The future of general practice?
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6516 (Published 18 October 2011) Cite this as: BMJ 2011;343:d6516
Abstract
Peter Watts, chief executive of The Practice, talks about his organisation and where it will fit in the future landscape of primary care
The Practice, partnering with the NHS in primary and community care settings, was established in 2005 by two general practitioners with a vision to improve the delivery of healthcare. I was invited to join shortly afterwards to add business experience, and as a result The Practice has a unique mix of clinical and commercial knowledge, making local patient care a priority and running on sound business principles.
We run 60 general practitioner (GP) surgeries in England, including eight walk-in centres, and more than 100 community based outpatient NHS clinics a week. Much of our work supports underdoctored communities, and we often work with patients who have complex and challenging needs.
More than one million patient contacts a year means that our workforce is constantly growing. We have more than 800 employees to date, 220 of whom are clinicians.
Last year was an exceptional year for our team, as we embarked on new initiatives and expansion, helping us to become the United Kingdom’s largest independent provider of GP surgeries. Our clinical assessment and treatment services also expanded as we added ear, nose, and throat services to the ophthalmology and sexual health services already provided. Being awarded primary care provider of the year at the 2011 HealthInvestor awards saw our team’s efforts in innovation recognised.
The wider commissioning agenda
A momentous period of change in the commissioning and provision of NHS care has begun. The debate around the passage of the Health and Social Care Bill has been important for organisations like ours, which want to move ahead with improving patients’ experience and outcomes. We recognise that change in the NHS is an emotive subject that needs serious discussion, which is why we were actively engaged with the policies of the last government and are equally engaged in the current policy debate and emerging architecture. We firmly believe that the independent sector can work with the NHS to deliver improved care at reduced costs under the new proposals.
We have supported the government’s proposals for reformed commissioning and have consequently devolved responsibility to our GPs through clinical commissioning groups. In November 2010, in recognition of our national best practice and “readiness” for this change, The Practice, with other colleagues in Buckinghamshire, was awarded national pathfinder status. I believe that our clinical leadership and experience have given us a unique insight into commissioning clinical services effectively, and the pathfinder is seen to be one of the most advanced in the South Central strategic health authority. We are actively engaged with the local authority, undertaking shadow budgeting and direct management of prescribing, drugs, and referral processes. Owing to this success we have other similar relationships developing around the country in areas where we operate, with the goal of tailoring commissioning to local needs.
The effect of recent health reforms, in extending the role of “any qualified provider,” will not only raise service quality but will increase choice for patients, something we stand firmly behind. The same goes for better integrated pathways of care, which will also give us the opportunity to offer seamless “start to finish” services. We believe this makes for a more efficient health service, delivering improved care at reduced cost, and helping to contribute to the required NHS savings.
Working closely with commissioners to design and deliver high quality services that offer good value for money, with legacy practice based commissioning groups, and with clinical commissioning groups, we will continue to provide first rate services to local communities. Operating across multiple geographic commissioning boundaries in an effective manner, we know that delivering long lasting, good quality health services is not just about responding to national guidelines but to local requirements too. With this in mind we are currently establishing a transparent partnership model, ensuring that elected representatives, voluntary groups, and patient bodies are able to influence the services we offer, staying true to the NHS ideal of patient involvement and choice.
We are all aware of the financial challenges facing the NHS, with £20bn in efficiency savings needed to put our health service on a sustainable footing for the future. Structural changes are needed, but this provides opportunities too, with more care delivered to patients closer to their homes, not in hospital, which for many people is not a necessity. With this in mind we aim to help provide a more cost effective service that relieves pressure on hospitals but, more importantly, that also better suits the needs of our patients.
Workforce development
Ajit Kadirgamar, a practising GP and one of the founders of The Practice, set up The Practice Academy, an umbrella initiative covering a diverse range of training. The scheme not only trains registrar GPs at various stages of their career development but also teaches patient care and customer care to front of house staff and runs specialist organisational development courses such as leadership and life coaching.
Our approach differs from the traditional model of GP training, and our emphasis is on providing exposure to a wide range of teaching styles, patient demographics, and learning opportunities and interests, thus offering a well rounded, experience based approach to training. As testament to this, doctors who have completed their training with The Practice Academy often choose to continue their careers with us.
Our GPs have the opportunity to embark on a unique career development programme when qualified, either concentrating on the delivery of clinical services or pursuing an expanded role, taking on increasing clinical leadership, decision making, and managerial responsibility in a supportive leadership structure. We have seen much interest throughout the year, attracting career minded GPs who are put off by the traditional partnership model but who feel limited by the lack of opportunities in salaried work. There is a growing realisation among GPs that, under the reforms planned for the NHS, clinicians will need to have expanded skills, and as a result they are looking for opportunities to develop and apply them.
Recent growth
This past year has been a busy one for us, as we integrated surgeries from ChilversMcCrea Healthcare towards the end of 2010 and UnitedHealth Primary Care in early 2011, bolstering an already extensive network of GP surgeries and walk-in centres around the country. In implementing such integration initiatives, we continually look for ways to ease the administrative strain on our surgeries and clinics, letting staff focus on looking after their patients while ensuring their continued development. In our experience, improving patient outcomes, combined with increased clinical performance, requires scalable, centralised infrastructure across information technology; human resources; performance management; legal, governance, and regulatory affairs; finance; risk management; procurement; training and development; patient and stakeholder communications; and referral management, to name just a few.
