A review of primary care is looming, and the Government reportedly favours GPs being directly employed by trusts. But what have existing models of this type achieved so far? Rachel Carter reports
A seemingly innocuous visit by the Department of Health and Social Care to a hospital trust in the West Midlands last year may have major implications for GPs across England.
The visit by officials to the Royal Wolverhampton NHS Trust in November – revealed by Pulse – was designed to ‘explore alternative ways to deliver primary care’, the trust said. And the ‘Wolverhampton model’ is certainly ‘alternative’. In 2016, the trust took over the running of three GP practices, later going on to run 10 practices.
It has caught the eye of the health secretary. In January, a headline in The Times1 declared: ‘GPs nationalised in Javid plan to reduce hospital admissions’. The headline may have been a little overblown, but the article reported on a plan by Sajid Javid to review primary care.
Part of this review will look at how to better integrate GPs with hospitals, which The Times claimed could see GPs incentivised to link up with trusts. This would include ‘academy-style’ hospitals that are similar to the Wolverhampton model. A think-tank report – backed by the health secretary – has also since recommended that the GMS contract be phased out by 2030, with the majority of GPs employed by scaled providers such as hospital trusts.
This model – dubbed ‘vertical integration’ (VI) in DHSC-speak – has been cropping up in various pockets across England. But, despite Mr Javid’s apparent interest, there has been little analysis of how it has worked for GPs or patients.
So is this something GPs should fear? Or could it represent a lifeline for a profession on the edge?
The Royal Wolverhampton could be seen as the flagship for VI. It houses nine practices now, from a high of 10 in 2018. The trust told Pulse in a recent statement that it believed integration could ‘offer solutions to some primary care challenges, such as rising demand and a high number of the workforce nearing retirement’. Local GPs agreed, telling Pulse in 2016 that the move would reduce stress by ending ‘the grief of a small business and issues with staff’.
As the best known example of the model, it is no surprise it was referenced in The Times’ article. Yet there has been no extensive independent evaluation of its outcomes. The sole (publicly available) analysis – by a specialist NHS team in the Midlands – was published in the BJGP in 20202.
Importantly, it drew no conclusions about the effect on GP workload, patient satisfaction or health outcomes. But local GPs told Pulse of issues with satisfaction and fewer patients joining practices run by the trust. The latter does seem to be a concern, and being in the trust appears not to have improved recruitment and retention much.
In terms of the effect on GPs’ working lives, however, anecdotal information suggests it has been broadly positive. One local GP told Pulse there had been no heavy-handedness from the trust when taking over practices, nor any wholesale changes imposed with regard to how the practices are run.
The trust told Pulse that the benefits are ‘soft’ ones, such as dedicated back-office support for GPs – including finance, HR, estates etc. GPs also have access to professionalised governance, which supports things such as CQC processes, complaints and incidents, while patients have access to more services from their practices.
Another benefit of the model is that the trust has been able to analyse primary care data from the integrated practices and use their larger analyst team – and GP knowledge – to interpret the data.
There is a concern that a two-tier service could develop, where patients at trust practices get priority access, but commissioners, local GPs and the LMC are keeping a close eye on this. It has also been pointed out that once a practice joins, it is difficult to leave – partly because staff move to different terms and conditions.
The very first example of VI was in Northumberland, however. And, unlike in Wolverhampton, there was one overriding metric of success: keeping practices open. In 2015, the Northumbria Healthcare NHS Foundation Trust set up Northumbria Primary Care Ltd as a wholly-owned subsidiary to support local practices. It started with three practices, and now runs seven across Northumberland and North Tyneside.
‘We had a number of situations – not quite “last man standing” – but where practices just couldn’t continue for whatever reason or had great difficulty, and to a certain extent in the early days the trust did underwrite [that] and take the risk,’ says Dr Jane Lothian, a retired GP and Northumberland LMC’s lead officer, who was clinical director for community services within the trust at the time.
‘Some practices have had financial problems, some have had personal issues that weren’t foreseen, some have had premises issues… and greater scale has allowed them to ride this out.’
Dr Lothian, who was involved in the planning of the model and later worked as a salaried GP within it, says the practices chose the trust model because ‘on the whole’ they considered it was preferable to have the protection of employment, and there was a good relationship between GPs and the trust. The move was treated with suspicion at the time but has been a ‘lifeline’ for the practices involved.
‘I’ve had quite a number of GPs and partners [from within those practices] come to me and say we would never have survived if we hadn’t been members of Northumbria Primary Care,’ she says.
‘Nothing in the garden is rosy – it is not as if they are all going to work and sitting back with nothing to do but, put it like this, they are all still standing.’
In 2016, the organisation reported that 100% of GPs felt they were meeting patients’ demands better following the move and 82% said that workload had improved.3 Meanwhile, all practices achieved more than 98% of QOF points in 2018/19, according to its website, and all have a CQC rating of ‘good’.
