Working at scale within general practice is big news. Rarely does a day go by without talk of mergers, federations, and Multi-Speciality Community Providers (MCPs) – and various organisations seem to be constantly running research and trials on the subject.

While the various organisations involved with the above are busy following their own agendas, we thought we would discuss whether or not working at scale can actually be successful in general practice and wider primary care delivery.

The expectation of NHS England – and the various thinktanks and healthcare bodies looking into the subject – is that large-scale general practice collaboration can deliver on a wide range of ambitious objectives. These include being able to:

• innovate with and strengthen the primary care workforce
• increase access and extend the range of services available through practices
• improve clinical quality of care and reduce unwarranted variation in service delivery
• create efficiencies and economies of scale in order to make general practice more financially sustainable

And it appears that the promise of the above benefits is making a difference – a survey undertaken by the Nuffield Trust and the Royal College of General Practitioners in 2015 confirmed that GPs are indeed scaling up, with 73% of GP respondents stating they were part of a large-scale collaboration. This figure is likely to rise as, earlier this year, NHS England announced financial incentives to support every practice in the country joining a network of at least 30,000 to 50,000 patients.

But can working at scale really help the primary care sector?

The Nuffield Trust’s study, Is bigger better? Lessons for large-scale general practice, is probably the only study to get into the nitty gritty of the topic – and it highlights some interesting points.

The potential is there:

• In targeted clinical areas, such as immunisation or diabetes, proactive care planning and screening targets improved, as did a variety of health outcomes.
• Networks can drive improvements through standardised data collection, shared IT systems, peer-review dashboards, shared network managers and financial incentives at network rather than practice level, which encouraged collaboration to achieve targets.
• Standardisation of incident reporting, increased learning between practices, and enhanced training and support is possible.
• Competition between practices to achieve performance targets is easier to implement.
• Partnerships have stabilised GP services by pooling resources, standardising ways of working, and bringing in more income – which is often reinvested.
• Collaborating to share and develop staff  has also helped tackle shortages, and improved satisfaction among most professional groups.

There are downsides:

• Achieving meaningful patient and public involvement in planning and implementation of changes to the organisation of health services has proved consistently challenging.
• There is a subsequent risk that reorganisations of health services do not address patient needs.
• Results do not point towards consistent or marked improvements in patient experience as a result of scaling up or integration. For example, while patients may value greater coordination of care, the evidence indicates that changes in routes of access, even if they increase opportunities to access care, may not always be well received by patients.
• Likewise, while the large-scale multi-site GP practice organisation described above led to improvements in some areas, there were also unintended consequences affecting workforce turnover and continuity of care.

Helping practices to cope

 The Nuffield Trust report suggests that forming large-scale GP organisations can help to sustain general practice in the face of intense financial pressure and shortages of doctors and nurses. However, analysis found that so far they had performed no better than average on the national framework of indicators for quality and outcomes of care. Most did better than average at prescribing drugs in line with best practice. But they failed to buck downward national trends on other indicators of care quality, including patient satisfaction.

The case studies found that while some patients were enthusiastic about opportunities to access their GP in new ways, others were worried they would lose contact with their usual GP and find it hard to use their local surgery.

Commenting on the findings, Nuffield Trust Senior Fellow and GP Rebecca Rosen said: “Most English GPs are now joining large organisations, and this research shows how that can help to keep practices going after years of financial pressure and rising workload. What they need now is time and support to develop good relationships with other parts of the NHS, and to make the investments needed to realise long-term benefits.

“It is important that political and NHS leaders don’t let expectations of these new organisations run away from the reality. These are early days, but so far we see no sign that larger organisations are leading to better standards of care. Taking on new services is a major task and will take time. These groups will have to develop much further before they can take on the very complicated task of managing change across the health service.” 

The jury is still out 

This research suggests that the jury is still out when it comes to measuring effectiveness. And that view is shared by research into The Primary Care Home (PCH) model, which is being developed by practices in more than 180 sites serving 8m patients.

Further analysis of three case studies showed the PCH model acted as a strong catalyst for collaboration between organisations in health and social care, redefining relationships between GP staff and the wider primary care community and creating new multi-disciplinary teams, often co-located. However, the research was unable to assess the cost effectiveness of the model or whether it was meeting its main objectives. It also suggests the NHS should balance new money for individual GP practices with investment to support these types of multi-disciplinary work at scale.

The evaluation shows the model has promising signs of success and, like most NHS transformation, is on a journey that is likely to take time working with partners, refining initiatives and building capacity to deliver long term outcomes. More on the PCH model can be found here.

Time will tell how successful scaled-up partnerships will be – and what benefits they will bring to practices. All we know is that, despite the lack of real knowledge about outcomes, they’re not going to go away!

There’s more

If you already have a PCH implementation in the pipeline, or are thinking about one, don’t miss our handy top tips, case study and key points document. Packed full of handy advice, it’s designed to help practices with the roll-out of new partnerships. Click here [PLUS] to read more.

What are your views on large-scale practices and PCH models? Can it work? What are the pros and cons in your opinion? Let us know by commenting below or in the forum here. 

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