Is bigger really better when it comes to general practice? Funding cuts, increasing patient demand and a push to provide more care in the community have all made it increasingly difficult for smaller practices to survive.
In this challenging climate many practices have found advantages in merging and increasing in size. One such practice is the Priory Medical Group in York.
The group operates on a scale similar to a medium-sized business. Comprising nine surgery sites, a 56,000 patient-list size and staff headcount of just over 200, including 17 GP partners, two associate partners and 33 salaried GPs and registrars, it has become one of the country’s largest practices.
It grew in size both organically and through acquisition. In 2013, a merger with Abbey Medical Group increased the number of surgeries it had from six to nine, expanding the practice’s geographic reach and patient numbers.
The merger effectively gave the practice, which works on a PMS contract, full city coverage across York, says Martin Eades, managing partner.
‘There is a push for bigger practices in order to find greater efficiencies,’ he says. ‘Cornershop GP practices are not really viable anymore.’
So what are the benefits of working on such a large scale?
Mr Eades explains its aim has been to increase efficiency but still maintain the ‘family doctor’ ethos based on individual care.
‘Despite the number of surgeries in the practice, a patient’s relationship is still with their own GP and nurses at the surgery they usually visit. That continuity of care is particularly important for vulnerable elderly patients and those with long term conditions so we see each separate surgery as an "island" supporting its community.’
However, patients greatly benefit from the increased convenience a larger practice can afford to offer.
‘Patients can use any of our branches for an appointment,’ Mr Eades explains. ‘If they can’t get an appointment at their usual practice in the time they want, we can offer them a more convenient appointment at another surgery.
‘We have one medical system so records are not an issue. We can flex the system, which we couldn’t do if we were smaller.’
He adds: ‘We have set an ambitious target in that we also offer urgent care in each of our surgeries all day, every day. So if a patients calls up and asks to be seen the same day we will accommodate that.’
Clinical staff and services
In terms of delivery of care, a key benefit is that there is a range of expertise and specialist skill on tap within the group, Mr Eades says.
‘We have broad clinical specialist GP skills that we can make use of. We have an internal referral model so instead of a patient automatically being sent to hospital to see a consultant specialist they might first be sent to see another GP colleague for their view. It expands the clinical service offering.’
And that enhanced clinical service offering extends beyond the GP. The practice employs its own team of around 35 nurses, including specialist nurses to run various clinics such as diabetes or asthma. And, because of its practice population size, two dedicated teams of community nurses employed by the local hospital, support patient care.
Mr Eades explains: ‘Two teams of community nurses operate out of two of our surgeries, each covering East and West York. Although the community nurses are employed by York Teaching Hospital NHS Foundation Trust they are housed with us and use our facilities free of charge. In return for that, the agreement is that the nurses see our patients.
‘This means they have access to our medical records and clinicians and are an integrated part of our team, encouraging more holistic discussion about patients and improved provision of care.’
Mr Eades says being able to innovate is crucial. Working on a larger scale extends the scope for testing new ways of working and securing more contracts beyond PMS or GMS work.
For example, the Priory has been working as part of a two year CCG-funded pilot project, called the York Integrated Care Team, which provides multidisciplinary care to high-risk patients.
Although the pilot began at the Priory it has now expanded to include four other practices in York. A team comprising a care-coordinator, social worker, third sector worker, GP, nurses, and care worker (a new role that is a hybrid between a healthcare assistant and social carer) come together every day in a multidisciplinary team meeting to review all admissions to, and discharges from, hospital that took place the previous day, across the five practices’ patient population.
‘As a result our admissions are down by 3% against an overall average in the area being up by 6% over 12-24 months,’ Mr Eades says.
There may be clinical advantages but working to scale also means the practice can drive up efficiencies. Back office support such as HR, IT and finance is centralised, delivered from one site to all nine surgeries. Because the practice has entire teams in each of these support roles it is also able to sell support services out to other practices and bring in extra revenue.
Mr Eades also explains that added capacity as a result of being so large means the practice can boost income by offering health services on a private basis to schools, prisons and psychiatric hospitals.
‘This also makes us an attractive place to work because we aren’t just providing standard GP services. We can expose doctors to all sorts of experiences and training opportunities.’
Ultimately, Mr Eades says, the practice size and its wide-ranging patient demographic affords the group local influence, and gives it a powerful voice with commissioners and other bodies, which can be a real advantage when trying to shape and innovate delivery of healthcare.
‘If the CCG wants to pilot or test change we are of a suitable size and scale to do it properly, and we have the internal resources,’ Mr Eades says. ‘We can tap into what patients want from us and provide it.’