Can super-hub practices work?
Wednesday, 22 March 2017
I am trying to get my head around the new drive to create 1,500 super-practices out of the 7,500 practices that exist in the country. The health minister David Mowat has recently been quoted as saying that he would like to see practices becoming more centralised in the future.
But what does this actually mean? Are they proposing to start shutting down practices in a small geographical area and moving them into one site? For rural practices, maybe just closing them and forcing patients to travel to the nearest town for primary care services?
The scale argument comes up time and again. Putting practices into hubs means that they are able to do more things at scale than they would as smaller entities. Consider back office support, if I were to look at centralising my scanning for example over a larger group of practices, I might be able to pool my administrative staff with those at other practices, but it is likely that they will be working remotely outside the building. Therefore, I stand to lose my practices individuality and may have to sign up to similar processes and pathways across all the super-hub practices.
Also, many of my staff in general practice can turn their hand to several different roles. So, our excellent receptionists might be meeting and greeting for part of a shift, then taking calls and then finishing with an hour or two of scanning or coding. They also have an in-depth, personal knowledge of our patients and can highlight issues to the team, thanks to their close relationship with them. Inevitably, we will be faced with compartmentalising roles - for example, staff would attend a new generic hub for a shift to cover paperwork for all cluster practices.
I guess on the positive side, clusters would have greater resilience and standardisation across the group. There will be practices who improve the quality of their processes learning from those who do it well. Taking the scanning example, practices may not find they have gaps in the week when the scanning isn’t done because of illness or lack of availability. In addition, larger groups will also evolve a more specialised team who become much more knowledgeable and confident in delivering this role.
However, I realise that change is unsettling for many people and doctors are no different. There are doctors who wish to see everything about their patients at all times, so they know exactly what is happening to them. The development of a super-hub will erode this personal service and possibly further destroy the bedrock of continuity. But, with many GPs now working 4-5 sessions per week, with portfolio careers and other interests, continuity may already be past the point of no return. So, the evolution of the super-hub may simply be a structural model that fits the new workforce and how it now wishes to work. Gone are the days of the 10-session all-seeing senior partner, who exclusively knows everything about all his patients.
The real pessimists will have an opposing view on the development of groups of larger practices, that they are ripe for corporate takeover by companies only interested in the financial bottom line to please shareholders. If am honest, I am not sure that a commercial company would be that interested in a disparate group of practices, being more keen on the model of one large building housing primary care for 40,000-100,000 patients. In practice, I am not sure this radical structural consolidation will actually be achievable to make them interested in taking on the risk.
My view is that this is about resilience planning. To support those practices who are really struggling with the daily workload. Those that are finishing a surgery with a mountain of additional paperwork, resulting in another two hours before getting home. Those that are struggling to fill their clinical posts due to the mountain of additional work required over seeing patients. If more and more practices do start failing, it will be disastrous for those left, further stretching those that are just holding in there.
So maybe the ‘at-scale’ model has its benefits and could work by keeping practice individuality, but collaborating on areas that can make a tangible difference to workload. The trick to success is to maintain the personal, individual lifeblood in each practice so valued by doctors and patients alike and not become a homogenous, corporate entity purely driven on standard protocols. If this change is led by GPs who interrogate their practices’ resilience, then maybe they can deliver better models of care whilst maintaining individuality.