Harry Longman, chief executive of GP Access, critiques the ‘GP at scale’ model of care favoured by NHS England and sets out a path to patient satisfaction based on a demand-led system
‘GP at scale’ has become such a mantra promoted by NHS England that I worry about the evidence which might underlie the policies – for example, we recently witnessed a report by the Nuffield Trust which highlighted the lack of evidence for improved outcomes. I was surprised, too, when figures from NHS Digital showed that expenses per patient were slightly higher in larger practices. And what about patient satisfaction? It’s not the only thing that matters but it should concern us. I couldn’t find a single study so I turned to the most recent GP Patient Experience Survey (PES) and compared results for all England’s 7,852 practices, in size band increments of 1,000, 2,000 up to 18,000.
Sizing up satisfaction
The results were clear: overall patient satisfaction falls steadily as practices get larger. The difference is all between ‘very satisfied’ and ‘fairly satisfied’ – we should never lump these together as the story is all contained in these two numbers. Only 15% of patients tick the bottom three levels of satisfaction, constant across all sizes.
Well, the obvious next question is, why the change in satisfaction? There may be several factors, but patients often say how much they value a relationship with a GP they know and I think this is likely to be the main reason. The PES data lets us test this very well and I looked at the percentage of patients who said they always see their GP of choice; from 54% in practices of 2,000, it falls below 30% for the largest practices – no surprise there.
So what to do? Larger practice size has no bearing on secondary care costs, little on expenses and it’s worse for patient satisfaction; if you are thinking of merging, you would need to have other reasons. UK practices already have a wide range of sizes, all of which have their own challenges, but there’s one which the larger ones need to work very hard on to build their patient satisfaction; continuity of care – allowing patients to choose a named GP when they want to.
Starting with a clean sheet
Our work with many practices has shown that over half of patients don’t mind who they see, which makes life easier for us but, for the 25 – 40% who do want a named GP, we need to make it easier for them. It’s actually more efficient, as problems are dealt with in one go, as well as giving better clinical outcomes. The secret is to run a demand-led system, where every day starts with a clean sheet. In this way patients don’t need to wait longer for a named GP, and continuity is restored. GPs can work at any scale – but you should treasure your patient relationships.