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How a Somerset GP practice made the ‘John Lewis’ model work

23 December 2022

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Recruitment struggles within general practice is a longstanding issue facing primary care. Last week, it was also revealed that over two thirds of GPs never want to become a partner of a practice. In Somerset, one GP practice has found an innovative solution to the challenging partnership model. Katherine Price finds out more

Minehead Medical Centre recently implemented a ‘John-Lewis-style’ employee-owned operating model, after rejecting a potential merger with a local hospital trust.

This structure offers employees within the practice the opportunity to have a say in the leadership of the surgery without needing the money to invest in a partnership.

The aim was to protect the ongoing stability and sustainability of the practice, as well as remain within local control.

Dr Ed Ford, a GP at Minehead Medical Centre spoke about the model in a future of primary care webinar earlier this month with Dr Mohit Venkataram, executive director for Primary Care at East London NHS Foundation Trust (ELFT).

‘You’re creating a business in perpetuity where you don’t have to worry about succession planning of partners, and it’s in everyone’s interests to keep the business going,’ says Dr Ford.  

‘You don’t end up with a shrinking number of partners holding ever bigger risk, essentially forcing people to leave. We would have lost a number of GPs had we stayed as a partnership, because they weren’t willing to take on the risk in involved.

‘People have been less inclined to be partners and a lot of clinicians just want to get on and do the job at hand rather than run a business.’

Minehead Medical Centre is thought to be the first individual GP surgery in the country to operate as an employee-owned trust (EOT). The move, which happened five months ago, gave each employee part-ownership of the surgery. The decision was taken after the practice struggled to recruit staff due to its rural location.

Dr Ford said that, despite the reducing number of partners, there was a ‘real desire’ for the practice to stay locally owned and run, and while fewer doctors wanted to be partners, they still wanted to work as GPs.

Engagement is key

Staff were approached at the start to ask if they would buy into this new model. What followed was communication with patients, councillors, and key members of the local population.

‘It wasn’t about saying, “we’re changing our service delivery model”, it was a case of saying, “we need to change our structure so that we have a business that can still deliver the contract”,’ says Dr Ford.

Once the practice had permission from the local commissioner to move from a partnership to a limited company, an EOT was set up to hold the shares, a process which took around seven months.

‘It’s quite an expensive process, and obviously being the first to do this was probably more expensive because the legal teams were finding their feet. It does need commissioner financial support if it’s going to be viable. But it can be done fairly quickly,’ explains Dr Ford.

He emphasised the importance of ensuring staff members were on board and not changing the terms and conditions in their employment contracts or their roles as they transferred from one company to another under TUPE (Transfer of Undertakings) regulations.

‘We were not looking to make people redundant and have lots of redundancy pay outs, which I think a lot of partners were fearful they could be exposed as result of the change,’ says Dr Ford. It was about giving staff an option, he adds.

He said no members of staff left because of the transition – in fact, the change has attracted more applicants to roles that were historically difficult to recruit for, such as administrative and reception roles.

Challenges and obstacles

Dr Ford stressed the importance of remaining focused on the end goal, which was ‘to make every employee equal and to have increased patient involvement in the running of the business.’

For example, for a limited company to hold a GMS contract one share needs to be owned by a GP, so it was decided that 1% of the shares would be owned by the medical director, but it would be a non-voting share that doesn’t give any more power than to any other employee.

And although non-NHS employees cannot be official trustees, a patient group representative has been appointed as a nominal trustee, involving patients within the governance structure.

A management team oversees the day-to-day running of the business, while a board of employee trustees is voted into post by employees and acts like non-executives, holding the executive team to account. Dr Ford said a dedicated management team was key since ‘this isn’t something that can just be done on top of the day job’.

Funding was secured to appoint a project manager for the process, who had the time to have one-on-one discussions with trustees and directors about their responsibilities and liabilities, and link them with up the legal team to ensure all staff were comfortable with what they were signing up to.

‘All staff members are equal partners in the business but without any of the liabilities that go with running a partnership or having to invest money in the business, being responsible for contracts, and putting your house on the line if it all goes wrong,’ he says.

Securing financial support from the Integrated Care Board (ICB) was also key.‘You need to make sure that that commitment is in writing and it’s very clear what you’re getting. You can’t afford to set up a new company and immediately be in debt to the tune of tens of thousands of pounds from legal fees,’ Dr Ford explains .

Culture shift

Dr Ford said it’s ‘still early days’ when it comes to seeing any noticeable improvement in patient outcomes.

‘We’re hoping we can improve things. We’ve started to build up our clinical team, use less in the way of locums now.’

The main change to date, he says, has been to practice culture, with conversations among staff now more open and honest. ‘It has allowed staff to have greater understanding of how the business works, and why decisions are being made. We’re now having conversations as equals.’

‘With the governance structure that we’ve got, staff have to be listened to because they are the shareholders in the business,’ he adds.

It took several months  for the former partners to step back and allow team members to step into that space, Dr Ford admits. However, now, staff are more forthcoming with cost-saving ideas, which staff would never have felt empowered to do before.

Other members of staff who aren’t GPs have also stepped into leadership roles. ‘And they do it better than we do, to be perfectly honest,’ adds Dr Ford.

He said having only one GP director was important to demonstrate a willingness to empower staff and change the culture.

And, he warns, it is vital to have someone in the organisation ‘sufficiently clued-up to keep a tight rein on finances’.

‘You’ve got to make sure that the income you’re getting on a monthly basis matches your outgoings – budgeting becomes much tighter’, Dr Ford advises.

Although the GPs earn less than they did as partners, the practice and partners have more stability as a result, Dr Ford says.  An additional benefit has been the fact that conversations with patients about finances are more open and honest.

‘They can see exactly what income we’re getting, where it’s being spent, what we’re doing to deliver services. And patients can influence how we change our service provision,’ he says.

Of course, Dr Ford warns that this model may not suit every practice.

‘For practices with management or financial issues, or struggling to find clinicians to provide a service, changing the model isn’t going to fix that. But if you’ve got a good culture to start with, this builds on that and empowers staff as well as makes them feel more part of the business.’