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Gold, incentives and meh

Why mega practices are the future of general practice

Dr John Couch believes multi-partner mega practices will put GPs in a strong position – he explains why

When the first group practices began to appear in the 1950s and 1960s they were regarded with some scepticism by their peers. GPs before the start of the NHS were fiercely-defended one-man businesses.

Gradually, as the grind of perpetual on-call took its toll and the attraction of partnership was boosted by the partnership allowance, more and more GPs decided to join together. Initially there were serious inequalities of workload, with many senior partners – who often owned the premises – working their juniors unfairly hard. One of my predecessors used to have one Sunday off per month in the 1950s!

Thankfully equality has been well-established for many years, and on the whole GP partnerships have worked well in coping with the previous format of primary care for four decades.

A front-page news story in Pulse recently highlighted Dr Mark Hunt and his colleagues in Frome, Somerset. Their mega practice consists of 26 GPs, 15 nurses and 95 staff. Although there have been large practices like this around for some time, there are signs that this trend is likely to increase. Personally I have felt for some time that this is the most promising option in ensuring GPs continue to play a leading role in the future of primary care.

Threats and opportunities

The changes that make mega-practice a better option have been taking place for some years. The first of these is GP recruitment. While it is becoming a little easier to employ salaried GPs, there is still a shortage of quality partnership applicants in most areas. For smaller practices, and those 50 per cent that own their own premises, this has made life particularly difficult. In many cases this has affected viability and will increasingly do so.

The next threat is from private companies entering primary care. There is already a warning to be seen in dentistry. Smaller practices were bought out one by one by private companies. Anyone planning a new UK dental service for the new millennium would certainly not come up with the current mess. In general practice PCOs can now commission private companies for enhanced services.

The sale of goodwill for both enhanced and additional services was made legal by this government, surreptitiously, exactly for this reason. The likes of BUPA, PPP, Primecare and several overseas health care companies will be looking to establish footholds, with a view to increasing primary care services in as many profitable areas as possible.

The extra money being pumped into primary care, which is a lure for health care companies, is also an opportunity for general practice. The new contract offers the prospect of higher partnership incomes for measurable achievement. Partnerships that are able to perform well across the range of services will see profits rise to much more appropriate levels. At last our earnings have the potential to be on a par with equivalent partners in firms of solicitors and accountants.

What could mega practices offer?

A mega practice is in a very strong position to bid for a wide range of enhanced services, even if it is in competition with private companies. A spectrum of GPwSI services can also be offered.

The prospects for attracting more private income should also increase. As singlehanded GPs retire, their lists can be assimilated rather than face the prospect of a private company taking them over.

Recruitment should also benefit. A very large practice is unlikely to disappear overnight.

Most young salaried GPs prefer a secure, thriving and stimulating environment. A large practice ensures work with other salaried colleagues and enhanced opportunities for education.

Prospective partners will be attracted for similar reasons or, just as likely, be recruited from existing salaried staff. A tempting differential between salaried and partner income will also help this process.

For property-owning partnerships with many partners, the sale and purchase of shares becomes less alarming and the reality of career moves more practical. The scale should also make partnerships more attractive to PFI companies, an advantage if new-build premises are required.

Mega practices should be more able to cope with doctor illness, maternity leave and resignations. Imagine the effects of two GPs resigning in a four-doctor practice.

Economies of scale should also drive down expenses. This would particularly cover areas such as management, administration and bulk purchase of supplies. In addition, efficient systems to maximise the new contract could be uniformly set up and applied. Employment of IT personnel also becomes more feasible.

Finally, if general practice ever follows the dentistry model, it is the mega practices that are more likely to survive and thrive.


Such a large organisation is bound to have disadvantages. Getting a super-tanker to change direction can take much time and planning! Partners will need to elect or employ an executive to effect policy and be prepared to be more hands off in order to let them achieve this. Some GPs will find this difficult.

Turnover of GPs and staff will be more frequent, making cohesion tougher. With 26 GPs, on average one will move on or retire every year.

Inevitably the move away from personalised lists will accelerate.

It will be more difficult to ensure personalities blend in to the existing group. HR will therefore become more essential.

Property-owning issues may be more difficult initially, especially if three or four property-owning practices combine.

How far to travel?

Mega practices may not be the only possible model for the future, but they would certainly fit well into the current and planned NHS format. It is likely that many practices will initially form loose associations to gain some of the benefits outlined above. Once confidence grows practices will start to combine formally. Eventually, firms or companies will be established.

This will of course no longer be general practice but primary care for the 21st century with doctors retaining a defining role. I really hope it happens.

John Couch is a GP in Ashford, Middlesex

Advantages of mega practices

lEasier to recruit staff

lWider range of services offered

lHigher earnings for partners and staff

lAble to compete with private health care companies

lAttractive to PFI companies

lBetter able to cope with partner/staff absence

lEconomies of scale

lEmployment of IT and other specialist personnel possible



lHigher turnover of staff

lCommunication harder

lPossible problems over property

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