How can practice managers create a super-practice? Paul Conroy started originally with the invitation to all 38 practices in the area; 15 expressed interest and shared data initially, and 12 have crossed the finish line.
In North East Essex, we had a strong practice-based commissioning group in the days of primary care trusts, and we still retain a close-knit forum of local practice managers.
In 2004, we formed a GP provider company to bid for work, and have secured a number of contracts. But for many of us, there remained a feeling that there were further benefits of at-scale-working to be achieved by looking at changing how we run our core businesses. We recognised that economies of scale in staffing, procurement and professional services such as banking, legal or accountancy as well as the potential for new service delivery models required a different way of thinking.
With the support of North East Essex CCG, we ran an event in January 2016 to explore the options with all the practices in the local area. Out of this, three groups came together to form different types of organisations, with others focussing on looser federations or contracting models. Our group decided that a full-merger partnership was the only way to achieve the benefits we had in mind, because of wanting to hold GMS contracts in the centre, and the impact on NHS pensions.
We adopted the name The Colte Partnership, representing the two localities we currently cover (Colchester and Tendring). Our slogan ‘beyond better’ is intended to denote that we envisage a broader model of health and wellness, rather than just a sickness service, and also that the organisation will move beyond incremental improvement to something that would be unique and remarkable. The drafting of the partnership deed has been a long process, but the core values have been to ensure that the original practices (referred to as ‘branches’) retain full autonomy, while maximising the potential benefits, with an ‘opt-in’ approach to system and service changes. Practically, this means that the only requirements are using the same bank and accountants, but practices can choose whether to join in other schemes to create savings and explore new models on a case-by-case basis.
To complete all the necessary work prior to formation, we partnered into workstreams for the key areas of governance, finance, business planning, IT, estates and communications. Each group had a set of tasks to complete and it was tracked through an online project-management platform in which we could share documents, manage the meetings and project calendar and discuss ideas via forums. Each practice has put forward their manager and as many GPs as are available. For some, this has meant several of their team are involved, as they might be larger practices. Other practices with shortages of staff or GPs contribute where they can. We’ve balanced this out by accounting for our time, with those who can’t put in the hours having to pay slightly more to buy in.
In the early stages of the formation process, it became clear that we would have to be careful in selecting practices to join the merger, and so a detailed due-diligence process was created, examining practice accounts, staffing ratios, QOF achievement, CQC registration and premises compliance. Through this process, we decided on
a number of red flags that would bar a practice from membership: eg the Care Quality Commission (CQC) rating a practice as inadequate; a partner-to- patient ratio below a certain cut-off; and which after formation would act as warning signs of a branch that was struggling.
Our accountancy and IT systems allow us to monitor these issues in a monthly dashboard and take early action to assist a branch, step in to take over or remove a branch from membership.
There have also been a number of way-points where we have brought the partners all together to sense-check the work we have been doing, and to confirm that we still have everyone on board, and understanding what we’re doing and why. This has culminated in practices having to make clear decisions about committing, with an initial non-disclosure agreement and submission of data, followed later by a commitment to bear the costs up to formation, and a small interim financial contribution on a cost-per- patient basis towards the formation costs, then a final signing of the partnership deed and the final buy-in payment. At each stage, there has been the opportunity for practices to pull back, as well as continue.
We started originally by inviting all 38 practices in the area to join; 15 expressed interest and shared data initially, and 12 have crossed the finish line. In total, we are 40 partners (including three non-GP partners) and 118,000 patients, with a second phase of joining already planned.
The organisation is run by a board of GPs, and an executive leadership team of practice managers. The board is headed by a clinical chair, who was appointed through a voting process run independently by our local medical committee (LMC). The chief operating officer is a practice manager. Each key role has a pairing of a GP and practice manager – for example there is a commercial lead GP, and a commercial director practice manager. The exceptions to this are on the medical role, where a nurse is to be appointed to mirror the GP, and finance, where an accountant is needed to balance the pairing.
Our CCG has really grasped the vision of working at scale, and has provided seed investment to each of the groups in the area to get them started. We agreed to match-fund this in cash, with further investment in the form of time contributed, and a loan facility with our bank to provide working capital to pump-prime the many ideas we have in the pipeline to generate new income streams and new savings.
By simplifying our accounting processes, bringing resources in house and moving to a cloud-based platform that we share with our accountants, we have reduced our accountancy fees by 60%, and have created significant savings on our banking costs by using a single provider. We conducted a series of interviews with both banks and accountants to ensure we got the best deal and allowed them to pitch to us the detail of how partnering with them would benefit Colte. Each presentation was scored, and in both cases we were unanimous about the winner. We then set about gaining the necessary clearances and approvals from:
- The Pensions Authority.
- NHS England.
- North East Essex CCG.
- The Dispensing Doctors Association.
- Other commissioners, including the clinical research network and local authority, from whom we had contracts to move to the new body.
Our professional advisers – accountants, solicitors, bankers and others – have been essential to the process.
Changes and staff
Regulations for the transfer of staff ensure that there are very few changes for our teams, except for the name at the top of their pay slip.
Because branches remain autonomous, and our vision is for growth, there are no redundancies. But we expect new ways of working will see savings as a result of choosing not to replace people as they leave through retirement or natural turnover.
The message is very much one of evolution, rather than revolution, when it comes to our existing staff. We knew beforehand that up to half of our back-office staff are due to hit retirement age in the next five years, so we expect significant savings can be made if needed, but our plan is for growth and new approaches, rather than a shrinking horizon.
We already have some exciting pilots in our membership, with clinical pharmacists and a community matron shared with the local district nursing provider.
Fears to overcome
There has been much to overcome in the process – most notably the fears, doubts and politics that inevitably come to the fore when you try to do anything new and bigger that challenges the boundaries of the historic models people feel at ease with.
Initially it felt at times like we were knitting fog, but gradually it became clearer what we were achieving and how we were progressing. Communication in any change project is a constant challenge – with everyone so busy in the day job, with the added work of the change. People often don’t read the documents you send, or they attend a meeting and ask the same questions you’ve already answered. But the only route forward is to keep persevering and to recognise that sometimes picking up the phone or going for a coffee is more effective than a hail of emails.
We officially merged on 1 June, 18 months after our original discussions began in earnest. In some ways, it felt like an anti-climax, as all the hard work of formation was now over, and nothing looked different on that first merged day. But we all know the real work starts now, in turning the wide range of opportunities and ideas into action. We have the framework, and now we have the freedom to make it happen.
We think the future is unlikely to involve keeping things the same. For some practices, now will be a good time to consider forming a super- partnership. But others may find they are better off joining an existing one, or considering whether working with local hospital or community providers might be more beneficial.
Find out more
For information about Colte, including future joining phases, or to follow our progress, see coltepartnership.co.uk
Paul Conroy is a business lead at Mersea Island Medical Practice, the Colte Partnership. He was previously commercial director for GP Primary Choice, a GP provider company in North East Essex.