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What does it take to run a super-surgery?

Dr Howard Freeman explains how his 30,000-patient practice, spread over four sites, still manages to deliver continuity of care

Dr Howard Freeman explains how his 30,000-patient practice, spread over four sites, still manages to deliver continuity of care

Over the past 20 years, our inner-London practice has almost quadrupled in size.

It now has a list of nearly 30,000 patients and operates over four sites across two London boroughs.

Its growth has been through a mixture of a philosophy of providing the very best patient-centred care, embracing change where we believe that has promoted quality, encouraging and developing all staff and reviewing our services regularly to ensure they are tailored to patients' needs.

A practice of this complexity requires excellent management to ensure it runs properly, both administratively and clinically.

It has moved a huge distance from the simple inner-city practice I joined 27 years ago.

The structure we have evolved suits us, but could also be adapted for groups of practices who wish to come together in a collaborative polyclinic approach.

The franchise principle

We operate the practice like a franchising organisation.

If you walk into any of our sites it is clear that you have come into one of the practice's surgeries, but each site, which serves a slightly different demographic, operates in a subtly different way – allowing services to be tailored to that population's requirements.

The whole practice is overseen by a board of the sharing partners or contract holders. Also sitting on that board is the practice manager.

Each site has a sharing partner responsible for it but they do not manage the site; that is the role of a site manager who is accountable to the practice manager.

Similarly there is a clear clinical governance chain for all professionals in the practice, which comes together at site level through the board level partner.

Paralleling the practice management structure is the clinical management structure, overseeing our 10 or so nurses and healthcare assistants.

We have always maximised the flexibilities around skill mix. When I first joined the practice, family planning, hypertension and cervical cytology were already being run by nurses.

This was unusual in an inner-city area, where many practices had no nurses at all.

Our size allows us to train our nurses so we have some with generic skills and others with specialist skills.

The nurses with specialist skills work across the sites.

Similarly, we have always encouraged doctors to develop clinical interests. We had GPSIs long before the term was invented. Again, their skills are used across the whole practice – although they are always based on only one site and we refer patients internally across sites.

Complex staffing

The medical staffing of our surgeries has always been complex.

We have encouraged part-time doctors to work just two sessions a week as we are able to match their sessions with our timetabling needs.

We discourage doctors from working across sites as we believe that working on only one site promotes teamworking and identifies the doctor with the patients there.

We are actively engaged as a training practice and have recruited most of the doctors from ones we have trained.

We always try and keep registrars in the practice even if it's only doing locum work. And with such a large and complex practice, we are able to offer a career structure.

We have for many years recognised that some doctors only wish to have a clinical commitment and do not wish to take part in the running of the practice, and we've been able to offer this.

We know some doctors wish to become more involved in the other aspects and we have catered for them as well. We actively support doctors who wish to take on more responsibility and reflect that with increased pay.

This has also been reflected in the doctors who have become contract holders in the practice over time through development. I have always seen this as no different from the career path in other big professional practices such as solicitors or accountants.

Each of our sites has a very slim management capacity.

We have centralised most of our management structure on one site and the practice manager and her team are responsible for issues such as HR and procurement.

It is they who liaise with the PCT. Were we to be running four separate practices of a similar size, our management structure would be far larger.

Patient benefits

For patients, there is the benefit of all of the additional services we can offer as a practice employing at any time nearly 50 members of staff.

Yet the front end of the practice is the patient's local surgery and many of them are unaware of how large the organisation is and how it is run. That's just as it should be.

The opening hours of the sites differ slightly to cater for patients' wishes. Just like the Windmill Theatre, we never closed on a Saturday and indeed two years ago moved from Saturday morning opening to all-day Saturday opening. It is not a decision I have ever regretted.

The big primary care debate at the moment is of course Lord Darzi's plans for polyclinics – a particularly hot topic in London – and how these new centres would be able to deliver continuity of care.

Although our practice is not a polyclinic, it does operate large sites for London and because we encourage part-time working there are a number of healthcare professionals on each one.

Parts of the practice serve a relatively deprived population who generally do not have good advocacy skills.

Yet they are still able to access the doctor they want and indeed that is an area in our annual practice survey in which we do well.

We balance this with the facility to access any doctor in an urgent situation and I believe we've got the balance right.

Patients with chronic problems or the terminally ill gravitate to a doctor they feel comfortable with, and we offer them long-term care.

But we increasingly find patients who are acutely unwell and who do not have a chronic condition are happy to see any healthcare professional.

Part of our success in achieving this balance has been that the sites are still relatively small – our largest has no more than 9,000 patients. It would be much more difficult to achieve such continuity of care in a site serving, say 30,000 or 40,000 patients.

Personal relationships between the staff, many of whom are very long-serving, and the patients facilitate this continuity, even though our staff work a shift system.

I have yet to be convinced this could be replicated in a polyclinic managed by a big provider.

Our model is one that works for us. It was not designed to be rolled out more widely, but it could be the basis of a model for further grouping of practices.

Dr Howard Freeman is senior partner in the four-site practice based in South London

What does it take to run a super-surgery?

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