General practice at scale: is it working for front-line GPs?

There is an assumption among policy makers that the inevitable path for primary care leads towards operating at scale. And that, with scale, comes opportunity.

The GP Forward View and, more recently, NHS England’s Next Steps document paint a picture of practices working harmoniously and closely in large groups, reaping the benefits of economies of scale, offering better access and delivering extended services in the community. But what is the reality on the ground?

The journey towards large-scale general practice started almost two decades ago as groups of practices began to join together. The organisations the Nuffield Trust showcased in our report 'Is Bigger Better: Lessons for large-scale general practice organisations' last year - AT Medics, Harness, Modality and GP Care – were unusual back when they were founded. Ten plus years on, many small and single-handed practices have closed and federations, multi-practice organisations and networks have become more commonplace.

GP collaboration

Our 2015 survey, in partnership with RCGP, found that nearly three quarters of practices were operating in some sort of collaborative arrangement. Motivations for collaboration were wide- ranging but centred on a desire to offer better access and more services and to achieve economies of scale through merging back office functions.

Most strikingly, what the survey also revealed was just how long enacting change can take – at least two years to even begin to achieve what they’d set out to do. Finding the time to do the work, convincing colleagues of the benefits of collaboration and building trust presented challenges to those leading the change.

Two years on from that ‘temperature check’, what have scaled-up organisations been able to achieve? Our new survey seeks to answer that question and to understand whether operating at scale is delivering its intended benefits.

One of the reasons why policy makers are so enthusiastic about larger scale general practice is that it offers opportunities for integrated working with other providers. STPs have been charged with creating place-based integrated care systems, drawing together providers from across the system. The ultimate form that these systems will take is uncertain, but the implications for general practice are significant.

Natasha Curry, Senior Fellow in Health Policy, Nuffield Trust

But, of course, the future is not just about general practice in isolation. One of the reasons why policy makers are so enthusiastic about larger scale general practice is that it offers opportunities for integrated working with other providers. Sustainability and Transformation Partnerships (STPs) have been charged with creating place-based integrated care systems, drawing together providers from across the system.

The ultimate form that these systems will take is uncertain, but the implications for general practice are significant. They may offer opportunities for groups of practices to hold budgets for services other than core primary care. GPs may also be given the option to change their contractual status, moving away from independent contractor status and formally contracting with the integrated provider. What is unclear at the moment is what the appetite is among GPs to embrace these changes.

Take part in the 2017 GP at scale survey:

The Nuffield Trust is running a new survey on general practice at scale in conjunction with the RCGP. The survey runs until 31 July 2017, and forms part of a joint programme to support practices in scaling up.

• If you’re a GP, please click here to have your say. What’s happening in your area? Will working at scale deliver all that it promises? Would you be keen to change your contractual status to work as part of an integrated provider?
• If you’re a CCG chair or accountable officer, please click here to give us your perspective. Are practices working at scale in your area? What challenges are you facing in bringing about change? Do you think scaled working will deliver the anticipated benefits?

A version of this article was first published in GP Online on the 24 May 2017.