Is bigger better? Lessons for large-scale general practice
The report looks at pooling GP resources and the impact that this will have.
The BMA Public Health and Healthcare team have done a very useful summary of the report which is below for information
Summary: Is bigger better? Lessons for large-scale general practice (Nuffield Trust)
- 15-month study of large-scale general practice organisations in England.
- Study examined the factors affecting their evolution and their impact on staff, patients, the wider health economy and the quality of care.
Key findings
Rate of formation
- Almost three-quarters of general practices are in some form of collaboration, around half of which formed during 2014/15.
- The two commonest reasons were to ‘achieve efficiencies’ and ‘offer extended services’.
Sustainability
- Larger scale can help improve sustainability in general practice through technology operational efficiency and standardisation, maximising income and enhancing workforce.
- The resources needed to introduce and maintain these approaches are significant.
- Quality of care and patient satisfaction
- Analysis of 15 quality indicators in eight organisations was unable to detect marked differences in quality of care compared to the national average; nor reductions in variation.
- While three of the case study organisations performed significantly better than the national average on over half of the measures, particularly in prescribing, no single large-scale organisation consistently outperformed or underperformed the others on all indicators.
Patient involvement and experience
Patients had mixed views. Some valued new forms of access offered by the larger organisation but others voiced concerns about losing the ongoing, trusted relationship with their own general practitioner (GP) and their own practice.
- Staff experience
- Staff were broadly positive, with administrators and receptionists reporting the highest overall satisfaction scores and salaried GPs reporting the lowest.
- Staff particularly valued education and training opportunities and peer support arrangements across practice boundaries.
Extending the range of services
- The case studies had established high-quality community specialist services that were popular with patients. However, they were mainly small scale and none had yet tried to redesign care delivery across a whole speciality.
- Working with the local health economy
- The quality of relationships shaped the ability organisations to develop extended services.
- Harder for organisations in multiple CCGs to build strong relationships with commissioners.
- CCGs had to manage the paradox of supporting large-scale groups to develop so they could contribute to commissioning plans while also managing conflicts of interest (of GPs who are both CCG members and owners of these organisations).
Realistic expectations
- The case study organisations had been operating for many years and newer groups may struggle to establish the systems needed to deliver efficient, high-quality services if too much is asked of them too quickly.
- Practical insights
- Governance
- No ‘off the shelf ’governance plan: governance arrangements must be designed to support organisational goals and values.
- Whether member practices or the central organisation holds the contracts for core services will influence how the board and executive team work with individual practices.
Models of change
- A more directive model of change where the central organisation held member practices’ GMS/PMS contracts as the executive team had authority to direct day-to-day operations.
- Where practices retained their core contracts a model of ‘concertive’ change was used, which involved member practices and was implemented through peer review, peer pressure and outreach support from the central team.
Economies of scale
- Few efficiency initiatives were groundbreaking, but there was added value from implementing them at scale using standardised systems and processes that could be extended into weaker practices that would not otherwise use them.
- Economies of scale allowed investment in staff, technology and support that would be unaffordable in smaller practices.
Workforce
Creates new opportunities to strengthen and diversify the workforce.
- Investment in training, skills development and peer support seemed to improve job satisfaction at the same time as helping to achieve strategic goals.
- Formal and informal support networks for different staff groups were relatively low cost to organise, highly valued and helped to reduce the sense of isolation felt by many staff in small practices. However, often rely on ‘heroic’ senior staff finding time to support them.
Leadership
- Inspiring clinical leaders played an essential part in engaging and supporting staff
- However, leaders worked long hours, stepping in at short notice to fill staffing gaps and address operational problems – need to disperse leadership roles across a wide group.
Clarity about goals and values
Goals generally included:
- sustaining and improving core general practice services
- delivering extended services in community settings
- leading whole-system change as and MCP (multi-speciality community provider)
- Recommendations
- Recommendations to large-scale general practice organisations
• Invest the time needed to agree the purpose, values and short- to medium-term goals of the organisation.
• Consider including specific and measurable quality improvement goals that are consistent with local commissioning priorities in order to improve care, build relationships with the local CCG and create a rationale for CCG investment in the organisation.
• Invest time and resources to develop staff roles across practice boundaries and to create peer support and peer learning opportunities.
• Design the simplest governance arrangements possible to deliver agreed goals and be prepared for them to evolve and become more complex. Agree the level of decision-making authority to be ceded by member practices to the board that will best balance the pace of change with ongoing engagement of member clinicians.
• Ensure that resources are available to achieve agreed goals and be clear about the level of risk (in terms of investing money and/or resources) that members are willing to take to attain these.
• Engage with patients to design services that address diverse needs and preferences.
• Where member practices are seeking to establish extended services, ensure that these are underpinned by positive, collaborative relationships and shared goals with specialists.
Recommendations to clinical commissioning groups
• Have realistic expectations about the capacity of large-scale general practice organisations to take on extended roles and develop new skills and services.
• Facilitate local debate between patients, the public and other stakeholders about how best large-scale general practice organisations can contribute to population health improvement and what other part they might play in the local health economy.
• Follow guidance on conflicts of interest, but avoid excluding GPs with an expert knowledge of a specific area of care from service redesign work.
Recommendations to national policy-making and research bodies
• Ensure a phased introduction of the alternative contract for large-scale general practice organisations and MCPs.
• Acknowledge the time needed for large-scale general practice organisations to develop
• Commission research on the impact of larger-scale general practice organisations on the quality of core services; the extent to which they deliver the ‘expert generalism’ and continuity of relationship that is valued by patients; and their impact on use of other services.
