My journey from single-handed practice to super-partnership

On 1 July 2014, after 21 years as a single-handed GP, I became a GP partner in the Vitality Partnership – now Modality, a super-partnership in Birmingham.

What was the tipping point for me to do so? As a religious man who has long asserted that ‘small is beautiful’ and ‘continuity of care’ are as essential as God’s laws (the sick will always need ‘healers’ who know them personally, based on a relationship founded on mutual knowledge, trust and advocacy evolving over time), why did I commit this act of apostasy?

I was bored, demoralised and greatly disillusioned with general practice. But there were also some, perhaps more unprincipled, reasons: (i) I feared it was becoming financially unsustainable for me to continue as a single-handed practitioner; (ii) the guarantee of 6 weeks’ annual leave and one week of study leave left me drooling; (iii) after two decades of resisting ‘polyclinic-ism’, I was exhausted.

Single-handed practice was – and still is – fading. I only managed to maintain quality standards by being a GP trainer. Without trainee GPs, I simply could not have coped with the enormous burden of clinical work and tick-box managerialism.

In this context, I thought it best to opt for safety in numbers rather than die a slow death as a small practice. So, how has this ‘marriage’ unfolded since then?

There have been many plusses. No more need to worry about paying business bills, cash-flow, payroll and book-keeping – all of that is done centrally by Modality’s 'back office'. My lowest-paid receptionist received a pay rise through a standardisation of pay scales across practices. Fears of financial unsustainability were allayed by increased salary rates for managing partners (like me), improving income which was falling fast for single-handed GPs.

Happily, my small practice has not been ‘McDonaldised’. Providing a clinical service is no different from before. Although the practice is now called an ‘outlet’, its old name takes pride of place on the new practice signage, which also carries a Modality logo. Not one patient has commented to me about the new branding. Is it possible that patients haven't noticed the seismic change that has taken place behind the scenes? They should have: our patients are now enjoying access to an in-house dermatology and rheumatology service that is satisfying for both patients and practice staff. The Care Quality Commission are due in any day, but that holds no fears as the Modality management team will handle it with me.

Inevitably, it has not all been plain sailing. There have been one or two disagreements along the way and my ego has been dented by the fact that I am no longer a big fish in a small pond. Rather a small one in a lake. 

So, what of the immediate future? Vanguard status, leading to becoming a multi-specialty community (MCP) provider, is our main hope for finding the funds to solve the clinical workforce recruitment crisis we face. These are extremely stressful times for general practice – no-one really knows the true long-term repercussions of becoming super-partnerships. For me, it is important that meddlesome micro-management is not inflicted on to outlets by the central management team. This is a potential concern, as I have heard the word ‘harmonisation’ being used worryingly frequently.

During my weak moments, I worry that this is a euphemism for homogenisation, reflecting an expectation that outlets will eventually operate like a franchise model. We are constantly trying to identify the best compromise between rigid central control and maximum devolution. Getting that one right is not easy. In my view, primary care organisations in the NHS have never cracked it. Ultimately, the name of this game will never change – it will always be critical that the distribution of precious financial and human resources to outlets (or practices) is done equitably. That, for me, is truly the greatest test of good political leadership, and in my opinion, partnership rather than federation remains the best way to promote equity.

In conclusion, I am delighted to report that my morale has risen significantly compared to two years ago: I'm still a curmudgeon but not bitter! I am certain that being part of the journey from single-handed practice to Modality has been important in my rejuvenation – to the point that I am willing to stick around as an NHS GP for a few more years. Impending MCP status really excites me! 

Please note all views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Trust.

Modality is a super-partnership of GP practices. It was one of four case study sites we examined in depth during our 15-month research project into large-scale general practice organisations. The study examined the factors affecting the evolution of a sample of collaborations and their impact on quality, staff and patient experience. The findings are laid out in our new report, Is bigger better? Lessons from large scale general practice.