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Primary Care at scale isn’t just about size – it is about the ‘right’ size
John Copps looks at what it means to provide primary care services ‘at scale’ and the implications for the existing landscape of organisations.
‘Primary care at scale’ is a phrase that has crept into NHS management jargon over the last decade in response to a system under pressure.
Burgeoning patient demand, squeezed budgets and an acute shortage of GPs all mean that, in many areas, the current structures are close to breaking point. Providing services across a larger footprint, so the argument goes, can alleviate some of its problems by opening up space to innovate and to support patients in different ways.
But what does ‘at scale’ mean in practice? What does this imply for the existing landscape of surgeries, community providers and GP federations?
What is primary care ‘at scale’?
Firstly, and obviously, ‘at scale’ means delivering primary care services to a larger population. It is a challenge to the status quo of the traditional GP surgery, where a partnership of doctors run first-contact medical services for a defined list of patients, typically of six to ten thousand.
A year ago, the NHS Long Term Plan announced the introduction of Primary Care Networks, or PCNs, across England. These are groups of GPs surgeries, working together to serve populations of 30,000-50,000. Given this, ‘at scale’ clearly means more than the list size of a single practice.
Secondly, at scale means primary care that is about more than just General Practice. PCNs aim to bring together multi-disciplinary teams to support first-contact with the patient, which will include pharmacists, physiotherapists and the new role of social prescriber.
Thirdly, ‘at scale’ is about efficiency. Delivering across a larger footprint can produce economies of scale, releasing resources to be used for front-line patient care. Rationalising and sharing back office could produce savings and mean fewer GP hours spent on non-clinical work. Managing them differently could also create more professional and resilient support services, and enable better use of the primary care estate.
Structures for primary care at scale
Primary care systems broadly comprise a tiered structure – individual GP surgeries, fledgling PCNs and GP Federations, across a commissioning area with CCGs increasingly linking up through Integrated Care Partnerships. As PCNs establish themselves and grow more confident, this will have a significant impact on these structures and organisations’ roles.
Already, individual GP surgeries have been forced to see reason for collaboration, driven both by the move to PCNs and by trends in the workforce. The expectations and preferences of younger GPs have changed. Surveys show that new GPs want to combine General Practice with other clinical work and are turned off by the administrative demands of being a partner. Retiring GPs partners are finding it harder and harder to find a successor.
The result is likely to be primary care practices with a greater number of surgeries and new models of management that remove the burden of running a practice from GPs. Already there are examples such as Modality, a ‘super-practice’ of GP surgeries run by a professional management team and board of directors, Sussex Primary Care Ltd, a wholly-owned subsidiary of Sussex Community NHS Foundation Trust, and Granta Medical Practices in Cambridgeshire, a limited liability company with shares held by an Employee Ownership Trust.
Working at a larger scale means that these organisations have more opportunity to work differently and increase efficiency. A word of caution here though. Arguably the biggest savings in primary care are likely to come from changing the model to be less dependent on GPs, distributing responsibility for patient care among lower cost clinical professionals. But this requires a culture change among clinicians and patients as much as it requires a change in the structures of care.
Federations too are feeling the pinch as PCNs threaten to steal their thunder as the ‘at scale’ vehicle for primary care. Their role in providing back office services, delivering services such as Urgent Treatment Centres or out of hours provision, and as a ‘voice’ for primary care, are potentially in jeopardy. Federations may face competition from ambitious PCNs and any new transformation money looks likely to spread itself more thinly. Federations must react quickly to this new world.
The future of primary care at scale
On one level, it is hard to avoid the conclusion that the notion of primary care at scale is a response to the pressure services are under and the acute workforce challenges. But with it there are undoubtedly opportunities to provide a better service to patients.
In my view, the question underpinning primary scale at scale should be ‘what is the right size to do the job?’. In answer to this, primary care must be small enough to provide the personal care valued by both patients and GPs, but large enough to have impact and economies of scale.
Primary Care Networks can be the spur for change. But they won’t be the answer for everything. Some services will be best delivered at individual surgery level, others at PCN and others at a larger scale. CCGs already let contracts for out of hours services across their whole-patch, for example. Would it make sense to break this down to individual contracts for each PCN?
How these changes play out will depend on local circumstances and relationships, and how GPs in leadership positions react. And to respond to the opportunities of primary care at scale, we will need new organisational forms which mirror these requirements.
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