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At the heart of general practice since 1960

Read codes rule puts the cart before the horse

The Government has implied that the future of general practice lies in large group practices.

Dr Ron Thew, whose practice has 17 partners, describes what life is like with 34,500 patients

Latham House Medical Practice in Melton Mowbray, with 17 partners and a list size of 34,500 patients, is one of the largest GP practices in the country. Twelve of the partners are credited as GPSIs, providing both 'in-house' activity and sessional activity at the two local community hospitals. The total number of directly employed staff is 55, including 18 nurses.

When meeting GP colleagues elsewhere, the size of the practice is invariably greeted with somewhat incredulous surprise. Two questions always follow: 'How do you make decisions?' and 'How can 17 partners possibly get on?' I have long felt like an apologist for large practices in an unfavourable environment, but is the climate now changing?

The advantages of size

Our large size has enabled is to develop an ethos of providing comprehensive medical care.

We can offer our patients a wide range of opinions in different specialties on site much quicker than would be available by referral to secondary care. Specialisation adds to our job satisfaction, and has the advantage of promoting in-house education by informed discussion.

Encouraging specialisation helps with recruitment. We have demonstrated our ability to save resources that can then be ploughed back into primary care investment, thus providing extra services. (see table on page 34).

Size encourages discussion and innovation, with many personal skills and interests to call upon. We have been able to go for first-wave fund holding, total purchasing, PMS, and now practice-based commissioning with the confidence that a big team instils.

Effectively managing resources has enabled us to invest in premises, equipment and staff. A system of nurse triage for same-day appointments has taken away some of the pressures of the 'unexpected' demands of general practice, and freed up time to take on outside commitments, including an active role in the PCT.

With a large practice population, we have been able to plan our health delivery strategically. We recruit partners targeting the service needs of the population, with particular specialties in mind.

Commissioning

It is easier for a large organisation to develop and bid for enhanced services. For a long time we have provided an INR service for our patients (now remunerated under an enhanced service agreement). We expect to contract for the remuneration of our minor injuries service which treats more than 10,000 per year on site, and who would otherwise have to attend the community hospital or district A&E service.

Four of our 13 nurses have received training to provide what is essentially a nurse-led service on site. Support is provided by the partners, including a daily X-ray/fracture clinic by a GP at the nearby community hospital.

We are able to develop commissioning skills, with a designated partner devoting time to the development of practice-based commissioning. Large budgets are more flexible.

Lastly, many of the irksome issues that might challenge a small organisation such as illness, maternity and resignation are less of a headache when diluted by size.

The drawbacks

Communication can be a problem. We are a big business ­ our total purchasing budget was some £20 million ­ and you cannot rely on coffee breaks to organise and co-ordinate activities. It is necessary to have formal practice meetings professionally managed. You may see some partners only occasionally, or indeed not even know how many partners you have. So we have invested in high quality staff, with effective division of labour. We have good practice management, and a dedicated IT manager who has enabled sophisticated communication via our own intranet service on which important practice issues can be posted. We have dedicated audit staff to give us feedback on performance. All the partners are provided with statistics on prescribing and referral activity on a monthly basis.

The practice is totally democratic, but democracies are not always efficient in times of crisis. We have developed a process for decision-making which seems to work well. We have had to forego the right of veto, and major decisions, such as those affecting issues in the practice agreement, are decided on a majority of 80 per cent to prevent inertia. Day-to-day decisions are decided on simple majorities.

Management can be a problem too in a practice this size. The practice is run by a team headed by a practice manager who has an incentive scheme linked to practice profits. Following the advice of a management consultancy, we have an executive of five partners (elected annually) who meet with the management team weekly, and which creates the core of the practice meeting agendas.

Nonetheless, I am sure that many would consider that a small practice able to meet more often and informally would have a distinct advantage over what might seem a necessarily cumbersome structure. Certain freedoms must be sacrificed for overall efficiency.

Personality issues are widely perceived to be a potential hazard of having multiple partners. Our experience is that any clashes are actually minimised by size. I am sure that a fall-out in a small practice must be more difficult to manage than in a large practice in large premises.

Complexity can be a problem, especially in the current environment of GMS2, government and PCT targets. In a large practice any goal can seem daunting, and I am sure that our practice manager would say that ensuring everyone 'delivers' is her major headache.

Continuity of care is a challenge for a large practice, which could be perceived as impersonal. We combat this by operating a personal list system, which we adhere to strictly. We encourage patients to change their GP if they so wish by registration, thus mitigating the potential for doctor-hopping.

What does the future hold?

The current intention of the NHS is to integrate primary and secondary care. With the development of practice-based commissioning and the increasingly demanding management agenda, large practices will be ideally suited to embrace the next cycle of reforms.

My view is that we will see large practices venturing into the provision of GMS in areas where recruitment is a problem. We may see both friendly and hostile takeovers.

We are likely to see territorial issues between primary and secondary care providers becoming increasingly important, with the key being collaboration. There is likely to be assimilation, but with varying models. Small practices will be under pressure to co-operate as satellite organisations, sharing budgets for joint commissioning facilities and expertise.

Ron Thew is a GP in Melton Mowbray

Advantages of a

large practice

·Provision of many services to patients

·Speed of provision of services

·Job satisfaction for partners and staff

·Partners can specialise

·Good scope for

in-house education

·Recruitment easier

·Bulk buying saves money

·Innovation encouraged

·Bidding for enhanced services made easier

·Personality clashes minimised by size

·Illness and resignation more easily accommodated

Disadvantages of

a large practice

·Communication can be a problem

·Management issues tend to be complex

Sub-specialties

at the surgery

·General surgery

·Ophthalmology

·Plastic surgery

·Gastroenterology

·Gynaecology

·Cardiology

·Dermatology

·Rheumatology

·Orthopaedics and sports medicine

·Urology

·Diabetes

·Lipid medicine

·ENT

In-house services

·Counselling

·Psychiatric nurse

·Nurse-led minor surgery

·In-house ultrasound

·Minor injuries unit

·Diabetic retinopathy screening

·CHAT clinic (confidential health advice for teenagers)

·Diabetic specialist nurse

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