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28 June 2018
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Acute trusts are running more and more GP practices. Ali Moore investigates.
Castle Place Practice in Tiverton took a major step in January: it became part of the local hospital trust.
The 50 members of staff, including GPs, joined the Royal Devon and Exeter Foundation Trust in a move described as aiding integration of services.
Former GP partner Dr James Squire says: ‘It was important for us that wed secured a future that was true to our core values and principles.’ Dr Squire is now GP clinical lead at the trust.
In December, our sister publication Pulse revealed that the practice had not been able to recruit GPs who wanted to become partners. The remaining partners wanted to concentrate on their clinical work, seeing themselves as doctors rather than business owners – so a takeover seemed the way ahead.
It’s a story that is being repeated across the country. The number of practices run by trusts is still small but it is steadily increasing, and more trusts are becoming involved.
The driver for secondary care is often a desire to provide more integrated services, such as through a primary and acute care system vanguard. Or to exploit synergies by providing both primary care and other services.
Trusts may also be concerned about instability in primary care putting pressure on their services, with practices potentially closing at short notice.
Even taking over one or two practices in an area can help to stabilise the situation. For GPs, the reasons are more complex. Mandy Seymour-Hanbury is the managing director of Symphony Healthcare Services, which runs practices for Yeovil District Hospital Foundation Trust, and has about 25 GPs.
She says the motivation and circumstances for practice takeovers are different in every case. For her, the inability to recruit partners to share the burden of running a small business is one of the biggest reasons.
Some GPs may be looking ahead, seeing a position a few years down the line when they will want to pull back, but may not be able to find someone to take over. Others simply want to concentrate on the clinical side of their job.
There are also practices in distress and even facing closure following a bad Care Quality Commission (CQC) report, or dealing with financial challenges, such as aging buildings. A non-general medical services (GMS) practice can come to the end of its contract period, or the operators decide to withdraw.
In one case, Symphony was asked to step in when a practice with 14,000 patients was under threat of closure following a poor CQC report. It was turned around, and within eight months it had been judged good in a re-inspection.
In an emergency, a practice may be taken over very quickly, but more often it takes several months for due diligence to be completed, the GPs to reach agreement on terms and conditions if they are remaining as salaried staff, and for the transfer to take place.
Few trusts can take on more than a handful of practices a year. Humber Foundation Trust provides mental health services and is one of the few non-acute trusts running practices. It has three or four practices hoping to join but does not expect to take on any more than that in 2018.
‘We are not predatory,’ says Julia Harrison-Mizon, the trust’s care group director with responsibility for primary care. ‘We are not out there selling our wares to get GPs to come and work with us. We have a bit of a waiting list.’
The trust currently runs six practices and Ms Harrison-Mizon suggests this could be no more than 15 in five years’ time. But they will cover significant populations and enable the delivery of place-based care.
So does a practice have to be taken over to reap some of the benefits of this new model? Ms Seymour-Hanbury says that Symphony could help practices that are struggling with back-office issues but want to remain fully independent.
Larger organisations will be able to exploit economies of scale and expertise. This could apply to tasks such as payroll and HR – but also to areas such as preparing for CQC inspection.
This could be attractive to practices over a wider area: generally, trusts are running GP surgeries within their core patch (although Yeovil also operates one in South Devon).
Ms Seymour-Hanbury adds: ‘Somerset is our core business and we would assess any approach [from outside] on a case by case basis. We would need to ensure that we could provide high-quality services. There are issues with being further afield.’
Is there a natural limit to the expansion of this model? At the moment, no trust runs all the practices in its area. And only a minority of trusts are involved – although that means there is potential for more to explore the opportunity.
Amber Jabbal, head of policy at NHS Providers, suggests there are constraints. In some areas leaders are caught up with the day job of managing services and performance in their own organisations. Others may also be thinking of horizontal integration with other trusts.
Running practices is unlikely to yield much profit – although if it helps contain non-elective demand, there are obvious benefits.
