The problem
Our practice, Chestnut House Surgery, was an average-sized practice in Thorne, near Doncaster. We had historically enjoyed excellent rates of satisfaction – well above average according to our 4,500 patients and the NHS Choices website. However, our practice was crammed into the back of a LIFT building in a premises designed for a single-hander and a registrar. As our list grew, so did our staff; before the merger we had three partners, plus a registrar, two nurses and two healthcare assistants to meet the needs of our population – and we were forced by space constraints to consult in our back office and the storage room. We had nowhere to see patients. Permission to extend the premises was denied and we knew that closing our list would be financial suicide.
Our neighbouring practice, Moorends (3,500 patients), had lots of space but was struggling to find staff. It had been a two-handed practice, but one partner had retired and the other was about to go on maternity leave, meaning the practice would have to be staffed by locums for six months – an untenable situation.
What we did
At the start of 2012 the senior partners at Chestnut House and Moorends initiated the merger. We began the process in July 2012 by trying to manage everything ourselves and sharing the work, but ended up hiring a management accountant with a ‘change management’ background for half a day a week. We drew up a Gantt Chart with time in months across the X axis and a list of areas of the business such as premises, IT, phones and staff on the Y axis. We then had partners’ meetings on a weekly basis during the 12-month run-up to formal merger on 1 July 2013 and continued to meet weekly until last April.
The practice manager at Chestnut House left in September 2013, but having a consultant overseeing the merger was very helpful. She had a non-NHS background, which was refreshing as she was less naïve than some NHS managers.
The key task was to complete due diligence, ensuring there were no issues outstanding in either partnership. We formed a new partnership with a new partnership agreement to indemnify each other for any issues that may arise from the individual practices.
The challenges
The merger was very time consuming; on average, I have spent an hour a day on it since we embarked on the project.
It has also been expensive for the four partners involved. Drawings had to be reduced for the first nine months, our QOF score suffered, falling from 100% to 98%, and differences in coding clinical activity caused confusion over searches for LES and DES payments.
Although we were well prepared, we felt blind-sided by a number of issues we had thought would be straightforward.
First, we took nine months to establish which NHS organisation was responsible for our phone system. After the PCT closed, no one would accept responsibility. We struggled to merge the two practice telephone accounts (and lines) into one and some patients were able to ‘play the system’ if they were struggling to book an appointment.
Second, we had switched both practices onto SystmOne before the merger, but it was time consuming to deal with the paperwork and the process for merging the computer systems has not been straightforward. Allow plenty of time if you undertake this type of switch.
Third, given that Chestnut House already had a good reputation, there were some complaints from patients after the merger. When we explained the space issues we had faced (which are also detailed in a patient leaflet) patients were generally sympathetic to the challenges of the newly merged practice. Patients at Moorend now have better continuity of care so seem happier than before.
Although we made no redundancies, another concern was that staff morale fell after the official merger date. We managed this as well as we could by running fortnightly staff meetings and trying to keep everyone informed.
Finally, the premises owners want to charge almost £6,000 to change the names on the two leases for the two surgeries. We have a quote indicating it should only cost us £750 and we are still making the case to reduce this bill.
Results
We are now all in a much better position than we were before.
The list for the merged practices is growing at a manageable 20 to 30 new patients a week. We have been able to recruit two new full-time equivalent GPs and have delegated specific areas of practice business to each of the four partners, making us better organised. We haven’t had any redundancies, although some staff have retired or moved on, and morale is now better than before the merger.
We now have a centralised call and administrative centre, which has freed reception staff to handle all face-to-face requests for appointments and prescriptions without having to field calls at the same time.
Dr Joe Firth is a GP in Thorne, Yorkshire
