While GPs that merge to form bigger partnerships are common, past research shows that patients still prefer smaller practices, writes Rebecca Rosen

Rebecca Rosen

Rebecca Rosen

Rebecca Rosen

For many GPs, the intense demands of their day-to-day work leave them feeling a bit like frogs in boiling water. Desperate to get out, but too paralysed by work overload and general fatigue to do so.

Some are making the jump and leaving clinical practice, but others are wondering whether working at larger scale could offer an escape route from the saucepan.

In common with schools, lawyers and dentists, GPs are increasingly working in larger groups – merging to form bigger partnerships, forming networks with neighbouring practices or working in chains run by a parent company.

Workforce initiatives sought to tackle widespread problems with recruiting and retaining staff

Policy makers and clinical commissioning groups see this trend as an essential way to leave behind the small-scale ‘cottage industry’ of traditional general practice, which is considered no longer fit for purpose.

They want modern, technology-enabled general practice to provide new forms of access for patients and work with the wider NHS to deliver specialist care in community settings. But how likely is it that large-scale general practice can meet these ambitious expectations? 

‘Is bigger better? Lessons for larger-scale general practice’ reports findings from a Nuffield Trust study of large general practice organisations. Combining national surveys, in-depth case studies and analysis of quality data, the report examines the effects of working at-scale on staff, patients, GP practices and the wider NHS.

Research and development

Our survey of CCGs and frontline practice staff found that three quarters of GPs are already working in some form of collaboration. Most have formed ‘federations’ with a group of local practices, creating a registered organisation that they own and run to help deliver care in their own practices and also to offer additional community specialist clinics.

Others have merged their practice contracts into ‘super-partnerships’ with tens of thousands of patients and often many partners in charge.  And some have been taken over by ‘multi-practice providers’ which bid to contract for GP services in competitive tenders.

The organisations developed flexible work roles so staff could cover for each other in different practices

Whatever form of organisation they are in, our research suggests that larger scale can help GPs to withstand current pressures and become more sustainable by increasing efficiency, making selective use of new technologies and supporting their staff in various ways.

Measures to improve efficiency included centralised administration teams and central call centres to book appointments; support specialist clinics; identify people needing preventive care and bring them in. They also develop standardised ways of working and make savings through joint procurement of equipment and services. 

Technology was used to increase access to care and each organisation was involved in extending access to GP appointments through central ‘hub’ clinics open to all registered patients. They increased administrative efficiency through web-based functions such as new patient registrations and automated performance reporting.

Shared clinical information technology (IT) systems were also important to support standardisation of clinical care and improve communication among staff.  

Workforce initiatives sought to tackle widespread problems with recruiting and retaining staff. The organisations developed flexible work roles so staff could cover for each other in different practices.

Technology was used to increase access to care and each organisation was involved in extending access to GP appointments through central ‘hub’ clinics open to all registered patients

They trained clinical and non-clinical staff in new skills, increasing the diversity of their working life which many interviewees reported to increase job satisfaction. And they developed formal and informal support networks for different staff groups which were reported to increase skills and reduce professional isolation.

Each of the organisations we studied was also delivering extended services that used to be provided only in hospitals. Clinics in dermatology, gynaecology, urology and more were being delivered by GPs, nurses and other staff working with specialists in community clinics.

Although most of these extended services were small scale, they rated highly on patient feedback surveys and the staff that provided them enjoyed the work.

So what did patients make of these changes?

We asked patient participation group members in each organisation what they thought about their GP practice collaborating with others. Some valued the opportunity to access services in new ways but others were worried that they would lose contact with their usual GP and find it harder to use their usual surgery.

While policy makers have great plans for large-scale GP organisations, past research shows that patients still prefer smaller practices – although our research provided no evidence that they couldn’t see their usual doctor.

We need to be sure we that we preserve the best of general practice while creating the GP practices of the future

After 15 months of studying large-scale GP organisations, the research team are convinced that these organisations could help with the sustainability of general practice. However, the potential benefits don’t come easily.

They followed many years of sustained hard work by talented and committed leaders and it remains to be seen whether newer organisations will be able to follow in the footsteps.  

Our message to policy makers, who hold substantial expectations of large scale general practice, is to keep supporting them. But be realistic about how long it will take them to really start working differently. And look carefully at how patients are affected.

We need to be sure we that we preserve the best of general practice while creating the GP practices of the future.

Rebecca Rosen is a senior fellow in health policy at the Nuffield Trust and a general practitioner in Greenwich