The challenges and benefits of a practice merger

A merger can be a tricky and time-consuming process, but it can provide new opportunities for improving patient care and boosting income. Rima Evans speaks to two practices that formed as a result of mergers last year.

A practice merger is a complex, protracted process. A whole host of factors including addressing patient and staff concerns, integration of IT systems, as well as legal and financial issues can make it a daunting task.

Despite this, a growing number of GPs are choosing this path – and benefiting from doing so. How are they making it work?

Why merge?

In Telford and Wrekin CCG, three practices came together last April to form an organisation covering 45,000 patients, 17 GP partners and two salaried doctors, called Teldoc.

Its practice director Wayne Cooper tells GPonline the main driver behind the move was a need to remain ‘sustainable and resilient’ amid soaring demand, recruitment problems and tighter funding.

‘No different to anywhere else our CCG is keen for primary care to take on more services from secondary care and for services across health, social care and the community to be seamless. It’s about greater collaboration,’ Mr Cooper says.

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‘At the same time we need to boost income levels, which we think means moving away from relying only on GMS funding. Pursuing these aims and goals isn’t feasible as a single practice. Being a bigger organisation gives us opportunities to offer more services locally for our patient population.’

Meanwhile in Wakefield, West Yorkshire, Trinity Medical Centre also came into being in April 2017 as a result of a two-practice merger. Dr Omar Alisha, a GP partner at the practices says the spur for their merger was shared vision.

The two surgeries had already been working out of the same premises and sharing a nurse-led telephone triage system for patient appointments, but they were keen to forge a closer relationship in order to build quality patient care.

‘We could see the benefits of working at scale such as being able to share workload and offer more services. The two practices also got along so it made sense.’

Still, Dr Alisha, admits the challenges around the merger, which created a 24,000-patient practice, were steep.

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For more advice on mergers, Medeconomics subscribers can access our Guide to Practice Mergers here, which includes:
> The financial aspects of a merger
> The legal process of merging
> Managing staff through a merger
> Engaging with patients during a merger

Staff and patient concerns

First and foremost, he explains, was tackling the people issues in order to allay any anxieties or concerns.

‘We informed staff as soon the decision was made in February 2016, so there was no time for the rumour mill to start,’ says Dr Alisha. ‘We explained the reasons for the merger and set out its benefits, assuring them that nobody was being made redundant.

‘We were also keen to involve patients in our plans as soon as we made the decision public. This early and full involvement meant we headed off major problems, I think.’

What has also helped is appointing someone to a newly-created ‘customer service’ role, he says. ‘This person is there to sort out any issues patients are not happy about,’ Dr Alisha explains. ‘It’s a sort of PR role. It gives us a better understanding of where we need to improve and ensures the patient is happy with their care.’

Partnership agreements and finances

Negotiating the partnership agreement was trickier. ‘We had different sick leave, holiday entitlement and so forth, so we had to review everything,’ says Dr Alisha. ‘We had to reach a compromise between 10 or so GP partners but we did it by allowing ourselves enough time to work it through. It’s a process.’

Teldoc had additional financial issues to consider – parity of earnings between partners and property.

Parity of earnings for partners can often be a stumbling block for many practice mergers. To address the issue the Teldoc practices had an initial frank discussion about their expectations and then sought expert advice from a specialist accountancy, explains Mr Cooper.

‘They reported on our level of earnings and put together a proposal on how we might achieve parity. That was a valuable investment. Currently, we are on schedule to getting to our agreed level of earnings.

‘Property is another thing we had to plan since we have nine sites,’ he adds. ‘We looked at our entire property portfolio and agreed we needed to put leases in place between the property-owning partners of each building and the new partnership.’

Day-to-day issues

IT is an additional challenge. Both practices found that integrating the clinical systems was relatively straightforward. What was more testing was unifying different clinical protocols and staff working systems.

‘The change of technology is the easy part,’ warns Mr Cooper. ‘It’s how the technology is used and reconciling different procedures and systems staff use that is difficult. We decided to delay integration of the clinical systems until we were ready with this side of things.’

A merger may also require practices to rethink the way they operate. Teldoc has created a management board, chaired by a GP and with representation from all founding practices, which meets weekly to make and drive decisions. 

Meanwhile Trinity Medical Centre holds a weekly operational meeting to ensure the smooth running of the practice. ‘Running a large practice is very different,’ says Dr Alisha. ‘We have to regularly go through everything from prescriptions to appointments to ensure nothing is missed.’

Benefits of merging

So what are the benefits of merging? At Trinity, Dr Alisha says, patients now have access to a wider set of specialist services because the skill mix from the two teams is bigger. So, for example, they are now able to offer a minor surgery clinic and MSK expertise to all of their patients. The practice’s triage centre, which was already in place, has also now been extended to cover the entire CCG patient population during out of hours.

Meanwhile, Teldoc says it has made progress in improving how it handles demand. It is working towards introducing a split of routine care from urgent care which hopefully will see the use of 15 minute appointments for routine care and phasing in a system that allows patients to book appointments at any of its sites. 

Both practices also say they have seen a marked improvement in recruitment, which they attribute to the fact their larger size meaning that workload can be better managed and there is more scope for career progression.

‘We have attracted lots of interest from GPs, advanced nurse practitioners and practice nurses and been able to increase our clinical workforce,’ says Mr Cooper.

At Trinity, four salaried doctors have been recruited since just before the start of the merger.

Mr Cooper says: ‘We are still at an early stage but we feel we have boosted our resilience and sustainability. It has set us up to put in place ambitious plans to take on a range of care services.

Tips for a successful merger
  • Enlist support from your CCG and NHS England. A merger cannot happen without their approval.
  • Look to merge with like-minded people if possible.
  • Communicate well and often to both staff and patients.
  • Set a realistic timetable, allowing yourself ample time to prepare.
  • Be upfront and honest about the financials such as parity of earnings between partners. Devise a plan and timescale to achieve what is agreed.   
  • Be prepared to spend time on integrating clinical systems, and protocols and procedures. It may be valuable to engage outside help from the CCG.
  • Be bold in your thinking. If something is not working a completely new solution might be better than than tweaking what exists.

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