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At the heart of general practice since 1960

My 2017 prediction: All GP practices will merge into one

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There are two words guaranteed to strike fear into the heart of almost any man: size matters.

Nye Bevan knew it, when he said that he ‘would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one’. The BMA recognised it when, in 2015, they published a blueprint for the future of general practice in which they suggested that all GP surgeries should either federate or form ‘super-practices’, and in a recent survey showing that GPs want to collaborate more. And NHS England most certainly know it, and have placed great emphasis on working at scale in the GP Forward View.

When did the Government ever allow themselves to be constrained by something as trifling as evidence?

When it comes to delivering primary care, bigger is so often better. Super-practices benefit from economies of scale so are more cost-effective to run, freeing up cash which can be invested in ways that directly improve patient care and working conditions. Larger practices often employ allied health professionals to work alongside GPs to reduce their workload. One local super-practice uses a pharmacist to manage patients’ medications, and as a result, their GPs very rarely have to reauthorise prescriptions. Another large surgery, which serves a deprived inner-city population, employs specialist nurses to work with their homeless patients – a measure which improves the care that these vulnerable patients so desperately need, while also ensuring that GPs’ time is freed up to manage clinical issues. Furthermore, large surgeries are better equipped to deliver extended access to patients, as there is a larger pool of clinicians available to share the burden of working antisocial hours.

Of course, super-practices are not the only surgeries which use allied health professionals in creative ways. I live in south Cheshire – bucolic, beautiful, but remote, an hour’s drive from any city of significant size. Whole towns are chronically under-doctored, with multiple surgeries struggling as older GPs retire or burn out and cannot be replaced. Some of these practices would not be able to stay open without the pharmacists, nurse practitioners, or extended scope paramedics that they have recruited to plug the gaps. However, when these allied health professionals are working in lieu of GPs, usually workload will be heavier than in a surgery which is using them to augment a full complement of doctors.

Recruitment is another field in which large practices often have an advantage. Most young GPs nowadays have an aversion to entering into partnership, and quite reasonably so, given the huge financial and contractual risk it entails. A particular deterrent is the idea of ending up as the ‘last man standing’, the final partner remaining if all of one’s colleagues resign and cannot be replaced. Due to GP partners’ personal liability, a last man standing can end up financially crippled if a practice closes and staff require redundancy payments. In a small practice, any new partner is just a couple of retiring colleagues away from financial ruin. A large partnership feels like a safer investment.

One criticism levelled at large primary care organisations is a lack of continuity of care. However, this need not be the case. Some super practices operate a team-based system, in which GPs work in small groups sharing a list of patients. Even if a patient is not always able to book in with their preferred GP, this ensures a degree of continuity. And, of course, many large GP partnerships operate over multiple sites, often staffing each site with the same small team of doctors – in effect, offering the same continuity as they would if they were a “normal” small surgery.

Change is certainly coming, in one form or another: recent research by the Nuffield Trust showed that almost three-quarters of GP practices are in some form of collaborative relationship. This research showed that working at scale can boost sustainability. However, the study found no detectable difference in the quality of care offered by large-scale organisations compared with smaller ones, and patient views were mixed.

Still, when did the Government ever allow themselves to be constrained by something as trifling as evidence? Like seven-day access, working at scale is fashionable, and if GPs do not embrace it willingly, they are likely to find it forced upon them – either by politicians, or simply out of economic necessity as smaller practices become less viable.

So my message is simple: I hope you enjoyed this year’s festive do – by next Christmas, your practice will be so big that you won’t all be able to fit in one restaurant, let alone pay for everyone to have a meal. I wouldn’t be surprised if the entirety of UK primary care doesn’t end up as one gigantic practice – a super-super-partnership.

Whether this is a good thing remains to be seen. After all, as every woman knows, size is useless unless you know what you’re doing with it.

Dr Heather Ryan is a GP registrar in Liverpool. You can follow her on Twitter @DrHFRyan

Read more of Pulse bloggers’ light-hearted look at the year ahead:

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Readers' comments (8)

  • I think medium sized is the way forward. 8-10k patients. Maintains enough GPs to cope. Still small enough to feel like you are part of a functioning team.
    The only reason GPs are suggesting it's the future is that's where the funding is going. There's enough money to fund GP as it is. Gov is not willing

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  • The Government needs to act as last guarantor rather than the poor hapless GP left standing, then you might get some new recruits to partnerships.

    Somehow I doubt this is in Government's thoughts. They want us to go under but they don't like the bad publicity.

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  • A virtual nobody

    I''m not convinced by the "massive super practice" idea. Sounds like an administrators wet dream, but big organisations are tipically inflexible, difficult to reform and self serving. Ideas come from the top and are imposed downwards, the possibility of nimble location relevant innovation is reduced and individual creativity is squashed. For a big centrally funded institution the 'customers' needs are of secondary concern. It's the funders agenda (aka government or soon maybe shareholders) that matters. This whole thing is driven by a desire for political centralised control. It sets general practice up nicely for large scale privatisation and take over by big companies. It serves the needs of the bean counters not the patients. It's Darzi centres all over again ready for shareholders and profit taking. Is the vain lure of the beauty of the big organisation and it's bollarks.

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  • I agree with jobbing doctor. Once General Practice is at scale it will not be what it used to be. We will have lost the essence of GP. It will no longer be worth saving. I certainly won't want to work in it.

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  • Question is not whether anyone likes it, question is what can you do?!!!

    Nothing!!

    Heather is spot on. The future is orange !!

    Though blue is my favourite colour!!!

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  • The notion that larger means cheaper (economies of scale) comes from an evidence free zone of government advisors.

    If it were true, GP's in larger practices would have more patients per GP, or they would be twiddling their thumbs all day. Not what I have heard.

    I have been the last man standing in my practice for the last 16 years, no problem as I am in control of my workload, yes the problem is a vulnerability in holiday and sickness cover, but since 2004 the out of hours is no longer the burden it used to be.

    Not all businesses benefit from scaling up, even the supermarkets are abandoning the large centralised shops for smaller local enterprises (yes this is probably where whitehall got the idea of federations, but there are massive differences between supermarkets and primary care)
    http://bjgp.org/content/59/560/e71

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  • Agree ..patients need care ...not a walk and out process with whoever is available
    I am off duty but still rang 4 patients to follow up care .

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  • We have to very careful, otherwise we will lose the personal care of the patient-we are already witnessing it due the effect of OOH services.

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