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At the heart of general practice since 1960

Practices must


or die

It seems clear that development funding and access to capital will be channelled increasingly to expanding practices and that it will no longer be enough for practices simply to consolidate existing work, says

Dr Jim Sherifi

The current climate in primary care is fostering a degree of innovation and entrepreneurship that has not been seen since

the last century and the heady days of


PCTs, unsure of their future and with their functions perpetually being redefined, seem to be trying to exert control while simultaneously losing it.

The relentless drive towards practice-based commissioning, with budget management at the point of patient delivery, is likely to increase GP awareness not only of the complexities of strategic planning and implementation but also of commonly held business tenets such as 'economies of scale'.

Practices can no longer expect to be allowed to bury their collective heads in the sand, keep concentrating on traditional patient care and hoping to be left alone.

The Our Health, Our Care, Our Say White Paper has made it clear that development funding and access to capital will be channelled in the main to expanding practices. Competition between practices and other health care providers will be fiscally encouraged. Practices will either grow vigorously or whither away.

In the White Paper, the chapter on primary care services includes:

· Helping people register with the GP

practice of their choice

· Rewarding responsive providers

· Increasing provision in deprived areas

· Supporting primary care trusts (PCTs) to attract new providers

· Helping practices expand by assisting with costs and making more money follow the patient

· Reviewing the funding of NHS walk-in centres

· Giving people more information on local services

· 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.

Within the laudable sentiments of the document are some hard and significant changes to the way GPs will have to think about and deliver primary care. These include:

· The service to be shaped by what the

consumer wants

· A less 'doctor-centric' primary health care service with many health care providers such as nurses, physiotherapists, mental health and even job counsellors working out of one centre

· Investment to expand the range of

services provided in general practice,

rewarding improvements in clinical quality and patient experience and recruiting and retention of key professionals; more money will follow the patient

· Financial encouragement to practices to expand lists and opening hours

· Increasing accessibility to health care

including easing restrictions on

registration, changing practices, reviewing closed/full lists and 'dual registration' near the place of work as well as home

· Increasing competition and choice with GMS, PMS, alternative provider MS and PCTMS all tendering to provide medical

services; allowing out-of-hours and walk-in services to run 'traditional' surgeries and register patients

· Bringing in alternative, private, health care providers in areas where health care provision is poor; focus of resources on deprived areas

· Beefing up of PCT powers to commission and review services

· Renegotiation of the minimum practice income guarantee.

Undoubtedly, not all parts of the White Paper will be relevant to all practices. Locality will decide whether elements relating to deprivation and competition need to be considered. In many rural areas, where practices can be 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 in direct proportion to the remoteness of the area itself.

However, the increased resources being directed at inner-city areas may well entice commercial providers whose clout and business enterprise may threaten existing, and perhaps struggling, practices in a big way.

In the light of the White Paper, the movers and shakers in each practice will need to draw up a strategic plan. This should include practice and personal objectives that can be worked towards and met as a team.

The structured thinking required of a business plan may be worth considering and a good guide and template can be obtained from the British Venture Capitalist Association website1.

For example, a practice chooses 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 per cent within y years. Can attracting people moving into the area in 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 implications of even a simple initiative can be far-reaching, and serious thought must be given to every move. Each initiative needs its SWOT analysis (Strength Weakness Opportunity Threat). This can be undertaken in-house or under the supervision of an external, expensive, but arguably cost-effective business consultant.

Sifting carefully through the wording of the White Paper, it can be seen that its main thrust is customer satisfaction ­ ie pleasing your patients. But satisfaction is a highly subjective emotion. The perception of improvements in experience can range from decorative improvements to a waiting room through to a change in surgery times to meet the needs of patients who work.

Opinion polls continue to show that in general, patients hold their doctors in personal high regard but are irritated by the difficulties they have to overcome in order to see them. That path can be smoothed by the use of strategies such as:

· sophisticated and user-friendly telephone systems

· internet access to consultations and also backroom functions such as appointment bookings and test results

·videophone/webcam consultations

· digital photography ­ eg for diagnosing skin lesions.

Many of these will use new technology. PCTs are being encouraged to reward such innovation. Applications for grant monies to improve IT infrastructure, as long as a clear case can be made for a subsequent improvement in patient services, will always be well received.

The holy grail of general practice has always been to try to meet seemingly insatiable demand with limited resources. Practices that progress furthest in that quest will be rewarded most under Our Health, Our Care, Our Say.

Jim Sherifi is a GP in Sudbury, Suffolk

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