Letters

Is bigger better for primary care groups and trusts?

BMJ 2001; 323 doi: http://dx.doi.org/10.1136/bmj.323.7303.49 (Published 07 July 2001) Cite this as: BMJ 2001;323:49

Small can be beautiful and effective

  1. Jon Levick (Jon{at}vindomora.demon.co.uk), chairman
  1. Derwentside Primary Care Group, Shotley Bridge Hospital, Consett, County Durham DH8 0PW
  2. Huddersfield HD3 3SH
  3. Meanwood Group Practice, Leeds LS6 4JN

    EDITOR—Bojke et al highlight the importance of deciding the optimal size of primary care organisations.1 Their article reinforces my view that if these organisations are to fulfil their potential then false economies of scale must not be the main driving factor, as they have been with so many NHS reorganisations in the past.

    For once the development of an NHS organisation should be based on its key roles and the environment in which it works to enable it to be as responsive as possible. This is especially the case for primary care organisations. It would be a disaster for primary care and local services if these organisations became reincarnations of health authorities or developed into the inflexible hierarchical institutions that are hospital trusts.

    To Bojke et al's conceptual framework I would add the question “What type of organisation is needed to deliver the potential of a primary care trust?” The tasks faced require our organisations to be flexible, dynamic, supportive, enabling, and learning organisations. The organisations also require ownership from the people on the ground and time to develop before we move headlong into another straitjacketed, bureaucratic institution.

    We shouldn't let a good concept get lost in political short termism or false economies of scale and risk losing the considerable gains so far. Small can be both beautiful and effective.

    References

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    Culture and leadership are also important

    1. David Verlander (panswers{at}aol.com), principal, People Answers
    1. Derwentside Primary Care Group, Shotley Bridge Hospital, Consett, County Durham DH8 0PW
    2. Huddersfield HD3 3SH
    3. Meanwood Group Practice, Leeds LS6 4JN

      EDITOR—Bojke et al discuss the positive and negative aspects of larger primary care trusts.1 Rapid responses to the article on bmj.com have pointed out that, despite the concept that greater size equals greater equality, larger primary care trusts do not necessarily deliver better health care.2

      As Bojke et al suggest, the increased size of a primary care trust (through merger) does not guarantee greater efficiencies and effectiveness—in fact, quite often the opposite is true. The larger the organisation the greater the bureaucracy and the greater the remoteness from customers (patients). Indeed, many of the researchers into mergers have concluded, in the commercial sector at least, that under two fifths of mergers are successful.

      Organisational, cultural, and leadership issues are important. Healthcare organisations are similar to many other businesses in the way in which they develop identities and are led. Many mergers have failed because the new organisation was unable to absorb the previous organisations successfully. Pressures by health authorities and others to merge unwilling and often quite different primary care groups into one primary care trust are, in my opinion, doomed to failure. Cultural clashes, divided loyalties, and lowered staff morale will not yield the benefits and equalities for which some people yearn.

      The real focus should be on the delivery of primary health care in the most local and effective way possible while exploring the benefits of efficiencies through wider shared services arrangements.

      References

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      Larger trusts may reduce inequalities

      1. Richard Vautrey (Vautrey{at}ukgateway.net), general practitioner
      1. Derwentside Primary Care Group, Shotley Bridge Hospital, Consett, County Durham DH8 0PW
      2. Huddersfield HD3 3SH
      3. Meanwood Group Practice, Leeds LS6 4JN

        EDITOR—Bojke et al highlight the debate taking place as primary care groups realise that they will have to merge to be able to cope with the increasing agenda being set by central government.1 As primary care trusts get larger it is imperative that an equal emphasis is placed on developing and empowering smaller localities within the trust.

        The authors fail to examine one of the main reasons why mergers of primary care groups and trusts should be encouraged, particularly in cities. In many large towns and cities several primary care groups have been created where once only one health authority covered the area. This increase in independent organisations has meant that, rather than historical inequalities in the provision of health care being addressed, the differences between areas are increasing. What postcode you have is becoming the main determinant of the standard of health care you receive.

        The best way to avoid increasing inequalities in primary care is to ensure that as few organisations exist as possible.

        References

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