Insider advice: Managing small practices
As profits shrink and funding becomes harder to maintain, four experienced singlehanded GPs give their advice on sustaining business at a small practice
Don’t let people make your size out to be a disadvantage
Dr Patrick Craig-McFeely Salisbury
Our principle has been to offer everything a larger practice offers – no-one can say because we are small our patients are missing out. We offer lots of enhanced services, are open as much as possible, have same-day access irrespective of medical need and listen to what our patients want and then try our hardest to provide it. We shut on Tuesdays at midday and another practice covers emergencies. On Thursday I run a clinic for cryotherapy and medicals instead of opening the surgery.
Get involved, but know when to say no
We have been involved with commissioning from the start of practice-based commissioning, and I work hard on networking with local practices and beyond. I still lead our locality but had to stand down from the CCG board as it was too time-consuming. I wasn’t prepared to disrupt the practice by reducing my clinical commitment.
Aim to employ a small permanent staff
I jobshare with my wife: I do all day Monday, Wednesday and Friday from 8am to 7pm and Thursday afternoons, and she does Tuesday and Thursday mornings. You have to work hard as a small practice but we are helped by having a small team with very few changes in staff. We have a GP assistant, and never employ locums. Make sure you have a good team of permanent staff able to cross-cover so you never need additional short-term help and can then develop standard ways of doing things that everyone understands.
The key is to have a very clear idea of what you are trying to do and let this guide the rest of your business.
Focus on key principles
Our culture is to put patients first and with their help to manage as much of their care as possible ourselves or in the community. It seems to work as we have high satisfaction rates, do very well in all the parameters measured by the PCT (like vaccination and screening uptake rates) and are well within budget for prescribing and hospital care.
The key is to have a very clear idea of what you are trying to do and let this guide the rest of your business. We wanted continuity, quality and accessibility and this means you have to employ enough people to do this. We are continually changing to keep on track.
Use your independence to improve your business quickly
Because we don’t have to get agreement from more partners, if something seems a good idea and will improve the quality of care we implement it almost immediately. We don’t have a practice manager so understanding all aspects of practice business means we can be very efficient, cutting out waste and running our service exactly as we want. We think about the financial implications of our decisions but not too much, as we have found that going for quality usually leads to being better-resourced later on.
Maximise income and control expenditure as far as possible
Dr Steven Shepherd, Ashby-de-la-Zouch, Leicestershire
I employ two part-time salaried GPs, which frees me up to devote two to three sessions a week to administration. To achieve a
good profit I use my IT system as much as I can – referral letters are generated by the computer so I do not need to employ a secretary.
The main costs to my practice are salaries so I only employ the people I really need. And I find that marketing is not something I have to do. Most people prefer singlehanded practices and my list is growing slowly and steadily without any action on my part.
Look out for new NHS funding streams
Even in today’s cash-strapped times there are always packets of money for the latest political or clinical favourite. Sign up for as much as you can.
We all know that NHS health checks have limited clinical value, but they are quick and easy to do and most can be done by nursing or HCA staff. At present there is no cap on the number you can do. These packets of money often move around or change and being singlehanded enables me to respond to change quickly without having to spend valuable time reaching a consensus with other partners.
Make sure all your work is profitable
It is important to make sure that doing any extra work is cost effective.
My practice has a business cost spreadsheet, which enables me to check that any extra work is profitable in terms of time and other resources. For example, by auditing health checks for those with learning difficulties I discovered they weren’t economical, so unfortunately we had to cut them.
Include a record of your administrative work in your appraisal
A lot of commissioning and the QOF work can also go towards my appraisal and revalidation. The key is to write up and reflect on things as you go along.
Play to your strengths, deal with your weaknesses
I have been a singlehanded GP for three years now. The main benefit is not having to discuss with and get other GPs to agree with any action. In my experience, many GPs find it hard to reach business decisions – if you have three GPs you will have four opinions. Being singlehanded saves you the interminable meetings with discussions going round and round in circles for hours, weeks, or months.
The main disadvantage for singlehanded GPs is the immense and ever-increasing administrative load entailed in running a practice; being singlehanded means that this load cannot be shared. These are some of the things I do in order to cope.
