Breaking up the 'corner shop' model of general practice

Next month, the first wave of clinical commissioning groups (CCGs) will be authorised. It’s an important milestone on the road to the new world of clinical commissioning, a road which has consumed a large amount of resources and energy in its construction.

Ensuring that all GPs are actively engaged in CCGs is a key test for authorisation: critics have always maintained that the majority of GPs are essentially indifferent to the task of commissioning, and are instinctively much more inclined to come up with new kinds of services.

Many of the supposed gains from clinical commissioning can only come from invigorated, active general practices that have some form of connection with each other.

Whether clinical commissioning is the best vehicle for achieving this is unclear and some are beginning to question whether the policy energy should have been directed instead into breaking up the ‘corner shop’ model that still dominates general practice.

In challenging commissioners and GPs to ‘scale-up’ the constituent units of primary care, The King’s Fund report: Transforming the delivery of health and social care of two weeks ago provoked widespread debate. An (unrelated) consultation from the Royal College of General Practitioners followed soon afterwards, inviting views on how to further develop general practice for the medium term.

If networked, organised general practice is what you’re after, there are plenty of models to choose from, especially if you look abroad. The Nuffield Trust’s latest report: Primary care for the 21st century: learning from New Zealand’s independent practitioner associations, takes an in-depth look at one international case study which has important lessons for the NHS.

Independent practitioner associations (IPAs) are private networks of independent general practices that came together in the 1990s in response to both threats and opportunities posed by a change in Government policy.

Contracts for running community services such as pharmacy or mental health services were up for grabs, and New Zealand’s generally isolated and dispersed body of single-handed GPs were in an otherwise weak position to compete for these.

IPAs sprang into life based on natural communities of like-minded GPs. They were owned and run by GPs and other health professionals. The IPAs provided training, IT support and professional development to their member GPs and have played an important role in modernising general practice.

Some of the IPAs have proved very successful innovators and have grown into profitable businesses, specialising in providing management support services to GPs and other community health bodies.

As they grew, so did their status in their local health economies, and many are now coordinating efforts to build more integrated systems of care.

Their energy comes from provision, not commissioning and their longevity from the fact that they are non-statutory, autonomous bodies that cannot be abolished (although one Labour administration in New Zealand attempted to impose a rival network of organisations directly on top of them, in a bid to boost the public health system).

Their relations with policy-makers and Government are revealing. Public accountability over private organisations has been hugely challenging, and at times the Government has struggled with the diversity of the mission, and an (initial) tendency of some IPAs to neglect population health and genuine engagement of local communities.

Lessons for the NHS? Bottom-up, GP-owned organisations can bring isolated practitioners together into productive, self-improving networks. Their private, autonomous status supports innovation, but it also creates enduring headaches for those wanting full transparency and accountability for public funds.