Alternative provider medical services (APMS) contracts have a growing foothold in England, with the traditional model of general practice increasingly being bypassed for one in which non-medics are in charge.
So, is there scope for more practice managers, nurses and pharmacists to provide primary care services? The answer from three such professionals who have already done it is 'yes'. And they say that GPs should not see this as a negative step.
Practice manager Val Hempsey has been sole 'partner' of the PMS surgery Bridges Medical Practice on Tyneside since 2006. She employs five salaried doctors as well as other practice staff including a nurse prescriber, a pharmacist and administration staff who double as healthcare assistants.
Holding the fort
She says her status as sole partner came about by default, after the departure of the three GP partners, with whom she shared PMS partner status.
'Sometimes I think the reason I'm sole partner is that I'm last person standing,' she says. 'In 2003, one GP partner went on long-term sick leave. In 2004, the second partner emigrated to Canada. Then the third GP had an accident and was off sick for six months.'
For almost a year, Ms Hempsey ran the practice with locum GPs. So when the third partner announced that he intended to retire, becoming the sole partner seemed an obvious move for her.
'There was nothing in the contract that disallowed it and I had been there since the 1970s,' she says. 'In autumn 2005, I informed the PCT of my intention. In June 2006, I was sole partner.'
The practice has found ways around the fact that Ms Hempsey is a non-clinician. The LMC is supportive and on its advice, Ms Hempsey appointed a medical lead. While she is an educational supervisor for a GP retainer - an arrangement that was approved by the deanery - Ms Hempsey does not provide clinical supervision.
'The doctor has peer support from the other GPs for that,' she explains.
Respecting GP values
She says that, in all other respects, the practice is traditional: 'I have not done anything revolutionary. The model is as it would be in another practice, except that I am leading it rather than a GP. I don't think of myself as non-NHS.'
Greg Moorhouse, managing director of IntraHealth, which runs four general practices in different areas of England, also sees himself as part of the NHS. He is a pharmacist who says his company espouses the values of general practice, with an emphasis on continuity of care and best practice.
'I don't consider myself as challenging anything but the difference is the way we are structured. Yes, we are a company but it's just a different model. It's a privately owned, NHS limited company,' he says.
Mr Moorhouse sees the traditional model of a medical partnership as bureaucratic and inflexible. He says that there can often be tensions between older and younger partners who want to push the practice in different directions. So, six years ago, Mr Moorhouse started IntraHealth. Now the company has 100 staff and four NHS general practice contracts - three under APMS and one under PMS - covering 15,000 patients. None of the practices was acquired via competitive tendering.
'All of them have been by invitation. IntraHealth is not confrontational and I'm not trying to take over,' he says. 'For example, at the West Cornforth medical practice in Sedgefield, Co Durham, the GP was retiring due to ill health. He had the choice of the practice being merged with another practice but he chose to hand it over to us.'
Mr Moorhouse says that operating on a commercial basis has allowed IntraHealth to focus on specialised skills such as financial analysis. The board comprises executive and non-executive directors, all of whom are practising in primary care although not all as doctors.
'We have pharmacists, GPs and NHS managers as shareholders. Anyone who's interested, not just GPs, can get involved in the business side,' he says.
Mr Moorhouse believes that GPs should not feel threatened by non-medics getting involved in general practice. The way IntraHealth is structured enables doctors who want to opt for a leadership role to do so. Others are supported to develop different interests. For example, one GP has become a GPSI in substance misuse while another has become interested in education.
'We have four practices, so we can accommodate that. The GPs can choose the model they want,' he says.
Catherine Baraniak, one of the first nurses to run a practice as a self-employed, independent contractor, also believes individuals should be able to choose a career path, regardless of their profession. Nearly 10 years ago, she set up her own PMS practice in Derby and employed GPs. Now she has GP partners and runs two practices, with a third opening next year.
The model at her practices is for nurses to see patients and to resolve 80 per cent of the problems they present with. This allows the GPs to concentrate on the more significant problems, and 20- to 30-minute doctor appointments are typical.
Ms Baraniak says there should be more encouragement of non-medics to provide primary care medical services. 'We should promote nurses in leadership roles. We need to develop those positions and should be encouraging nurses with entrepreneurial skills.'
Non-medics with practice contracts
Practice manager Val Hempsey, Tyneside
- Sole 'partner' of a PMS practice since June 2006, following the departure of her three GP partners.
- She employs five salaried GPs.
- Educational supervisor, but not clinical supervisor, for a GP retainer at the practice.
Pharmacist Greg Moorhouse, four practices in England
- Managing director of IntraHealth. Began his career as a pharmacist in a large fundholding practice 13 years ago.
- Started IntraHealth, 'a privately owned NHS limited company', six years ago, running three APMS and one PMS practice.
Nurse Catherine Baraniak, Derbyshire
- One of the first nurses to run a practice as a self-employed independent contractor under PMS when she started in August 1998.
- Three years ago, she formed a partnership with GPs and now runs two practices in Derbyshire - one inner-city and one rural - with a third planned for next year.