trainers.

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  • My view is that the drive is towards a fully salaried system. Even though the five year forward view is to move care into the community most of the work will be done by nurses paramedics and physician assistants with much more involvement of community pharmacists. The Family Doctor role will disappear into one of care co-ordinating and fire fighting demand.

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  • Vinci Ho

    We all know one plus one are two ; two plus two are not four , sometimes three , sometimes four , remember that ?
    Two practices merge together with more presumed 'efficiency' and hence total budget can be reduced even more . No new money, full stop. The old recurring question:where will the money saved go?

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  • We seem to have lost sight of the fact that the 4-5 GP/c.10k patient practice model is (was) actually very effective at managing usage. Not demand of course, that's almost impossible to manage. But when you know your patients and especially your high usage ones, you can help in ways that are just not open to the anonymous mega-practice style of medicine.
    Are the fabled economies of scale at best transitory and at worst a total mirage?

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  • 12:39 - Likewise, it felt courageous at the time, when I left. That was 2001. Never looked back.

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  • The whole proposal for scaling up is unscientific and poorly constructed. People who come up with these proposals should be sent back to training courses in health economics and business management. Scaling up in Primary Care and merging sites will not reduce the need for GPs. This will remain at a minimum of one GP per 1900 patients. To manage additional workload being imposed on GPs, we will not only need more GPs but also alternative workforce (such as Physicians Associates and Clinical Pharmacists). There is nothing in the current UK workforce development strategy that will build the required capacity of GPs and allied professionals in the next 7-10 years. Even staying in EU will not solve this problem. Meanwhile, our so called experts on transformation and change management will keep on bullying GPs and Practices to accept their new messy models and bringing chaos to the health care needs of the population. There is significant evidence that large practices have poor clinical outcomes as compared to small practices. Many in the health care system believe that the current policy of the government is to bring in disruption to the system and force privatisation on the back of failed GP led system.

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  • Is there any evidence that practices of this size are most efficient?
    How do you measure efficiency?

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  • Anonymous | GP Partner20 Sep 2016 12:20pm
    "NHS Manager 11:56 "Its not sustainable and GP trainees have said they don't want it".
    That's the sort of baseless bullshit that is managing us."

    Not baseless - Suggest you read the BMAs 'Future of General Practice Survey' from 2015 which states only 27% of salaried GPs and 29% of GP trainees want to become partners or contractors. Who's going to take on small GP practices if 70% of GPs aren't interested in that model of working??
    https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-surveys/future-of-general-practice

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  • Anonymous | GP Partner20 Sep 2016 4:16pm
    Is there any evidence that practices of this size are most efficient? How do you measure efficiency?

    Larger scale has the potential to sustain general practice through operational efficiency and standardised processes, maximising income, strengthening the workforce and deploying technology.

    http://www.nuffieldtrust.org.uk/publications/bigger-better-lessons-large-scale-general-practice

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  • @Anonymous | NHS Manager20 Sep 2016 5:17pm

    Yes, but it doesn't suit everyone does it? That's the point - if you're a thrusty business orientated city GP then go for it - fill yer boots - bigger is better, baby.

    If you're in a quiet rural practice you may prioritise other factors such as continuity, stress, patient satisfaction, logistics etc.

    It is not appropriate for group A to tell group B they are doing it all wrong and must change.

    Horses for courses, as they say.

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  • NHS Manager, I have just read the Nuffield link and the conclusion was;

    "In light of these findings, the authors argue that policy-makers and practitioners should be realistic in their expectations of the pace at which large-scale organisations can contribute to service transformation".

    I do think Jeremy has been brainwashing you.

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  • Re NHS manager's comments - perhaps the policy makers should ask themselves why this is the case and fix it instead of selecting stats to force through their own agenda. It's the management and other external elements that have changed, not the essential work.

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  • "learning areas with access to nutritionists"

    hahahahahahaha!

    All we need is a bunch of nutritionists to resolve the GP recruitment crisis.

    It just gets better

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  • absolute insanity purely imbecilic dogma to make short tern financial savings creating long term much higher costs in the system.
    no evidence base
    plenty of evidence moderate sized partnerships provide the highest quality most cost effective care
    much evidence that patients are EXTREMELY unhappy with poor continuity and personal care in large gp factories..and certainty patients will be FURIOUS if this proceeds without consent.

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  • logically why stop at 10,000 ?

    if u want scale - why not go to 65 million and base it in Manchester - i know who'd i'd volunteer to staff it.

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  • I feel sorry for the small practices - the days are now over where wife / uncle / aunty can no longer be Practice Managers of their cottage industry.

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  • "Larger scale has the potential to sustain general practice through operational efficiency and standardised processes, maximising income, strengthening the workforce and deploying technology."
    NHS Manager - Amazing that you can trot this out. Would you like to be treated with operational efficiency and standardised processes? Really?
    In addition, if you'd worked for long enough in a commercial environment, you'd know that these merger efficiencies often do not materialise. Not least because larger entities require more managers and overhead cost.
    Unbelievable.
    I shudder to think how you will react when you or your loved one is treated with a standardised process.