It is clear that providers of primary care need to be more cohesive in how they deliver care to patients. I believe that for our organisation to be fit for purpose we need to create a health network with a scale and complexity that small localised organisations alone cannot achieve. Bringing ChilversMcCrea and UnitedHealth Primary Care under our umbrella means that The Practice’s patients and staff can benefit from the advantages that a larger organisation has to offer. These include our investments in IT infrastructure, such as the clinical systems and telephony needed to deliver high quality, integrated care for a geographically diverse patient base.
Our focus on patient satisfaction is paramount, and we regularly use mystery patient and exit survey exercises at all our facilities, to ensure that we remain highly rated on all measures of patient experience and satisfaction. As a result our registered patient base, currently at 180 000, increases on average by 2000 a month.
The Practice’s future
We eagerly anticipate an even busier year ahead, and our aspiration to improve patient outcomes and maximise the quality of care provided to our patients will remain at the forefront of our activities.
Looking to the future as a well established, active, and fast growing partner of the NHS, we are keen to work with GPs and local health communities to apply our knowledge to help deliver services that are focused on improving health outcomes, quality of life, and the life expectancy of people across local populations. From a patient care perspective, The Practice firmly believes in leading with intervention and prevention. Key to this is establishing clinical support objectives that reduce the requirements for secondary and acute care while ensuring that the patient remains at the forefront of new medical policy. This will also allow us accurately and effectively to commission services on behalf of our patients at the same time as improving patient care pathways.
Unified technology solutions are being developed to provide our clinical teams with detailed insight into local and national care data. This not only leads to better patient support but will also allow us to provide locally driven commissioning solutions that are accurate, effective, and efficient.
In the context of a rapidly changing health policy environment, we will continue to remain at the forefront of clinical excellence and innovation, with the goal of working closely with the NHS commissioning board, clinical senates, and networks to help shape the future of healthcare policy and clinical practice while always staying true to our ethos that our patients come first.
Commentary: Few benefits, but huge risks
Beth McCarron-Nash, negotiator, BMA General Practitioners Committee
Nobody would argue that primary care is perfect or that it shouldn’t evolve. The corporate model of care described by The Practice, however, offers nothing above what could be provided by existing surgeries, but it risks diminishing the pivotal role of the GP as a local independent contractor, which has been the cornerstone of the NHS for the past 60 years
There is nothing different about the knowledge mix of The Practice’s staff, as many GPs already have extended clinical roles within localities. Although The Practice expounds the virtues of its work in underdoctored areas and with complex patients, this is simply what traditional GPs have been delivering for decades and will continue to do. The overwhelming difference between the two models of care is the size and corporate structure of The Practice, which means that it is accountable primarily to its shareholders rather than the local communities it serves. Yet there is no reason why groups of practices cannot share expertise while maintaining a system of care within our current general medical services contracts, where most GPs are usually partners and therefore have a personal stake in the practice. This is a tried and tested model that is responsive, cost effective, and highly valued by patients.
The Practice’s role in current health reforms is not unique. What we need for effective commissioning is greater collaboration among local GPs, secondary care colleagues, public health doctors, and patients to improve local services, not increased competition. We don’t need new independent organisations or the Health and Social Care Bill for effective GP commissioning. It was happening already in many areas, and claims that The Practice was granted pathfinder commissioning status because of its strong record are overblown, as most practices in England are now in pathfinders.
This pyramid model of corporate practice offers little benefit above the existing system, but the risks are huge. At present the Commonwealth Fund rates the United Kingdom’s system as one of the best in the world for quality, access, equity, and cost (www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf). The independent contractor GP is cost effective and delivers high quality care. There’s no evidence that increased competition in healthcare will improve quality, and it risks fragmenting care and existing NHS services. We only have to look to the United States to see that a plurality of providers can increase costs and risks, undermining the collaboration that should exist between primary and secondary care, with patients not profits at the heart of healthcare.
At a time when doctors are being given an opportunity to shape services, it should be GPs, consultants, and nurses driving them from the ground, not an organisation’s business model inflicting them from above.
And, finally, for GPs themselves this model represents a real threat to their working lives. General practice is at a crossroads, and this model is in danger of creating a hierarchical system with an underclass of salaried GPs who have no chance of partnerships or interests in health beyond the immediate clinical consultation. Evidence shows that the partnership model of general practice encourages greater continuity of care and is valued by patients. Although solely clinical work suits some GPs, many young doctors wish to get involved in commissioning and management roles, and this corporate structure will ultimately restrict their choice. There has been an 800% increase in the number of salaried GPs since 2004; but for its imperfections the partnership model at its best offers not just a clinical but a personal opportunity for investment in people, premises, and local communities that a company of employees cannot hope to match.
Dr McCarron-Nash was speaking to Edward Davies, editor, BMJ Careers
Footnotes
Competing interests: None declared.