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Supertanker partnerships

Hard-wired GP

Luke Koupparis

Tuesday, 07 August 2018

AdobeStock_85023858_supertanker.jpgEveryone is talking about big in primary care. Large scale reorganisation appears to be the latest drive that is heralded as the saviour of general practice. It has been publicised as a way to make us more resilient and efficient, whilst removing the chaff (i.e. smaller practices). It doesn’t appear to just be the Government who believe this, but now it has become clear that our own GP leaders hold this stance. Only last week, Dr Arvin Madan, NHS England’s director of primary care, made comments that we should be “pleased” when smaller surgeries close. Rightly, his comments have caused outrage and anger amongst grassroots GPs forcing him to resign. Many lost confidence that he represented all types of practices as his comments clearly showed he could not see the value offered by smaller surgeries. Following his resignation, Dr Madan has since apologised and stated that he believes “GPs in smaller practices serve a particularly vital role as a point of constancy in the lives of often very vulnerable patients”.

Not only is there a push to consolidate numbers of practices into larger federations, but also to integrate other community providers. The internal marketplace is now a dead duck and is now being replaced with a system that provides closer collaboration between NHS bodies and local councils. A new era is being constructed where we no longer need to be constrained within the empires of purchasers or providers. The new vision is that walls dividing organisations will be eliminated allowing a true population based, patient-centred approach.

However, I remain concerned that the creation of supertanker organisations is not the answer to better care. Looking at the evidence it seems to support this view. A recent review in The BMJ found that continuity of care was associated with lower mortality rates. The authors went on to show that patients across cultural boundaries benefited from continuity and that this was true of both primary and secondary care.

So bigger may not be better when it comes to general practice. Perhaps the clinicians and patients of smaller practices have long understood the value that they provide. Hence their furore when a GP at the top of NHS England suggests they can simply be left to wither and die.

Looking at the data as to what is actually happening across the country shows that we are moving to become larger practices. An interesting report in 2014 by the Institute of Fiscal Studies looked at changes in practice size from 2004 to 2010. Statistics show that single handed practices appear to have taken the brunt of all closures, accounting for two thirds of all exits despite only comprising 22.1% of practices. Larger practices were found to be the least likely to close.

So, the evidence shows that smaller practices are not sustainable and are actually reducing in number. There may be multiple reasons for these closures, but maybe the comments by the director of primary care are simply reflective of wider Governmental policy to rid the country of corner-shop general practice. With new funding being aimed at wider integrated care organisations this further starves smaller practices of income they need to continue to be viable. Forcing practices into larger integrated organisations will allow greater control on exactly what and how much they do.

If we truly believe that integration is the key to better care, then this should underpin any changes that are made, and not a drive to create superpartnerships or huge faceless integrated organisations where patients rarely see the same clinician twice. If the long-term vision is to improve patient care along with improved outcomes, then bigger is clearly not a structure that will achieve this. Perhaps a more local approach which preserves all the best parts of what primary care can offer, along with a clear understanding that one size cannot be applied across the board would be a start.

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Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group, LMC representative and chair of the locality provider group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist and likes to ski with his children.
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