Averting the crisis in general practice through collaboration

The annual assessment of health and social care in England

Chris Barker, Chief Executive of the Spirit Health Group, explores how to avert the crisis in general practice through collaboration. He believes a new generation of long-term partnerships could hold the key for GPs looking to retain their GMS contracts, offer their patients the continuity of a local practice and build a sustainable general practice.

The recent announcement of 450 GP surgery closures in the last five years will be viewed by many as further evidence that general practice is in crisis. This view has not altered despite promises made within the new GP contract, such as the introduction of the new stake-backed indemnity scheme and the announcements of funding for the formulation of primary care networks.

Investment in services is out of line with significant increases in GP’s workload. Already struggling practices are at risk of further upheaval with changes to general practice from new models of care. High-quality, skilled doctors are leaving in their droves and trusts are finding it increasingly challenging to recruit permanent staff.

According to the King’s Fund, ensuring the longevity of general practice will require a ‘willingness to do things differently’. The difficulty is in finding ways to ensure GP’s retain control of their GMS contract and continue to operate a thriving local practice. Opportunities to innovate are out there but require a willingness to adopt new approaches if they are to be successful.

The recent increase of Alternative Provider Medical Services (APMS) contracts, which allow clinical commissioning groups (CCGs) to commission primary care services from alternate providers, have been a notable change. Originally introduced as short-term stopgaps to allow patients greater choice, extend access and ensure ‘under-doctored’ areas don’t face a gap in provision, APMSs now appear to be the preferred option for CCGs looking to address the GP shortage.

But the willingness to innovate and explore new models for growth should extend beyond APMS. With an ageing population causing increased strain on GP services and threats from new care models, many GPs are finding the current situation untenable and need support if they are to retain their GMS contracts and continue to offer patients the benefit of a local GP service.

Innovative models should not be restricted to struggling practices but expanded to thriving surgeries. The willingness to innovate is crucial to offer more patients access to the local GP practices that they demand and the benefits they bring.

Driving Change

Not a single new GMS contract has been signed in the last five or so years, while over 250 new APMS contracts have been issued. A shift in the motivations of the younger generation of GPs can partly be attributed to the attractiveness of GMS contracts and growth of APMS.

As tenured GPs reach retirement, it is becoming increasingly difficult to persuade the next generation to replace them as partners. Perhaps influenced by the current reality of practice management, the drive for new GPs has shifted, with many seeking flexible working over the promise of partner status. This unwillingness of younger GPs to take on partnerships is perpetuating the cycle, increasing the necessity for CCGs to offer APMS contracts and placing traditional GMS contracts at risk. In under-performing practices, many are handing back their GMS contracts, anxious to avoid becoming the last remaining partner left with massive liabilities. This leaves CCGs with few options; with APMS tenders the obvious choice.

There is some development in Multi-speciality Community Provider (MCP) models and Primary and Acute Care Systems (PACS), allowing practices that hold GMS contracts options to integrate, collaborate or merge with other local practices or their acute trust. But these models will not suit all GP practice teams. Some will find the level of integration unworkable, while others might find it threatens the essence of primary care. So what are the options for practices looking to transform patient care while retaining control of their precious GMS contracts?

Which kind of collaborative agreement?

Entering into a new arrangement with a commercial organisation, while holding on to their GMS contract, is a possible solution. These long-term partnership structures can offer the advantage of reducing the administrative burden and freeing up GPs to spend more time with patients. In this model, practice partners maintain the direct holding of their GMS contracts with NHS England, while the commercial organisation is fully accountable for supporting GPs, ensuring they are able to offer the best patient care while delivering commercially as a practice. Transparent terms of engagement and robust governance offer GP practices financial protection and the ability to realise the full commercial benefit of the partnership while retaining control and, in some cases, can guarantee practice partnership income.

One potential advantage of this new type of long-term partnership arrangement is a reduced burden on management, administration and business development responsibilities, leaving practice partners free to focus on clinical leadership and decision-making. Not only does this allow practices to realise the benefits of working with commercial partners with expertise in developing innovative ideas and delivering sustainable growth, it also offers them access to technological and methodological solutions that enable them to offer patients the highest standards of care.

By capitalising on the expertise and capabilities of a commercial partner, practices can reduce the risk of decision-making in key areas, such as the adoption of new technology, administration, triage and service design. This will enable GP’s to concentrate on their main priority – treating complex patients and providing outstanding patient care. Another benefit of the approach is to offer an alternative perspective on key issues, one that is less influenced by established behaviours and beliefs and may help GP’s to arrive at decisions that embrace innovative new ideas.

Culture of collaboration

Collaboration is something of a buzz word in healthcare. The long-term partnership model fits with both current thinking within primary care networks and GP Five Year Forward View recommendations, both of which emphasise the advantages that collaboration between GPs and commercial organisations can bring. And yet, despite the advantages of collaboration being widely recognised, there are concerns among GP practices about retaining full contractual control and reaping all the benefits of the partnership. This can be an issue, particularly when joining at a later stage or when contractual arrangements are not established up front. Central to the long-term partnership model is a transparent memorandum of understanding, which helps both parties to understand their contractual obligations. Collaboration is built over time, through long-term cooperation and mutual benefit to all parties. The model is scalable, enabling additional GP practices to join the partnership and realise the benefits of the new care model, increasing the number of patients covered while retaining their GMS contract.

Driving the future of general practice

With the highly publicised crisis in general practice, there is encouragement both from commentators and within the sector for GPs to innovate and adopt new models of primary care. The door is open for practices to unlock the potential of working with commercial partners. Long term partnerships not only present options for struggling practices looking to unlock efficiencies, but also offer exciting opportunities for thriving practices to scale and expand their capabilities. With the rise in APMS contracts being put in place in a number of failing practices, long-term partnerships offer a viable alternative for GPs to maintain responsibility for clinical decision-making and retain their GMS contract. This ultimately enables GPs to continue to offer patients the type of care they value: life-long relationships with community doctors who can offer continuity of care.

In the current, challenging healthcare environment, long-term partnership models can offer a much-needed alternative to market trends. In a sector that’s crying out for an alternative way of operating, it could be the innovative solution needed. Long-term partnerships and collaboration could hold the key to enabling GPs to retain contractual control while delivering primary care services that are sustainable and deliver the highest quality patient care possible.