There has never before been such significant and sustained pressure on general practice – and many of these pressures are forcing GPs to consider changes to the size and structure of practices.
These pressures include moves to convert PMS agreements into GMS contracts; the removal of the Minimum Practice Income Guarantee; the move to a weighted capitation based contract; the withdrawal of enhanced services from individual practice contracts; and the direction towards single capitation contracts for a minimum of 30,000 patients (with indications being that this will ultimately increase to 100,000).
At the same time, the vanguard sites chosen to develop the models of care proposed by the NHS Five Year Forward View, are redesigning health and care systems and breaking down the traditional divides between primary care, community services, secondary care and social care.
General practice is facing pressure from many directions, both financial and workload. As a result, primary care in its current form, typically of small partnerships with up to six partners, looks unsustainable and super partnerships are emerging and evolving. These are mergers of primary care practices at a scale never seen before. Whilst it was not uncommon for one or two practices to merge, mergers of five to 20 practices began to take place and then Our Health Partnership (“OHP”) in central Birmingham, forming a super partnership of 37 practices and 300,000 patients, has changed the scale completely.
Several other super partnerships (most in the 10 to 20 practice range) are now forming. The Suffolk GP Federation, which has publicised its intention to form a super partnership, consists of 59 practices with a patient population of 540,000 and has potential to be even bigger than OHP.
OHP has 146 partners and covers a patient population of just under 300,000, which makes it three times the size of the largest existing super partnership and clearly the largest single GP partnership in the UK. NHS England chief executive Simon Stevens has already met with OHP, and supports its ambition to become a multi-specialty community provider which will have a pivotal role in the development of primary care across Birmingham.
Working with the leaders of OHP, we provided an innovative and secure legal framework for the partnership, providing both the benefits of scale, whilst retaining autonomy at individual practice level. Fundamental for the partners, was the principle of retaining a strong element of autonomy over their respective practices, whilst forming one new single partnership. This was successfully achieved and we ensured that the partnership agreements of the merging practices were not made redundant by the merger.
The benefits of a super partnership are based on economies of scale and include:
- Working together with local providers in health and social care to develop new and better ways of providing the best possible care for patients, and to keep patients out of hospital and treated in or closer to their home
- Freeing up time for doctors and clinicians to spend with patients by having management, administrative and regulatory requirements dealt with centrally
- Providing protection against the risks of competition from other providers
- Supporting the practices and reducing the risk of practices failing and closing, as is happening elsewhere.
Careful management of the merger can keep partners on board and deliver benefits to all. These all deliver benefits for patients who are, and always will be, the first priority of a super partnership. There are, of course, a number of important principles and issues to be carefully considered and these include:
- Vision: a merger at scale must have a vision and objectives (most likely linked to the benefits described above)
- Commitment: the merging practices must commit at an early stage to two key principles:
– Democracy: voting is a key issue but the scale of a super partnership means that individual partners (or groups of partners associated with a merging practice) will no longer have the absolute influence that they have in their existing partnerships
– Delegation: the move to a more corporate structure is essential, with a partnership board (supported by an executive team) taking over most of the day-today decision making, with some high level decisions being reserved to the wider partnership. It is interesting to see how quickly those who were initially concerned about losing influence have been surprised by the freedom this actually gives them to concentrate on what they do best – seeing patients - Autonomy: loss of absolute control is, as described above, a necessary aspect of moving to a more corporate structure. However, there are ways of retaining strong elements of autonomy for partners over certain aspects of their constituent practices within the partnership
- Merger of contracts: this can be a concern but the merger of individual GMS contracts/PMS agreements is not necessary at the outset, and the partnership can continue with a number of separate contracts and move towards merging them if and when they require
- Staff: mergers often bring about a level of uncertainty, particularly amongst the staff of the merging practices. However, this goes back to the vision and objectives of the super partnership and a merger at scale can actually create a number of new opportunities and progression for staff that can prove to be invigorating and exciting
- NHS Pension Scheme: The NHSPS is notoriously complex and continued access to the NHSPS is vital. Care is therefore needed to structure the merger in such a way as to ensure this is maintained.
One solution may be for practices to merge into larger organisations.