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At the heart of general practice since 1960

Is bigger better for GP practices?

Professor Robert Harris says that the super-practice model is the way forward in these difficult times while Dr Zoë Neill says larger practices will take away the autonomy of the individual GP

YES

In times of plenty, small independent GP practices represent a viable business model: locally owned, locally managed and serving local needs. However, in times of challenge, it’s a different picture. Contractual and payment changes that are already in the pipeline will hit GPs hard, making it very difficult to survive, let alone thrive, as a smaller practice.

But we have opportunities to build new, different, more resilient models of primary care, to redesign, rebuild and re-establish primary care as the force for good that we all know it to be.

There are various models of ‘primary care at scale’ currently being explored. We at Lakeside Healthcare eschewed the federation model, on the basis of its being too loose in design, in favour of forming a single super-practice, with 60 partners. Our super-practice has a single operating model, a single HR model, a single IT system and crucially a single financial model. By streamlining these support functions over multiple sites, we reduce the overall unit cost and introduce the convenience for patients of being seen at one of several sites. As a sizeable counterparty, a super-practice is much more attractive to banks, so our ability to secure funding at optimal rates helps development plans.

To enjoy a devolved budget from CCGs to manage the care of patients on GP lists directly, NHS England has suggested a minimum list size of 30,000 to 50,000 patients as for ‘multispecialty community provider’. The bigger the list, the more financial resources are at the disposal of the practice.

Being bigger also allows practices to employ more specialists, both clinical (pharmacists, nurse practitioners) and non-clinical (accountants), as this cost is spread over a greater denominator. And they can attract these staff more effectively; a super-practice can offer doctors and nurses a financially attractive career with a sustainable employer.

Increasingly, patients want more from their GPs in the way of services. A small practice will struggle to have the necessary clinical skills in house to design and deliver a fuller range of services, but a larger practice can offer these specialist skills.

The size of a super-practice means it can improve its operational resilience (based on the numbers employed) and improve its financial resilience (based on the variety of contracts and income streams). This allows it to improve the range of community-based services offered to patients.

Professor Robert Harris is a partner at Lakeside Surgeries, Northamptonshire, and CEO of Lakeside Healthcare Group

NO

Under the pressure of ever-increasing demand, it is easy to understand why worn-down, burnt-out GPs look up wearily from their desks, and say: ‘A super-practice? That sounds good.’

Joining forces, whether as a super-practice, a federation or simply via an agreement to collaborate, is the ‘new black’, but this is based on a set of assumptions it is important to debunk. For instance, will recruiting and retaining those missing 5,000 GPs somehow become easy for a larger entity? Super-practices offer ‘a varied and exciting career’, according to those that run them. But any GP can easily recognise the recruitment adverts for these super-practices. Peppered with blue-sky buzzword bingo, it is not clear that these jobs are anything different from those offered by big companies a few years ago. Will there be any fewer empty chairs because practices have got together, signed a big fat legal agreement and appointed an executive board?

Partnership has been attractive in the past because it offered GPs the chance to make decisions and to have influence over how they care for patients and how they run their practices. The predictors of job satisfaction (autonomy and control, variety, social support) are worryingly absent from the big practice model – decisions are taken at board meetings to which non-executive GPs are never invited and their opinion is not sought. The ordinary GP is there to do the clinical work, to process the non-stop conveyor belt of patients.

Sitting in an identikit room, ticking boxes on management-created pop-up windows, for whatever LES or quality scheme they’ve signed up to, GP partners will wonder what benefit merging into a super-practice has brought them, other than avoiding bankruptcy. Faced with annihilation, singlehanded or small practices have gladly agreed to the loss of autonomy to survive. But the staff, who were providing a personalised service characterised by unmeasurably valuable continuity, are less enthusiastic, complaining that everything has changed, no one listens to them and its it’s all about money and targets.

I know it’s hard; I know in many practices partnership is now an impossible job. But your fear of personal bankruptcy or loss of earnings is playing into the hands of those private providers waiting in the wings. It’s not just about money, it’s about the very core of what general practice is. You are not an industrial cog in a huge machine, but if you sign up to a super-practice you might well become one.

Dr Zoë Neill is a portfolio GP in Leeds

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Readers' comments (10)

  • Surely the model is critical here. If you sign away your autonomy - absolutely right, but if you retain a voting share then that's a different matter. Equally, if you are too small your ability to make decisions is limited by your scale and power. Big gives you the option on discussions you can't even dream of as a small or even medium practice.

    As the size of practices grows (as it has inexorably in years of late) the Carr-Hill formula will push first the small then the medium size practices off the edge.

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  • Russell Thorpe

    Its the connection between the doctor and the patient that is the key to job satisfaction. Working for Doczilla there is no connection with a stream of people you wont see again. Its the GP to pt link that generates continuity and reduced reliance on secondary care to do anything but provide the most basic and trivial medical care. NHS trusts beware the Doczilla, it will roar and stomp leaving chaos and destruction at your door.

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  • What is a single operating model? Soviet style autocracy?

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  • I think Super-practices are only beneficial if their leadership can throw around the weight of the practice.

    For example in many areas GPs have problems getting appropriate funding for hospital type work - like prostate injections.
    One GP sticking his neck out and declining to do it will be lambasted by the hospital clinicians.
    A few GPs demanding a DES can be easily ignored.

    A practice of 500k patients can tell the CCG/ hospital that they only want to do them if there is a DES that fully covers the cost of the appointment. A DES that undervalues the appointment (or the absence of the DES) means the super-practice declines to do them and the hospital gets an immediate referral of 500 patients to have 3 monthly prostate injections (and the CCG gets the accompanying bill).
    Suddenly the DES actually needs to mean something.

    Imagine doing the same with:
    -hospital cross referrals
    -chasing blood results for hospital staff
    -inappropriate referral forms requiring the GP to do more than they are contracted to do
    -insurance and notes requests.
    -etc etc etc.

    Will these practices really be militant enough to push these changes through?
    I hope so.

    (I am not a member of one of these practices)

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  • No

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  • Bit ironic a "portfolio GP" arguing for the defence of traditional practice

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  • Well Zoë, obviously you have not looked up the Hurley Group. A thriving, successful practice run by FOUR partners and with over 100,000 patients. The perfect model for the future general practice.

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  • 7.01 - is that you Clare Gerada? Firstly the Hurley Group has a rating of 1.5 stars on Patient Choices.... Patients obviously don't agree with the fact this is the 'perfect model'.
    Secondly there are 4 'partners' that make all the decisions and the salaried doctors do the consultations exactly like Zoë suggests these super-centres would run.

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  • 28 Oct 2015 11:01pm. God forbid!
    What amazes me is HG's power. I would have thought that one of PULSE's bright young reporters would have a field day searching the Internet - starting with the partners' appointments outside the group, and then move on to Company House records, on to the national press and so on and so on. It would make fantastic reading, and yet total silence. I wonder why.

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  • LOL @ 11.31
    I have been doing just as you suggest in recent weeks and doesn't it make interesting reading?!!! Careful what you say on here though. Free press? Hmmmm. I wonder what would happen if all their salaried docs resigned at the same time.

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