Working at scale: the story so far

With increasing pressure on GPs, many practices are looking towards super-practices and federations as solutions. In theory, working at scale makes for better contracts, more funding opportunities and the benefit of shared resources. But is this the reality of the new care model? Rosie Wilson investigates.

New care models

There have been a number of factors in the rise of demand for new care models; the Prime Minister’s Challenge fund of 2013, higher expectations from patients and the evolution of CCGs being the prevalent few. In order to develop new care models, many general practices up and down the country have been required to consider working at scale.

To work at scale, practices are presented with several different choices, including becoming part of a super-practice or federation. A super-practice is a comprehensive merge in which practices could lose their autonomy – and can therefore experience problems in terms of opting in and out of specialities. Practices that federate, on the other hand, retain more flexibility and can operate largely as single entities, but generally with a shared common interest. If a company is formed to enable the federation to operate, it does so independently from the practices’ day-to-day operations. If there are areas that individual practices want to lean towards or stay away from as part of a federation, they can, but they still benefit from the increased resources that make it possible to develop different ways of working.

Thanks to an ageing population, rising patient demands and concern over funding and GPs being stretched to capacity, working in a new care model is becoming an increasingly attractive prospect for practices. By joining together to share resources, practices can pitch for increased funding – and it’s often a case of strength in numbers.

It’s not always just a voluntary lean towards the benefits though, and particularly smaller practices are finding that the traditional ways of delivering general practice are no longer proving effective. According to one member, the manager of a small, rural practice, “We didn’t really have a choice [on joining a federation]. There was no way we could deliver the services expected from us with our funding going down and down each year. And they were expecting us to offer more in the community.”1

And even large practices are feeling the pinch with a set of different pressures and considerations that are nonetheless proving challenging. A GP at a larger practice said, “[Federating] is the only way we will cope with the demand to make healthcare at a primary level better.” 

Making it a reality

While NHS England’s claim that 50% of the population will ideally be registered within a new care model by 2020 sounds like a lot, sample research carried out by the Nuffield Trust and RCGP2 indicated that 73% of GPs and practice staff in England were already part of a collaboration, although not all of these were formal and registered at the time of response. 44% of these collaborations had been established in the previous 12-month period.

And other new care models are also proving successful. According to a study by the University of Sussex3, which took a sample of 34 practices in central London, A&E attendance was reduced by 10% on weekdays and 18% on weekends, thanks to the introduction of seven-day GP access pilots.

So perhaps the initiative is not only about working bigger, but working smarter. With CCG and government funding, there are myriad options available to practices looking to scale up their care model – but the fact that it is not ‘one size fits all’ has proved a challenge to some.

Challenges to the new model

Typically, it is the larger practices that flourish under a federation. For these, extended opening hours, big contracts and enhancing the skills of their GPs is not only driven by the Five Year Forward View, but a natural progression of the business. For other practices, though, collaborating can prove difficult.

Speaking to Medical Protection, one federation board member said: “We’ve not been able to do anything because nothing is being passed down from the CCG; there are no contracts for us to apply for. So we’re now looking at how to make savings from any economies of scale.” 

"[Federating] is the only way we will cope with the demand to make healthcare at a primary level better"

Economies of scale might seem like a minor aspect of forming a new care model, but they’ve been taken as somewhat of a ‘quick win’ by federations and super-practices whose funding and profits are taking time to come to fruition.

“It’s a delicate balance but we’re getting there,” said a different board member. “We are going into A&E to offset patients being unnecessarily kept in hospital overnight, which saves costs all round. We try and manage referrals within the community via satellite consultants, and we’re planning a whole list of new services and opportunities which help the community and manage our costs.”

While the advantages are recognised, there are hurdles to overcome; there have, for instance, been technological issues to combat. Many practices have complained of IT systems that do not integrate well with the systems of the other member practices, and the need for a single IT platform that is difficult to provide.

Indemnity is another concern for a lot of practice managers and board members, who have found that while professional protection for GPs is relatively straight forward, it can be a lot more complicated to indemnify a whole organisation, or nurses and healthcare assistants working across multiple sites. Medical Protection is currently working with members who have elected to work at scale in order to ascertain the most appropriate way of providing indemnity and supporting members through change.

On page 20, Dr Nick Clements, Head of Risk and Underwriting Policy at Medical Protection, answers questions about how new care models and other changes in primary care can affect your medical indemnity. 

Looking forward

Overall, the future looks promising for federations and superpractices that have elected to work at scale – although there remains a lot of work to be done. As profits begin to turn in the next few years, it will become evident what has been successful – and what hasn’t – in the formation of super-practices and federations. As the Nuffield Health survey2 surmises, while there is no marked improvement in the quality of care provided by federations compared with the national average in the initial stages of the project, large scales are found to “improve sustainability in core general practice through operational efficiency and standardised processes, maximising income, enhancing the workforce and deploying technology.” 

In profile: Leeds West Primary Care

Simon Boycott is the Head of Services at the Leeds West Primary Care Network. Here, he discusses with Medical Protection his experience of the relative merits and pitfalls of establishing - and maintaining - a new care model.

We applied for the Prime Minister’s Challenge fund to run an enhanced access service across Leeds West, but the scheme didn’t choose our proposal so we didn’t get government funding initially. However, the CCG was very keen to see it happen and so it was funded that way. For the past couple of years, we’ve been running an enhanced access service in two localities of Leeds, whereby the patients of several different practices can come to a hub site at the weekend; 8-4 on a Saturday and a Sunday.

It has forced us to look at the way we each run our services and find the best way, regardless of individual preference. And once you start reassessing general practice, you have to consider the current model of delivering care, and whether it’s still fit for purpose. And I think our experience of delivering enhanced access at scale has shown us the models that we might use and the approach that we might have to that, so it’s been very useful from that perspective.

When we saw the opportunity to scale it up across the whole CCG, though, we knew we were going to have to do something a bit more robust. We’re working towards introducing video consultations and better access to putting online services at the ‘front door’ of primary care.

Since then, we’ve been awarded an APMS contract as part of wave two of the Challenge fund, so we’re currently rolling it out across the whole CCG. To receive the money, we’ve registered as a limited company, and each practice in Leeds West had to buy shares in order to become a part of the group. So it has developed – we’ve gone from providing services at scale in smaller schemes to providing services at scale within a federation company.

Federating has thrown up a lot of interesting challenges, particularly around corporate and clinical governance. Indemnity arrangements can become more complicated and expensive when we’re looking at employing more staff to deliver unscheduled care, including nurses and healthcare assistants.

Medical Protection is helping us to find solutions – but we’re aware it’s been a national difficulty, not just for us. It’s fine for doctors, who are generally covered, but to get different staff members indemnified – particularly if their current indemnity is with different companies – has been problematic; and we’re aware that nursing staff are key to making new care models more efficient and effective.

So it’s been very successful, but not without its challenges. When you run something from the centre of a group, there are issues surrounding ownership, and this has repercussions on the practice managers, especially in the early days. I know of practice managers in our region that had a hellish few months while we were setting it up, because they were essentially doing two full-time jobs. It wasn’t until we used some of the scheme funds to employ a hub manager that we really started to see the benefits. It was the first indication that if you recruit separate staff for the middle, things will get done a lot more efficiently. I think that’s been integral to our delivering services at scale.