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  • How is going into schools going to help recruitment into the NHS? We can't recruit as conditions are horrendous and will only worsen. The junior doctors dispute is evidence of this.

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  • My MBA thesis covered the culture of GP practices . This has continued to interest me. Gold award to any CCG that can change this key item in any federation.
    If self interest and higher profits drive big practices, this is also the case in small practices..I would love to see sharing caring when 2 partnerships have always competed and by some slagging .

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  • Joe Mcgilligan | GP Partner20 Sep 2016 1:39pm

    That is certainly what NHSE see as the future.

    But it is unlikely to happen - even very good NP's and PA's struggle with simple medical cases.

    The medical legal cost goes up exponentially - at the moment solicitors have not targeted mistakes by nurses as there is always a supervising doctor on paper. If that changes which it will then any mistake will get legal minds asking - why wasn't more expert opinion sought immediately.

    Get the first PA or nurse being sued aand the whole construct will disappear.



    One of the pioneer practices for Nurses practitioner has now stopped using them after working out they were more expensive per patient seen!

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  • So our Governments which have always gone on about choice is now limiting our choice to large group practices and gone is the choice of registering with single or dual GP practices. I, in Worthing, registered with the nearest surgery which had two GPs and the local Clinical Commissioning Group (CCG) has since closed it down and told me to register elsewhere so I registered with the next nearest practice which has about 8 doctors although I have been given a particular named doctor whom I have not yet met. I asked the CCG why they closed down my nearest 2 GP practice but they have not replied so their much vaunted public engagement strategy is in tatters. They said in their invitation to register elsewhere that they had no choice but that is not an explanation. I want to know whether the list of patients was too small to attract applicants to take on the practice or whether there was no hope of finding any replacement GPs or whether they were so incompetent they did not know how to advertise for replacement GPs. If the UK is failing to recruit and train GPs (thus ruining a profession which was largely self replacing) then the CGG must advertise in the EU Medical Journals to attract a wider pool of applicants. But they must hurry because we, due to nonsense, fibs and ignorance, are going to leave the EU so that avenue for recruiting and training GPs is going to be closed off. I would abolish the commissioning function of the NHS for its incompetence in practical, clinical, and commercial matters: they could hardly run a piss-up in a Brewery and have not, despite garnering an increasing share of the NHS budget, benefitted the patient or the NHS or the taxpayer.

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  • 12.20
    Our 6000 patients rated us higher than most practices. We are most cost effective and perform better than most in other measures
    We had no issue recruiting.
    In fact locums say it is awful in the large practices

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  • History of general practice shows poor quality care in large health centres ..some small practices are bad but that is inner city issues and poor training

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  • It's the number of patients per GP that is important, not the size of the practice. The "ideal" list size used to be 1500 and should now be lower given the amount and complexity of illness being managed in primary care. We are currently 1900 and rising.

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  • Practice manager; 3:16
    Well said
    I think we are missing the point here
    Not only do we need more GPs, which is not achieved by merging practices, we also need the same if not more management
    As a population gets older and more complex the administration to manage their care gets more onerous and complex... Reducing management is a false economy in primary care. Not only that the only solution to reducing management costs is to reduce the demand on management in reports, and submissions and claims and.... The rest

    Also
    Let's not forget the statement " that we are preparing for a reduction in GPs by a third"
    And also let's not forget the other pulse article where a surgery of 18000 shut down as they were unable to recruit GPs... Not management as I understood

    So the bottom line is that the only solution, prior to how you strategically place practices ( regardless of size), is the training, recruitment, retention and recognition of GPs. Value, support, recognition, positive personalised supervision, personal health support (physical and mental), lifelong accessible/personalised training, career progression, the list goes on and on....

    Primary care is bleeding and the wounds are wide.... I know what a surgeon would say. You are going to die unless is stop the bleeding and close the wounds......

    My heart goes out to all battling in primary care and the wider NHS....
    Good luck wherever you are. The public needs us more and increasingly every day....

    P;)

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  • I believe this model of serving a large community with specialist services already exists, it's called a hospital. Maybe if they hadn't closed so many community hospitals, which patients liked, used well and which took pressure of acute service, GP services would be able to deliver primary care.
    I fear that soon we will have just four hospitals and GP practices one for North South, East and West of the country.

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  • coming soon - No practice to have more than one GP.

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  • When I became a GP in 1977 I was proud of my career choice
    But now
    • no emergency work or care of the dying
    • no freedom to prescribe the best treatment of patients
    •work with physician assistants doing the same work ( don't shit me you know it's true and with advanced nurse practitioners it most definitely is true )
    •plumeting respect from everybody
    . No street cred
    I would rather die than be a GP today
    Young doctors are not stupid the job stinks
    Recruitment crisis my arse
    Years of not having balls has destroyed General practice
    RIP a once proud profession

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  • This had exact parrallel's with the transformations of high street banking a few decades ago. Weekend working, branch closures, staff redundancies, dumbing down of processes and staff skills. The baank did it to make more profit, NHS E are doping it to plug a gap caused by their own inept management. Is anybody asking the "customers", patients, what they want? There is no doubt that the personal service provided by small practice is much loved even if stretched.

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