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Little evidence to support move to large-scale general practice, say researchers

There is little evidence to suggest that larger GP practices boost clinical outcomes or save money, researchers have warned.

Their paper, published in the journal Health Policy, found that trade-offs and unintended consequences meant that expected benefits from scaling up GP practices were hard to see on the ground.

The findings come as the NHS long-term plan has outlined plans to mandate GPs to work in primary care networks of 30-50,000 patients.

Researchers urged policymakers to move with caution before upscaling GP practice list sizes.

The academics at the London School of Hygiene and Tropical Medicine, Nuffield Trust and the University of Birmingham found that:

  • Economies of scale from larger organisations may not outweigh diseconomies of scale that may emerge due to new more complex governance and management processes;
  • Little evidence exists to suggest that integrated care initiatives have reduced the use of services or generated cost savings;
  • Improved clinical outcomes and cost savings do not automatically result from ‘scaling-up’.

If large-scale models were to succeed, ensuring GPs felt in control of the process was key, the report stated.

‘National and international experience underlines that the engagement of GPs is essential to increase the likelihood of collaborations succeeding. For this, GPs must feel they have sufficient autonomy and influence over any new groupings,’ it said.

The report noted that over the past decade, ‘new forms of “large-scale” GP-led provider collaborations’ have grown across England. By 2017, four-fifths of respondents to a survey of GPs and GP practice managers were working in some form of inter-practice collaboration.

However until now there has been ‘limited good quality research’ on the impact of upscaling general practice, the researchers said.

After reviewing the existing evidence in detail the researchers have concluded that the expected benefits, such as economies of scale, have not materialised.

The paper said: ‘While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size.

‘Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.’

GP contract negotiations are ongoing but it is expected that GP practices in England will be mandated to join networks of 30,000-50,000 patients in return for a major funding boost.

NHS England said the decision to roll out the model across England came in response to the success of the vanguard trials of multispeciality community providers (MCPs) and primary and acute care systems (PACS).

In 2017, NHS England said that initial data showed that these collaborative care networks were effective in cutting emergency admissions. 

Dr Peter Swinyard, chairman of the Family Doctor Association, said that while no practice today ‘can remain an island’ there were problems with making practices ever larger.

He said: ‘It’s very difficult to provide good continuity of care in large organisations. And it’s interesting that [the report] says that cost savings don’t automatically result from scaling up.’ 

Stephanie Kumpunen, fellow in health policy at the Nuffield Trust and the report’s co-author, said that while the study had not focosed on primary care networks specifically, evidence was still lacking that the long-term plan approach would be successful.

She said: ‘There’s mixed evidence. I’m definitely cautious. There isn’t enough evidence in the UK to say these will definitely work as the Government envisages.’

However she added: ‘But I wouldn’t say it can’t happen. There’s a lot to build on.’