New organisational models for general practice:
Dr Rebecca Rosen
Senior Fellow
The Nuffield Trust
General Practitioner
South East London
December 18th 2013
© Nuffield Trust
13/11/2013
Overview
1. Why do we need to think about changing general practice?
2. New models of practice organisation
3. Strengths and weaknesses of different models
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Compelling case for change: (inter)national context
• Primary care is having to balance financial constraints
with rising demand
• Widespread shift in services from hospital to community
is adding to demand for GP services
• Public expectation is rising
• Unwarranted variation between practices in many areas
of evidence based practice (Kings Fund, 2011)
• Fragmentation: Practices operate in relative isolation,
without formal links with other services
• .
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Compelling case for change: practice perspectives
• As small businesses GP practices are vulnerable to
marginal reductions in income – need to diversify
income streams
• Typically have insufficient staff to accommodate new
clinical, administrative & regulatory roles &
requirements
• Reduced income requiring more efficient business
model
• Potential to increase scope of business but need
scale
• GPs are becoming burnt out and open to wider variety
in their working lives
• Some are slightly bored of the status quo and looking
for a fresh challenge
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Making it happen: New organisational models for general practice
Super partnerships: Large practices on several geographically local sites. Formed
through practice mergers. GP led. Single legal entity created.
Networks and federations: Collaboration of local practices, which remain
independent. The collaboration may be informal (a network) or formalised as a legal
entity which can hold contracts. The aim is to increase scope of provision and create
efficiencies whilst maintaining core small business model.
Regional and national multi-practice models: Multiple practices distributed on a
regional or national basis, owned by a single parent organisation which may be a
traditional GP partnership or a public or private company.
Community orientated practices : GP practices embedded in local community and
taking a holistic, population focused approach to general practice – linking health
and wellbeing to employment, skills and social networks
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Super partnership model
Main characteristics:
Keeping what’s good about ‘small and local’
Built on local general practice with local GPs
Delivery at scale: 80k+ patients: practice mergers
Expanded general practice teams
Clinically and quality focused, managerially smart
Integrated planning and delivery of generalist,
specialist and community services
Provider-led population health care management
Foundation for large education provider
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Networks and Federations – Tower Hamlets
London Borough of Tower Hamlets has
established eight GP networks
Main characteristics:
36 practices were formed into 8 networks 2006/7.
Geographically aligned. 4 – 5 practices per
network.
Initially formed to improve diabetes care, then
extended to address other conditions
Substantial PCT investment (£8m over 3 years)
in admin staff to support networks, IT, care
planning and incentives for quality improvement
Focus for peer led change and improvement with
a linked education and training programme
Care coordination enabled by care planning,
shared electronic record and monthly MDT mtgs
Peer led performance review against KPIs for
incentive payments
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Networks and Federations – Suffolk Federation
Formed between Suffolk GP practices, April 2013
Main characteristics:
40 original practices invested a fixed payment
(30p per patient) to join the federation – now 60.
Membership organisation governed by a board of
9 GPs, 3 practice managers and the CEO
Each practice has 1 vote for strategic decisions
Covers a population of 539,000 patients
Formed to win contracts for extended services.
Portfolio of services now covers:
• Diabetes, Ultrasound, lymphoedema,
cardiology and urology
Diversifying roles into practice support including
running a locum bank, HP and procurement
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Multi-practice models
Main characteristics
Partnership and PLC versions
Run multiple practices and services through
multiple contracts
Variety of services offered: standard general
practice; urgent care centres; walk-in centres
Geographically scattered
Variable governance arrangements
Examples: The Hurley Group, The Practice PLC
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Proactive, population focused health care
Bromley by Bow Healthy Living Centre
Health – GPs, community nurses, health
networkers, artists, gardeners, community care
workers and a youth team to explore and
create new ways of thinking about health in a
holistic way.
Enterprise – ‘Enterprise Hub’ - eight social
businesses helping people return to work
Art use of art as a vehicle for breaking down
boundaries and promoting better health
Learning – ESOL, sewing and art groups, plus
opportunities for NVQ, HNC, HND qualifications
(eg working within the centre café)
Environment – a high quality environments
which raise aspirations and boost self-esteem.
Creche – supporting opportunities for working
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parents to return to work
Making it happen: essential ingredients
•
Strong clinical leadership and GP engagement
•
Clear vision for the organisation(s) who are trusted by their peers
•
Time and skills in leaders/belief it’s work making the effort in followers
• Infrastructure
•
IT systems for shared records and data analytics
•
Telehealth and telemedicine
•
Education and training
• Organisation and workforce development
•
New models of governance
•
Skilled managerial support and resources for OD
•
Developing skill-mix and increase multi-disciplinary working
• Financial logic
•
Contribute to financial stability of practices
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Strengths and weaknesses of (three) different models
infrastructure for
quality/efficiency
Super partnership
Multi-practice
Network/federation


+/(needs ‘external’ investment)

+/-


+/-
(culture, internal management)
(standard operating procedures)
(culture & local incentives)
Develop
integrated
services

+/-

GP prof.
development



Opportunity to
diversify ‘practicelevel’ income
Change prof.
behaviour
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Concluding thoughts
• Need to decide core aims for working together and then decide which model fits
best
• Unlikely to get agreement between all local GPs. Let enthusiasts lead the way
and others can follow if they want to
• Develop clear values and goals and ensure local leaders communicate these to
all involved – to develop organisational culture and drive change
• Essential to have management skills & capacity to develop new models at pace
• ? Need to have a single model in each CCG?
• Minimum population?
• Like minded?
• Local rivalries vs burying hatchets!
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