Photo: the Granta Patients Group
Partner James Morrow describes how a group of Cambridge practices are moving towards an employee owned partnership as part of the Primary Care Home drive, and describes the successes and difficulties so far.
Time for change
The traditional model for delivering general practice has had its day. A workforce crisis, burgeoning demand and the intention to move increasing amounts of secondary care work out of hospitals requires change.
Granta Medical Practices in the Cambridge area evolved over the past two years from three like-minded general practices. Together with the neighbouring Shelford Medical Practice (now planning to merge with Granta) it has become part of the third and latest wave of the National Association of Primary Care’s Primary Care Home network.
Several years ago the partners used a scenario building tool to imagine the future state of general practice and the impact that might have on us. We concluded that the historic model of small practices characterised by enthusiastic amateurism was unsustainable.
We set about transforming the practice. External professional management, the adoption of ‘lean’ as a tool and segmentation of patient flows all took place in rapid succession.
In parallel we opened discussions with neighbouring practices about merging. We dismissed federations as just paying lip-service to true integration; either we were going to work as one team or not at all.
Over the past two years we have merged twice, bringing together three geographically contiguous practices. Granta Medical Practices now has some 34,000 patients, 16 partners and a total staff of over 100.
Finances, practice lists and practice systems have merged. Any patient can be seen on any site. Staff move between sites and workstreams are shared. Access has been improved – 46% of patients are now on seen on the day. Without additional funding, the practice now offers extended hours opening five days a week. So far, so good.
The transformation has not been without challenges. Dilatory responses from NHS England to merger administration threatened to derail one merger. Partners and staff had to change the habits of a career as we created new ways of working. Not all staff felt comfortable about all changes. Some were vociferous in their opposition.
Not all staff felt comfortable about all changes. Some were vociferous in their opposition
A partnership of 16 is too big and cumbersome to get involved in all decisions. The partnership itself has had to move from a ‘living room’ to a ‘board room’ mindset.
Three partners and senior practice management now make up our operational executive with delegated authority to run the organisation. While remaining accountable to the full partnership, it has considerable autonomy.
We encourage robust discussion among the partners, but while tough on the issues we remain gentle with individuals. Our preferred method of decision-making is consensus. Partners have agreed to back all partnership decisions when discussing it outside the partners’ meeting.
For many this cabinet responsibility for decision making is alien, but it is needed to maintain organisational coherence. That external cohesiveness can sometimes be fragile. Staff who know the partners well are quick to spot equivocation.
Like most practices, Granta Medical Services holds its NHS General Medical Services (GMS) contract as an unlimited liability partnership.
Unlimited personal liability for premises, employment and potential medical negligence is a barrier to retention and recruitment of GPs. With increasing size of practice comes increasing complexity and a need to ringfence personal liability.
Nor does it make sense that the business must be owned and run by doctors alone. Our future success as a practice depends on a high-performing team. We believe that this is best achieved by fully aligned incentives, irrespective of professional background or job role.
The partnership has agreed to move towards a ‘John Lewis’ model of practice ownership – with the preferred model being an employee ownership trust. This single proposal has done more to engage current employees than any other.
We intend that all staff, including the current partners, will become salaried employees of the trust. Any surplus generated will be shared out among all employees as a percentage of their base salary.
There are significant legal, regulatory and financial hurdles to overcome before this becomes a reality. But it is a vision that aligns fully with our concept of a socially responsive organisation run by local individuals for the long-term benefit of our community.
Waiting for Godot
Throughout our transition we have struggled with the NHS establishment. Focussed on system-wide issues they appeared bound to a tyranny of equality. “You are already ahead of the rest, so we cannot allow you to move further ahead as that would widen local health inequalities,” was one comment.
We were denied access to merger funding on the basis that we were going to succeed anyway. For too long the NHS has invested heavily in failure and skimped on championing success.
Five Year Forward View, MCP and the Primary Care Home model
The NAPC model of the Primary Care Home is, for us, a flexible, bottom-up evolutionary way of moving towards a future Multispeciality Community Provider (MCP) model. We like the focus on a defined community, integrated teams, personalised care and aligned incentives.
Through the Primary Care Home community of practice we have already picked up some great ideas, shared our concepts and had exchange site visits. We are now connected with groups of practices – doctors, nurses and managers. Like us, they see a future which is both sustainable and exciting.