Scaling up general practice: Lessons 10 years on

The ‘retrospectoscope’ is amazing. It gives a clarity on priorities and approaches that, however prescient we might be, elude us at the time. Looking back to the formation of GP Care, what advice would I now have given myself in 2006?

The first, and the most pervasive recommendation of all, relates to communication. Be seen, be heard, be insistent and reiterate the vision. The odd email won’t cut it: get face-to-face with your constituents, commissioners, supporters and detractors. Actively listen to others, but be persuasive yourself and learn to articulate your points strongly. In the early days, our vision was strong but the wherewithal for delivering it was missing. Our financial position was such that it couldn’t support extensive communication and we didn’t do enough to secure additional funding for this critical activity.

To be fair to us, it was 2006 – two years after the 2004 GP contract and before the 2008 financial crash. Commissioners only paid lip service to scaled-up general practice and we were on our own – it felt as though no-one but us understood the need for it. Even then, the jeopardy that the health service faces was discernible, but I didn’t do enough to convince people of the solutions offered by an organisation such as GP Care. We were seen as a private-sector provider that trusts would work with. Commissioners considered us to be driven by extracting profit from the public purse. It was a travesty and a missed opportunity.

Second, recognise that your business strategy might need to evolve. Ironically, we have ceded the central space of our vision as a federation to a new organisation we sponsored. One Care, the Prime Minister’s Access Fund vehicle we established together with our local GP out-of-hours provider, now occupies the ground of direct engagement with, and development of, primary care that we had envisaged for ourselves. With a substantial dowry from central government, One Care can afford the investment in time and resource for the type of engagement I could only have dreamed of. I continue to support it as strongly as I can. After all, it’s what primary care needs. 

Third, when conflicts over values and priorities arise, take decisive action early. You will not succeed unless your top managers agree with and work towards the ambitions that motivate you. In particular, are they there for personal aggrandisement or financial gain; or have they bought into the rather more altruistic social responsibility aspects of the vision that you have?

I should have taken earlier action when I realised there was a growing rift in aspiration in my top team. Your team needs to be honest, challenging and challenged; it needs to avoid group-think and address the hard realities rather than shying away from difficult issues. But it needs to be motivated and agreed on the overarching aims of the organisation.

Fourth, aim to under-promise but over-deliver. Focus on patient quality and exceeding KPI targets. Keep the organisation concentrated on the local business deliverables rather than being seduced by the calls on your time that would easily distract you from your core delivery and growth in patient services. While it is tempting to share and spread best practice in health care, be certain that you only give your time to those requests that deliver real change. In the NHS, I’ve seen too much premature grandstanding of achievements when the actuality does not justify it. It’s hard to avoid committing to events that don’t add value.

Finally, I’ve come to recognise the realities of the business environment we’re in. As a generalisation, GPs are not very commercially savvy. Diversify your contractual income stream: don’t rely too much on one contract or one commissioner, which can be unsafe. Some NHS organisations may get 'interim funding' and eventual debt relief, but if you run out of cash you're dead and gone. In a small enterprise unlikely to be bailed out by the NHS, cash is king.

So would I do it all again?

I’m not sure. It’s been a huge investment of part of my life, and growth of the company has been much slower than anticipated. If we’d been welcomed in the way I believe we should have been by NHS partners, as a component of the solution to its issues, that would have been one thing. As it happens, we’re still trying to eke out an existence and persuade various NHS organisations to use our capabilities. Where they’ve done that, they’ve been very pleased. But it’s grindingly hard to build and retain momentum over a protracted timescale and in an obstinately conservative and risk-averse commissioning climate.

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.  

GP Care is a provider organisation providing a range of services to the NHS and primary care. 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.