New models of care: GPs must learn lessons from early adopters of large-scale general practice

New research on providing GP services at scale shows that successes have been limited and 'hard-won', writes Nuffield Trust health policy fellow Stephanie Kumpunen. But new ways of working are an opportunity to sustain a sector that is 'on its knees' - and lessons learned by the early adopters can help others work at scale more effectively.

Over the last few years, more and more GPs have been forming into large-scale general practice organisations. Stretched to breaking point, they are hoping federations, super-partnerships and networks might provide additional support in the face of rising demand, falling income, bureaucracy and regulatory pressures. Collaborations with other practices offer many potential benefits; including back office efficiencies and economies of scale in procurement.

As exclusively reported in GPonline last November, our joint survey with the RCGP revealed that collaboration was widespread and that three-quarters of practices are now part of larger-scale provider organisations.

The Nuffield Trust’s new report Is Bigger Better? Lessons for large-scale general practice, published today, combined the survey with analysis of quality indicators and in-depth case studies to examine what has helped and hindered the evolution of four large-scale organisations that formed around 10 years ago. It examines whether aspiring organisations can succeed; how they might go about doing so.

Large-scale general practice

So what did we find? One of the key findings of the report is that large-scale general practice organisations could help to sustain individual practices by improving efficiency, developing flexible roles in the workforce, and using technology to enhance patient access and support day-to-day operational management.

By investing in shared management and administration teams, organisations were able to centrally register patients, process referrals, and undertake audits. Leaders reported using quality dashboards to spot underperformance, and offered outreach support and shared staff to help meet local and national performance targets. And importantly, staff reported enjoying working in large-scale organisations: they valued training and development opportunities and benefited from peer-to-peer support.

However, the resources needed to develop and maintain a central management and administration team and to innovate were significant. Organisations not only had to rely on contributions from member practices when the organisation was formed, but also on infrastructure developed for delivering extended services.

So how can others make the most of the opportunities that their organisation might offer? For those who have started or are considering starting the journey towards working with other practices, we have been able to gather various practical lessons and insights from mature large-scale organisations:

Agree your values and goals

Invest time in agreeing the purpose, values and short-to medium-term goals of the organisation. From the organisations we looked at, we identified three main goals, which may provide a useful framework for emerging organisations to develop future plans:

  1. sustain core general practice services;
  2. deliver extended services; and
  3. lead whole-system change as a multi-specialty community provider.

However, organisations should be flexible to their needs; goals were not mutually exclusive and evolved as new opportunities arose.

Set quality targets

Consider creating specific and measurable quality improvement goals and targets that are consistent with local commissioning priorities in order to improve patient care, building relationships with the local CCG, and develop a rationale for CCG investment in the organisation.

Invest in your staff

Invest time and resources to develop staff roles across practices. Create career pathways and invest in organisation wide training and individual skills development. Provide ways for them to communicate with one another and your management team in real time, so they can quickly deal with issues in practice.

Facilitate peer support and peer learning opportunities, which staff told us decreased both professional isolation and variation in care delivery across sites.

Design the simplest governance arrangements possible

To deliver agreed goals and be prepared for them to evolve and become more complex as the organisation’s objectives develop. Also, agree the level of decision-making authority transferred from member practices to the executive team or board and ensure you have enough resources to achieve your goals.

Be mindful of patients’ needs

Engage with patient participation groups to design service delivery that addresses diverse needs and preferences, including rapid access to and continuity of relationships with clinicians. The case studies also demonstrated that large scale GP organisations can use their resources to engage with their surrounding communities.

Don’t rely on ‘heroic’ leadership

The success of many of the organisations we looked at required long hours of work from talented clinical and managerial leads, whose contributions to the organisations sometimes bordered on heroic. It is essential that organisations invest time and resources into developing a broad group of clinician leaders– and do not leave it to an enthusiastic few.

It is still early days for large-scale general practice. The pressures providers working at scale are facing are very real and it is clear that any benefits achieved are hard won. However, practices now have the chance to learn from early frontrunners, who have learnt many of the difficult lessons and whose successes can be now be built upon.

We know that getting these organisations off the ground is not going to be quick or easy. But, as our research shows, they provide a very real opportunity to sustain and stabilise a sector on its knees. 

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