Viewpoint: Primary care is at a crossroads and must embrace working at scale

Working in larger units has dangers for general practice, but GPs can no longer ignore the benefits, argues Dr Paul Charlson.

The strength of general practice has always been the practice unit, with mainly full-time partners delivering personalised care to patients known to them.

This model has worked very well with GPs investing financially, socially and often emotionally in a practice for sometimes their whole working life. It was a rewarding and popular career. Patients valued a doctor they knew and trusted and were prepared to tolerate the sometimes idiosyncratic nature of their care.

Times have changed. GPs are finding long-term commitment to practices less attractive, preferring either to be salaried or freelance locums rather than becoming a partner. The previous advantages of being a partner have reduced.

GP leaders champion the idea of federations where practices work together as individual units, pooling some resources yet remaining effectively independent. This is a model which may work in some areas but I suspect is not sustainable long-term. We need a new model or models.

GP contract

There is no doubt that some GPs want to have a financial stake in their business. A sense of belonging and ownership is important not just for partners but among many salaried GPs and this also needs to be included in a new model. Both these things create an ability significantly to influence what happens in their workplace and a degree of autonomy and are highly prized by motivated professional people.

Continuity of care is also prized by patients and clinicians. This is increasingly difficult to provide as the workforce becomes more fragmented but is essential in assuring good clinical governance, quality care and demand management.

New models of primary care are emerging with larger organisations forming. This might be a super-practice with several practices joining together within a geographic area. It might also be a provider organisation having practices in different areas. Both these models have the advantage of greater financial stability and the ability to pool resources.

It makes sense to pool resources such as HR and governance. Similarly larger organisations can be effective for back-office functions like IT support, secretarial work and clinical data processing.

GP specialist generalist

From a clinical perspective, there is a greater need for GPs to be specialist generalists with some expertise in a particular field as hospital specialists become increasingly remote. Why not have several GPs with a special interest within an organisation? Training and supervision is another area where pooling of resources can be effective. Joint tutorials with multispecialty training are often productive and time saving. Cross cover of sessions is attractive to organisations but also to individuals, allowing variety.

Other fruitful areas could be remote clinical triage, improved data and medicines management across a larger group. Then there are the benefits of group buying for just about any supply or service. Similarly the opportunity to commission services and work with other providers in a co-ordinated way is greatly enhanced in a large organisation.

When you examine the changing demands placed on primary care and the change in the demographics, diversity and attitude of the workforce the more it makes sense to look at larger units. However there are dangers in this. Local autonomy and identity is important for patients, clinicians and managers. Large organisations can quash individuality and flexibility.

Primary care is really at the crossroads - things have to change radically. Simply federating and running a few other services is not enough. I would not expect a significant upward change in the financial resources coming into NHS in the next few years nor can I see the ability to control demand altering. Primary care in its current form will continue to be the poor relation of other parts of the NHS unless it changes. However if there is radical change in what and how primary care organisations deliver, money flowing to other parts of the NHS and social care can be effectively diverted and in my view used more efficiently.

I do not think we need a one-size-fits-all model of primary care. A totally salaried service would be a disaster but the current model is becoming increasingly outdated. I believe the super care organisation is a potential way forward.

  • Dr Charlson is a GP in Hull, a director of One Medical Group and vice chairman of Conservative Health

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