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What does working at scale mean for GP practices?

There are a number of government and other initiatives aimed at supporting and encouraging practices to 'work at scale'. Fiona Barr reports on what they are aiming to achieve.

Smaller practices are struggling and there is a push towards larger practices or groups of practices (Pictures: iStock)
Smaller practices are struggling and there is a push towards larger practices or groups of practices (Pictures: iStock)

Patients and GPs have benefited from small scale general practice over the last 50 years. But that model is under pressure as momentum builds to provide general practice on a bigger scale.

At grassroots level GPs have started collaborating to deliver more care in the community, driven by the desire to achieve economies and tackle workload and recruitment problems.

Five Year Forward View

NHS England also wants to see general practice offered by larger units as outlined in its Five Year Forward View published in 2014. It argues that without a radical overhaul the NHS will not cope with increased demand.

It proposed two different models for local health economies that would involve general practice  – multispecialty community providers (MCPs) and primary and acute care systems (PACS).

The Five Year Forward View suggests that any new systems to deliver healthcare would develop depending on the local area. So in some places an MCP (or a variant of this) might be more suitable and in others a PACS would be more appropriate.

The DH recently said it wanted to see 50% of patients registered with these new models of care by 2020. Both of these models are being tested by a vanguard scheme run by NHS England, which wants the pioneers to act as an inspiration for the rest of the NHS.

What are multispecialty community providers?

The Five Year Forward View says MCPs are to be made up of groups of general practices covering a minimum registered list size of 30,000, employing a wider range of professionals including consultants and therapists and offering a wider range of care.

NHS England wants MCPs to deliver the majority of outpatient consultations, potentially run community hospitals and have admitting rights to hospitals. MCPs could eventually hold healthcare budget for their registered list of patients.

Dr Nigel Watson, a Hampshire GP and chief executive of Wessex LMCs, is chair of an MCP vanguard that has started to operate in the New Forest. He sees it as an opportunity for general practice to tackle the difficulties it faces.

‘It has become more and more of a challenge in general practice over the last couple of years and I believe that if we are going to provide out of hospital care at scale it won’t work unless general practice is at the core of that,’ he says.

What are primary and acute care systems?

Under the PACS model hospitals will open their own GP surgeries, for example in deprived areas where GP recruitment is particularly difficult, and eventually potentially take responsibility for the whole health care budget for a registered list of patients.

Whether the profession is feeling inspired or not, is clear is that practices are working more closely together. A Nuffield Trust and RCGP survey carried out in 2015 found 73% of GP respondents in England were now part of a formal or informal collaboration.

Primary Care Home

The National Association for Primary Care (NAPC) has also launched its own model of wider working, an MCP-based system called Primary Care Home, and had expressions of interest from more than 100 groups of practices and other providers wanting to pilot the scheme.

Dr Nav Chana, chair of the NAPC, says : ‘I was surprised at how much interest we had but I think people are fed up of fragmented care and fed up with the bureaucracy and having things dumped us.’

Primary Care Home will test ways of delivering population-based integrated care to registered lists of 30,000-50,000 patients. The NAPC has now selected 15 test sites that it will support to develop the model so that their experiences can be shared with others.

Challenges of working at scale

Dr Rebecca Rosen, a GP in Greenwich, south London and leader of the Nuffield Trust’s project on the new models of care, believes the big challenge will be to see GP collaborations working effectively for their local populations. She hopes the benefits of small practices will not be lost.

She adds: ‘We really need to keep an eye on the value of small practices and and keep the best bits of smaller units.’

Some GPs view the prospect of joining with others as a potential threat to their independence and fear losing control over their income, hours and working conditions. However, Dr Rosen points out that primary care doctors in other parts of the world have managed to combine independence within a networked organisation.

‘Hill Physicians in California is a very highly regarded organisation which is a network delivering efficient and sustainable care and all of the providers have maintained their independent contractor status,’ she says.

Support for those working at scale

Support for practices setting up large scale projects is coming from several angles. The Nuffield Trust has set up a Learning Network to enable 13 large scale general practice projects share their experiences and is also conducting an in-depth evaluation of four sites which it hopes to report on by early summer.

The RCGP has also set up an online network to support practices all over the country. Dr Michael Holmes, the RCGP’s clinical lead for its Supporting Federations programme, says the resource includes information on organisational models, leadership, patient involvement and procurement.

New contract for general practice

The government is also keen to push practices towards working at scale. Last year it announced a new voluntary seven-day integrated care contract for general practice that will launch in April 2017. The government said the contract will integrate GPs with community nurses and other health professionals and be developed as part of the new care models vanguards programmes to support the integration of wider primary and community care services.

So far little has been revealed about how the contract will work in practice, but it seems clear that it will only be viable for ‘scaled-up’ practices or groups of practices with larger patient populations, for example federations, networks or very large practices.

Dr Richard Vautrey, deputy chairman of the BMA’s GP committee and a GP in Leeds, believes the plans do not negate the worth of the national GMS contract and that the two are not mutually exclusive.

He argues that there should be no ‘one size fits all’ approach in the move  towards general practice at scale but points out that smaller practices that are isolated are increasingly struggling.

Dr Vautrey adds: ‘What’s imperative is that we move towards delivering what patients want.’

For GPs this is likely to be a future working as part of a system delivering community-based integrated care. The challenge will be to do that while retaining the benefits and values of smaller practices that patients value.

At a glance: General practice at scale
  • 2014: NHS England’s Five Year Forward View sets out plans for New Care Models programme including two models specifically targeting general practice
  • 2015:  Vanguard scheme of 29  new care model projects launched with access to £200m transformation fund and  specialist support
  • 2017: New voluntary GP contract encouraging  general practice at scale due to be introduced
  • 2020: 50 per cent of population expected to be registered with new models of care

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