Do as much work in house as you can
I try not to outsource any jobs and try to do as much work as I can in house. This reduces costs and means I can keep an eye on things and control my business much more easily. But within the practice, I delegate as much as I can. My practice manager is dealing with CQC registration and I can delegate a lot of the QOF work to the nurse or healthcare assistant. I do, however, do most of the QOF myself, but this is relatively easy to with a list of 3,000 patients.
Start off by supporting your practice income with other work
Dr Krishna Chaturvedi Westcliff-on-Sea, Essex
I have now been working as a singlehanded GP for 12 years. I had only been a GP for 10 years when I went solo.
Initially when I became singlehanded I did additional work alongside running the practice – mental health act assessments, social security tribunals, occupational health work and medicolegal reports on Saturday mornings.
Other GPs who are in a similar situation can increase their financial stability by taking on portfolio jobs like those mentioned above, provided that they do not overdo it and burn out.
Aim to earn as much from enhanced services as possible
We try to do most of the things that are part of our local, directed and national enhanced services. I do in-house minor surgery, and offer it for other GP colleagues, and have recently started doing intra-articular injections as a part of my role as the local musculoskeletal medicine lead. This kind of work is not only financially rewarding but clinically satisfying.
When I started at my surgery in 1994 my list was 400 patients – now it is 3,400
Network with colleagues at local small practices
We have an excellent reception and clinical team, which helps me to do a lot of networking with colleagues at other small practices.
We have formed a group of like-minded GPs; we meet monthly and discuss clinical and non-clinical issues such as QOF visits, QIPP targets and CQC inspections. It is a great platform to share thoughts about the recent political changes to the NHS.
We share our half-days with other practices. They are a useful resource while we have our well-deserved break or holidays. They are actively involved and are encouraged to participate in the clinical management of the practice and in the educational activities of our GP group. Since I am involved with my LMC as well as the CCG, local GP colleagues who are also solo practitioners are very supportive in covering my clinical responsibility.
Keep your practice profile simple
When I started at my surgery in 1994 my list was 400 patients – now it is 3,400. Most of the clinical details and services are on the NHS South East Essex website, where we highlight the services we provide, and that is enough to increase our list gradually.
Keep your practice open as much as possible
Dr John Cormack, South Woodham Ferrers, Essex
We are like the old Windmill Theatre – we ‘never close’ during normal working hours, except in exceptional circumstances. Nurses and healthcare assistants (all of them part time) share the clinical workload with me – I am there to be called if there is anything that needs a second opinion.
A certain amount of phone triage takes place but by and large we operate a system that could be best described as: ‘If you want to be seen, we’ll see you’. To facilitate this we have an hour of unbooked appointments between 9am and 10am, an old-fashioned ‘sit and wait’ surgery and we also have appointment-only surgeries. Two nurses with diagnostic skills run this, with me hovering in the background. They do it very well and the patients are happy with it.
Create strong relationships in and around the practice
We share cover from time to time. The practice managers in the town work well together and share what tasks they can in our lively locality group. As a recent example of collaboration, the practices have joined forces to provide a cryotherapy service, sharing the costs.
Find the time to diversify – if you can
Unfortunately we need to spend most of our time and stamina concentrating on the basic tasks. It can be quite enervating working with an inadequate budget. In 30 years in general practice I’ve never found it more difficult than it is now to provide even a basic service to my patients. That said, we will need to go out and market the practice if we are to stay in business – but finding the time is next to impossible at present.
Don’t do it for the money
Even in the small town where I practise, if a patient moves from my practice to any of the others, they immediately become eligible for a much larger slice of the NHS cake … although we all draw patients from the same pool.
It would, of course, be possible for me to make money from the practice. If I sacked all the staff and sat there all day on my own taking the phone calls I could afford to pay myself reasonably well. The patients wouldn’t get a service, of course, and it’s not the way a modern practice is run … but it would be a way of dealing with a situation the PCT has created that would find favour with 100% of financial advisers.
The financial pressure that all GPs feel will hit singlehanders hardest, but by engaging with LMCs and the local CCGs, and forming practice networks with neighbours, this vital model of primary care can continue for years to come. Read Dr Laurence Buckman’s analysis on the state of play for small practices on pulsetoday.co.uk/analysis.
Are you a singlehanded GP or a partner at a small practice?