Working at scale: How GPs can make faster progress

The rapid growth of collaboration between GP practices has created a complex web of overlapping organisations. Nuffield Trust policy fellow Stephanie Kumpunen looks at how CCGs and policymakers can help them make the most of working at scale.

Rapid shifts towards at-scale working have been underway in GP practices across England in the last few years.

In 2015 we found that three-quarters of GP staff worked in practices that collaborated with others, with their aims focused on improving efficiencies in their practices and winning contracts to deliver more community-based care.

But they also told us that achieving these aims had taken them time. It took over two years for most collaborations to make progress beyond developing an organisational vision.

Two years on, the Nuffield Trust sent out a follow-up survey to see how much progress has been made. So what’s changed and what can we say about the current state of play?

Primary care complexity

The proportion of practices working at scale has increased to over 80%, but the survey paints a complex national picture of collaborative working. GP respondents describe belonging to multiple, often overlapping, collaborations that operate at different levels of the system.

It seems it is not uncommon for a practice to belong to a collaboration with 100,000 patients that spans CCG boundaries while also belonging to a local-level collaboration established by a handful of practices.

Interestingly, the level at which a collaboration operates appears to determine its main focus: smaller operations tend to be focused on improving practice sustainability, staff experience and quality, while the larger ones signal a preference for improving access and transferring services into the community.

This suggests that certain activities are best suited to different scales and that rather than belonging to multiple collaborations creating conflicts, their activities actually seem to complement each other.

It’s not news, but it’s worth saying again: change takes time. Our survey found that progress is still hard won – a major finding of our 2015 survey. GP respondents reported that, out of the three main priorities they set out in 2016/17, only one-third reported having 'fully achieved' one or more.

Slow progress

Although just under half of respondents said their collaboration had set out to improve the financial and organisational sustainability of practices, only 11% said they had managed to 'fully achieve' what they had set out to do. Most progress was reported around improving access for patients, for example through an access hub. Some 52% set out to improve it and 34% said they had fully done so. A further 47% had had partial success.

I initially thought that the national funds directed towards access over the last few years may have made improving access an easier win, but only one fifth of those who said they had partially or fully achieved their aim to improve access had received financial support from the Challenge/Access Fund.

So if money wasn’t necessarily the key ingredient, what was it that made success more likely across all aims?

We found that size matters when it comes to a focus on the workforce. Collaborations operating at a CCG or multiple-CCGs level - and with over 100,000 registered patients - were better able to achieve the goal of improving staff experience, training and education.

We also found that the length of time since forming - the age of the collaboration - was associated with collaborations more likely to improve practice sustainability, transfer services into the community, improve clinical quality and improve staff experience, training and education. Crucially, making progress on all these aims took at least a year.

In the case of improving sustainability, progress took at least two years, most likely because it’s an aim largely reliant on bringing new funds into the organisation – a certain level of organisational maturity is required to do that.

CCG support

Almost all of the CCGs that responded (98%) said that they had actively encouraged collaboration by providing financial support, expert advice and staff for project management. But perhaps there is more that can be done to help collaborations make meaningful progress?

Barriers to progress highlighted by respondents – time to engage and workforce shortages – may not be within the direct gift of CCGs to address. But other issues were raised where CCGs and wider STPs may be able to have a real impact.

Respondents described a complex system where they need to engage with, and influence, a range of different stakeholders at different levels to tight timescales. It would perhaps be useful for STP areas to take stock of which collaborations exist, what they want to achieve and the nuances of their interactions. Creating a meaningful local map of collaborations could streamline communication and relationships and help to identify the support that emerging organisations need to achieve their aims.

As part of this mapping process, GP collaborations could be supported to think strategically about their aims and how these align with local commissioning plans. This organisational development function is nearly non-existent in primary care, but widely exists across hospitals.

Such strategic thinking will be all the more important as general practice collaborations seek to focus their priorities and start to look forward to the role they will play within newly emerging STP arrangements.

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