A combination of an ageing population, recruitment demands and financial pressures is creating severe challenges across the NHS. All raise tough questions for primary care providers. While change is always challenging and can be daunting it is clear that sticking to traditional GP practice models will result in many of those models becoming unviable.
For those willing to embrace change, there are solutions available that can help tackle the funding, recruitment and demand challenges GPs face. These models include GP super practices, which are created through a formal merger of a number of independent GP practices into a single larger entity. The numbers of practices involved can vary and the exact working of the model can be tailored to local needs.
Risks of GP super practices
As with any organisational change, during the planning and implementation phases of setting up GP super practices, there will be a range of risks that need to be understood and overcome, including:
significant transition costs
cultural differences and resistance to change
losing local connection with staff and patients and reductions in GP’s personal autonomy
lack of regulatory approval
legal and governance challenges
optimism bias and implementation costs
poor project management
existing commitments and contracts.
To deal with these risks there must be a clear strategy and budget to ensure all GPs understand their own accountability for the changes required to establish a successful super practice. All changes must be fully costed and accounted for in the budget.
Super practices have a greater chance of success and of managing the risks when there is strong local leadership and significant buy-in from GPs, staff and external stakeholders such as commissioners and regulators. Having a good communications plan in place which has a clear focus on the needs of all groups affected (both internally and externally) and delivers regular communications (including face-to-face meetings and local press articles) is essential in achieving this positive support.
Getting the partnership right
Another important element in the successful implementation of any new structure is the drafting of a comprehensive, well-crafted partnership agreement. Partnerships without an up-to-date deed expose themselves to the risk of complex and costly situations in the event of the death, bankruptcy or dissolution of the partnership by an individual partner.
Disagreements could also arise on clinical matters, workloads or culture or even a clash in personalities. Super practice partners should therefore consider including a ‘green socks’ clause (which enables partners to exclude another partner without having to give a reason and, more importantly, without having to prove an expellable offence). Or, at the very least, clearly set out the circumstances which would result in an individual partner being expelled from the group to avoid the costly and time-consuming process of dissolving the partnership.
Disruptive technologies are increasingly affecting primary care services. Super practices should set out in their business plan how they will harness new automation and digitisation to increase the efficiency and effectiveness of services provided.
A super practice is well-placed to invest in and benefit from technological transformation, given the economies of scale and greater purchasing power. Areas of focus might include digital prescribing, utilisation of telehealth and adopting digital patient records.
There are also opportunities to reduce the number of appointments where patients do not attend or ‘was not brought’ instances, through improved reminder and booking systems for patients, and more digital communication with them. The super practice needs to make sure that it has the decision-making processes which give it the flexibility to embrace new technology.
Top tips from an early super practice
An early-adopter super practice offer a number of lessons they learned during the process:
Communicate the benefits - one of the first of which is a really strong voice in the health community
You can’t have enough communication with partners at the outset (in particular focusing on exactly what is going to happen)
Repeating messages to partners is helpful - it is surprising what gets forgotten later
Be clear on the expectations with GP partners and don’t over-promise
Don’t under-estimate the importance of tax in the decisions you make
Producing accounts in-house takes a large amount of time in year one
To realise savings you need to standardise practices ie procurement and locum costs
If GPs want to reduce their own administration time they must cede responsibility to the super practice
Administrative time savings do not appear immediately due to time spent on managing change
Dealing with the CQC on merger can take a lot of time at the beginning.