Dr Lothian is clear though that one size doesn’t fit all – and says the Northumbria model was built on a ‘long history of having a trust that tries to understand primary care’, meaning relationships were in place to work through any problems. The main challenge, she adds, has been ‘getting two sets of organisations to understand each other’s culture’.
In Gosport, like in Northumberland, the move to VI was borne out of necessity. Four struggling practices merged to form the Willow Group in partnership with Southern Health NHS Foundation Trust in 2017, subcontracting to the trust with the GPs becoming salaried. The group was established after one of the practices approached the trust about a potential takeover due to workload pressures leaving its GPs on the brink of burnout.
The group’s former clinical lead told Pulse at the time that the move addressed ‘the difficult situation faced in Gosport in the past 18 months in terms of GP recruitment’, with the new model designed to ‘improve resilience to the capacity challenges we’re experiencing’. The move would ‘improve access’ and the ‘range of services’ that they can provide. 4
The model in practice is slightly different to the others. Rather than operating as individual practices, all four have different roles and work as a system. One practice houses a same-day access service, two offer routine and priority GP appointments, and the fourth focuses on long-term care. All calls go into a telephone hub staffed by a care navigating team.
One of the key benefits, says GP and the group’s clinical director Dr Robin Harlow, is improved governance processes: ‘We have a clinical team that every week goes through [any] concerns, complaints, serious incidents, deaths, in partnership with the trust, and incredible learning has happened through that.’
Yet GP recruitment problems – the main reason behind the merger – persist; two senior partners left after the first year. The group also experienced an exodus of patients although it is back up to its original combined list size of around 36,500 patients and has a relatively stable workforce, albeit with a reliance on long-term locums.
Crucially, Dr Harlow says, the trust model has ‘supported resilience and the ability to deliver primary care in Gosport’. But his conclusion is similar to Dr Lothian’s: ‘We are keen to support the development of this model but it’s not for everywhere and it’s not for everyone.’
General practice survival
In December 2020, NIHR published a rapid evaluation5 of three VI schemes – two in England and one in Wales (although it did not reveal their identities). It concluded the main beneficial impact was that ‘GP practices remained open that otherwise would very likely have closed’.
It found the historical division between primary and secondary care remained a challenge and that ‘significant financial investment’ was still needed to recruit and retain salaried GPs. A loss of autonomy for GPs was also noted. Some left ‘to become locums or to cease practising as GPs’. This affected clinical leadership in trust-managed practices, particularly those more reliant on locums, the report added.
Another fundamental worry is how trusts might use the GPs. North Staffordshire LMC chair and Stoke GP Dr Chandra Kanneganti warns: ‘There are big backlogs in hospitals and they will use [salaried GPs] to do the follow-ups and mop up their work… meaning patients will lose traditional general practice support.’
Tower Hamlets LMC chair and east London GP Dr Jackie Applebee is worried about the lack of consultation on a wider VI rollout: ‘It is just a top-down idea. I don’t know if [ministers] have looked at the pros and cons.’
GPs’ role is distinct from that of hospitals, she says. ‘We are a brilliant gatekeeper for secondary care, and we are expert generalists. I think that’s not understood – we do have a different specialism from hospitals.’
‘We’ve been able to borrow staff from the other practices’
Cheshire and Wirral Partnership NHS Foundation Trust – which provides mental health, learning disability and community physical health services – holds APMS contracts for three practices. All were taken on by the trust after being unable to recruit new partners.
A GP in West Cheshire describes to Pulse how the arrangement is working:
‘From a salaried perspective, the work is very equitable and manageable; we all work well together and there is very much a structure to your start and finish. If we stay behind and work extra hours, then we are paid for those hours. We have a clinical director who’s approachable and provides support for clinical decisions where we need it.
‘A huge positive – particularly during the challenge of Covid – is that because there are three practices under the same trust, we can share staff around. Where there’s been sickness absence, we’ve been able to borrow staff from the other two practices.
‘The big disadvantage to this way of working is that it can be very difficult for GPs to join in meetings with our PCN. In discussions about funding and services… we have to feed back and wait for somebody from the trust to give agreement. We have good relationships with GP colleagues and they understand, but it takes longer and is frustrating.
‘I think this model needs to develop because there are challenges. On a single practice level of just day-to-day care it can work, but it’s that wider picture of how do we all link together? If we go forward with some practices being trust owned and others partner led, then I can’t necessarily see it working well because we will hit the same obstacles.’
• Cheshire and Wirral Partnership NHS Foundation Trust was approached for comment.
- Smyth C. GPs nationalised in Javid plan to reduce hospital admissions. The Times, January 29, 2022. Link
- Yu V et al. Hospital admissions after vertical integration of general practices with an acute hospital. BJGP 2020;70(699):e705-e713. Link
- GPs who went salaried under hospital trust now ‘better at meeting demand’. Pulse, 19 October 2016. Link
- Five GP practices merge with hospital trusts to shore up their finances. Pulse, 26 April, 2017. Link
- NIHR. Vertical integration – acute Trusts providing GP services. December, 2020. Link