Ms Harrison-Mizon says: ‘Our intention is that it would not impact adversely on the bottom line. We expect every practice to be financially viable in its own right. The opportunities for us will come from being able to deliver that collaborative, place-based primary care.’
Generally, trusts seem to be thinking of a mixed economy, some practices remaining independent, while others join them, rather than running all practices in an area. This may help to address concerns around restricted choice, although there still might be a conflict of interest where GP referrers are employed by secondary care organisations.
In some areas there has been opposition from GPs. Back in 2015, doctors rebelled at the suggestion that they ought to join Northumbria Healthcare Foundation Trust as part of a PACs (primary and acute systems) model drawn up by North Tyneside clinical commissioning group (CCG). Practices would either be employed or subcontracted by the progress towards an accountable care system (ACS).
Despite initial suspicion, today the trust runs seven practices covering 46,000 patients through a subsidiary company, Northumbria Primary Care Limited. Its offer to GPs includes competitive rates for company cars and home electrical equipment.
Giving up security
Dr Richard Vautrey, chair of the British Medical Association’s (BMA) GP committee, says his organisation does have some concerns about practices being taken over.
Becoming a salaried a GMS contract – and giving up GMS may be a one-way move. He cautions against assuming that getting a big organisation involved makes investment in primary care easier.
‘What we have seen in the past is that where hospitals have run community services they have not necessarily concentrated on investment in community services,’ he says. At the moment many trusts are running significant deficits, which may mean investment in extra services at practice level will be hard to find.
He adds that practice income, largely population-based, is very different from hospital income flow, which is based on a fee per service.
There will be more family doctors joining acute trusts, he expects, but adds: ‘We need to look at the evidence on how effective that is. I suspect most practices would prefer to work at scale rather than being taken over by a much larger body.’
But for a few, a move away from the traditional model of general practice is very welcome. Ms Jabbal says: ‘Some of the conversations I have with GPs is that the practice model is not something that GPs themselves want to pursue. How they want to work is changing.’
What joining a trust means for practices
The first thing for both partners to accept is that change is unlikely to happen overnight. Three months is likely to be the shortest time for any transition and, in many cases, it could take up to a year.
Due diligence is likely to take up some of this time. It will cover financial and clinical matters. Trusts will want to know about income and outgoings, what the workforce looks like and premises.
Trusts cannot hold general medicine services (GMS) contracts themselves, so joining a trust will involve a change in contractual status for many practices. This may involve the trust taking on an existing primary medical services status or, as in Taunton, a GP nominee taking on the GMS status and sub-contracting delivery to Symphony Healthcare Services.
In most takeovers, GPs then become salaried employees with, in some models, a former partner taking on a senior clinician role. Staff transfer to the new organisation under TUPE – transfer of undertakings (protection of employment) – regulations. Premises may also be taken on by the trust.
The workforce may look significantly different after the move. There is no need for GPs to share the burden of partnership so portfolio careers, with a limited number of sessions as a traditional GP and others spent in different roles, may be easier to accommodate. Different professionals can be brought in to see some patients.
Humber Foundation Trust has introduced extra physiotherapy input in a practice with high orthopaedic demands. As a mental health and learning disability provider, the trust also sees synergies around care for those with long-term conditions and has colocated improving access to psychological therapies (IAPT) practitioners in one practice.
Clinical pharmacists and advanced nurse practitioners can also see patients who would otherwise need a GP’s input. Jon Duckles, head of primary care at Humber Foundation Trust, says: ‘The way I try to explain it is the GP taking a consultant role, with a multidisciplinary team around them’.
Julia Harrison-Mizon, Humber’s care group director with responsibility for primary care, says: ‘We have a vision around thinking big and acting locally.
‘We have the governance and the organisation behind us but for the people registered with the practice, largely, things don’t change.’
Yeovil has developed ‘extensivists’ – very experienced GPs who work with the small group of patients who place high demands on health services. These patients are often elderly with multiple co-morbidities and at risk of frequent admissions.
There are five in post, now a feature of the trust-run practices, together with a wider range of staff such as emergency care practitioners, pharmacists and health coaches.
Ali Moore is a freelance health journalist