Can working at scale help practices recruit GPs?

The push towards working at scale in general practice has aimed to break down divisions within the health service and tackle workload issues. For some practices, however, the approach has offered a way to beat the GP workforce crisis.

Recruitment is one of the biggest challenges facing many practices. Last week GPonline reported that one in five practices has two or more GP vacancies, with many partner and salaried GP posts remaining unfilled for more than a year. However, some practices are bucking this trend and managing to recruit and retain staff - and they put this down to embracing new ways of working.

‘Certain practice models with personal lists and an integrated team approach have certainly improved recruitment and retention,’ says Dr John Ribchester, executive partner of Whitstable Medical Practice in Kent, which comprises three medical centres, 20 GPs and a patient list size of 36,300.

‘We are working at scale and innovating, while still trying to retain a personal service with every patient having a named GP. We have never had problems recruiting GPs and sometimes we have a waiting list, which is unheard of.’

Likewise, Dr Steve Kell, the GP lead for Larwood and Bawtry Primary Care Home in Nottinghamshire and South Yorkshire, says that recruiting GPs has been easier since they embraced a new way of working at-scale.

'Because this is a new way of working in terms of ethos and culture we have had three new GPs join us, two of whom have become partners,’ he says. ‘One said in their interview that they liked the new approach because it was about working as part of a team rather than being isolated in a room.'

Improved job satisfaction

Dr Ribchester says that the evidence is GPs want to join this kind of model. ‘It can offer a good work/life balance and job satisfaction. If you are in a bigger group there are greater opportunities for a portfolio career and to widen your experiences or specialise in what interests you.

‘From a care point of view, our team is fully integrated,’ he adds. ‘We have around 40 consultants working with us out of one of our centres so it’s a blend of primary and secondary care. On site we have an urgent care facility, a range of outpatient services, diagnostics, paramedic practitioners and more. It’s a rich environment for innovating and building closer relationships with other parts of the health service. GPs can really feel part of a team.’

Dr Ribchester's practice is part of Encompass MCP (multispecialty community provider), which has effectively scaled up the model his Whitstable Medical Practice had developed, and includes 115 GPs from 13 practices. Its impact on GP recruitment and retention is not as obvious yet, says Dr Ribchester, who is also Encompass’ chair and clinical lead, but ‘it’s getting there’.

‘There is lots of work still going on to scale up. Having said that we only have one GP vacancy, so that’s not bad.’

Dr Nav Chana, chairman of the National Association of Primary Care (NAPC), which developed the primary care home (PCH) model, agrees that the culture of team-based care is a crucial reason new care models appeal to GP jobseekers.

‘When I speak to young doctors or medical students there is a strong sense that they want to work in a slightly different way, they want more variety and flexibility and to be part of a team setting, where people are working jointly to solve problems and the burden is not just on themselves.’

Evaluation of three PCH test sites that was published in March showed that they improved job satisfaction (67% of staff across all three sites agreed with this) and helped with staff retention.

'Where teams start to collaborate and address some of the challenges together it makes people feel more happy and motivated,’ says Dr Chana.

Shortage of GPs

Of course, while these at-scale approaches to general practice might be addressing recruitment issues within their own practices, the real issue facing the profession as a whole is the overall shortage of GPs.

The government is still aiming to recruit an additional 5,000 GPs by 2020. Fill rates for GP training places have increased, but last month the BMA warned that with increasing retirements and stagnating full-time GP numbers it was difficult to see how this target could realistically be achieved.

Dr Chana stresses that new care models are not a ‘silver bullet’ for a workforce crisis. He says three elements are required: increased investment in capacity to boost GP numbers overall, a model that matches the right people to the right job so skills and training are not wasted or underused, and collaborative working.

However, Dr Chana says, in the absence of increased capacity in the short term, allowing GPs to organise themselves differently by working together across practices and streamlining approaches to care is both efficient and effective.

Benefits of smaller practices

Dr Peter Swinyard, chair of the Family Doctor Association, points out that continuity of care is one of the big attractions of working as a GP and this is much easier to achieve in a smaller practice. Indeed, one of the criticisms levelled at at-scale models is that continuity of care can get lost.

‘Continuity of care is good for patients, good for doctors and saves the NHS money,’ he says. ‘In these new large hubs where much of the care may be carried out by nurse practitioners or pharmacists, for example, I think it’s much harder to achieve a good doctor-patient relationship. We are risking losing the most important thing, which is the competent generalist and the person who has the patient interests at heart.

‘Small practices can provide all the services offered in these bigger medical centres, the difference is that they may not all be on site.’

Dr Swinyard says traditional practice models still have a pull for GPs seeking new jobs. ‘If you give people the opportunity to experience the more traditional practice model people often like it. However, younger doctors are not being trained to understand the benefits of being your own boss and running your own business so they don’t look to do it.’

However, Dr Ribcheser says that working at scale does not mean you have to lose continuity of care.

‘At Whitstable, we have retained individual lists so a patient can identify a GP as their doctor and there is a line of accountability. That has to be managed but it is possible, we have done it,’ he says.

But it may not be a case of having one model or the other. Dr Sophie Lanaghan, chair of the RCGP associates in training committee, believes having both options available is what makes general practice an exciting career option for newly-qualified doctors.

‘One of the good things to sell about general practice is there is such a variety – you can be in the rural practice or you can work in a super practice – there's something for everybody,' she says.

‘I am open-minded. I would like to experience working in the spectrum of different settings before I make up my mind, and I feel really privileged that I have that opportunity. That’s a really positive thing about general practice – it’s a very broad church.’

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