Working at Scale

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.

Under the Five Year Forward View NHS England wants to see general practice offered by larger units typically serving a patient population of 30,000 to 50,000 patients. It argues that without a radical overhaul the NHS will not cope with increased demand.

NICS enables GPs to start collaborating between individual Practices to deliver more care in the community, driven by the desire to achieve economies and tackle workload and recruitment problems. It also enables GP’s to bid for services under contract to the NHS.

Challenges of working at scale

One of the the big challenges for General Practice will be to see GP collaborations working effectively for their local populations and ensuring that the benefits of small practices will not be lost.

Some GPs view the prospect of joining with others as a potential issue to their independence and localised patient care and working conditions. However, some primary care doctors in other parts of the world have managed to combine independence within a networked organisation.

Hill Physicians in California an example of a highly regarded organisation which is a network delivering efficient and sustainable care and all of the providers have maintained their independent contractor status.

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.