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At the heart of general practice since 1960

Practices must develop or die

Practices will increasingly need to innovate and expand if they are to secure funding and access to capital, says Dr Jim Sherifi

Practices will increasingly need to innovate and expand if they are to secure funding and access to capital, says Dr Jim Sherifi

General practice is more competitive than ever. The most successful practices are now innovative and sharp to a degree not seen since the days of fundholding and are under unprecedented pressure. PCTs, newly invigorated and empowered by the Department of Health through its latest white paper Our health, our care, our say, are driving through changes in healthcare delivery centred on a customer-centric ethos of accessibility and choice.

In this changing climate, practices will find compliance with these ideals essential. This is because practice income will increasingly be based on them. But they will be difficult to achieve without a significant re-evaluation of the resources needed for efficient delivery.

Competition between traditional general practices and other healthcare providers will be fiscally encouraged. Practices can either flourish – or wither away.

The pace of change is accelerating, as illustrated in the white paper, which contains an action plan or road map of development milestones through to 2009. In it, points specific to primary care providers include:

• helping people register with the practice of their choice

• rewarding responsive providers

• a new drive to improve the availability and quality of primary care provision in areas of deprivation, so that problems of health inequality and worklessness can be tackled

• helping practices to expand by assisting with costs and making more money follow the patient

• streamlining GP registration and appointments processes to improve access and convenience

• reviewing the funding of NHS walk-in centres

• giving people more information on local services.

Within the laudable sentiments of the document are some hard and significant changes to the way GPs have been used to thinking about and delivering primary healthcare. These include:

• the service to be shaped by what the consumer wants

• more money to follow the patient

• the provision of healthcare by other professionals such as nurses, physiotherapists, mental health and even job counselors to be expanded

• PCTs using various means to drive service redesign and increase the use and scope of local pharmacies

• investment to expand the range of services provided in general practice; simultaneously the removal of these from secondary providers

• a further development of GPSI roles

• financial encouragement to practices to expand lists and opening hours

• increased accessibility to healthcare, including easing restrictions on registration, changing practices, reviewing closed/full lists and dual registration near the place of work as well as home

• increased competition and choice, with GMS, PMS, APMS and PCTMS all tendering to provide medical services

• out-of-hours and walk-in services will run traditional surgeries and register patients

• bringing in alternative, private, healthcare providers in areas where provision is poor, and focus of resources on deprived areas

• beefing up of PCT powers to commission and review services

• renegotiation of the MPIG.

How can GPs respond?

Not all parts of the white paper will be relevant to all practices. Your locality will drive whether elements relating to deprivation and competition need to be considered. In many rural areas where practices are few and far between, the opportunities for competition will be limited and the likelihood of alternative commercial providers being drawn to the area will be inversely related to the remoteness of the area itself.

However, the increased resources being directed at inner-city areas may well entice such commercial providers, whose market-driven dynamism may impact in a negative way on the viability of existing practices. Following the publication of the white paper last October leading practice members have needed to debate and draw up a strategic plan for their practice.

For example, a practice might choose to increase its overall income by increasing its list size. The main strategic aim is financial gain. In order to meet its financial target it needs to increase its patient numbers by X% within Y years. Can attracting people moving into the area into new housing developments do that? Does the practice need to attract patients from other primary care providers in the area? What is its relationship with those practices? Are they working together in a PBC consortium? Will the increase in patient numbers require further staff? How will that impact on profitability?

The ramifications of even the simplest premise can be widespread, emphasising the need for objective planning. Each element needs its strength, weakness, opportunity and threat (SWOT) analysis. Planning sessions can be undertaken in house or under the supervision of an external business consultant – this is expensive but arguably cost-effective.

Likewise a practice might choose to increase 'accessibility' by extending its opening hours in evenings and weekends. What extra resources will be required? Can these be effectively gained by merging these additional services with other local practices?

Other innovative ideas include accessing Department of Health funding for the Expert Patient Programme to fund non-medically qualified individuals to assist and alleviate the workload of chronic illness or partnership with charities such as the Alzheimer's Association, to buy inpatient beds in the community.

Another Department of Health publication, Keeping It Personal, by Dr David Colin-Thome, the National Director for Primary Care (published February 2007), sets out the case for how GPs are still best placed to provide for the overall needs of their patients through the historic doctor-patient relationship and also by accepting new ways of working. It provides interesting reading and encouragement to doctors who recognise the need to expand mentally and structurally.

General practice has always tried to meet seemingly insatiable demand with limited resources. Practices that progress furthest on that quest will be the ones rewarded in the new, consumer-driven, NHS.

Dr Jim Sherifi is a GP in Sudbury, Suffolk

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