Managing rural practices without GPs

Invicta Health – well known for running seven-day integrated and GP services – also successfully manage two rural GP practices without any salaried GPs or partners. Instead, services are provided by a core team of sessional GPs, nurse practitioners, practice nurses, HCAs and a clinical pharmacist. Kim Horsford, chief executive at Invicta Health, explains how a focus on staff development has helped maintain high standards of service delivery

Everyone is aware that we have a major issue with GP recruitment in the UK, but there is significant variation across the country. Some areas seem to be fairly well-staffed whilst others struggle to find locums – and salaried doctors or partners are impossible to find.  We fall into the latter category, where the local area, having struggled to recruit GPs for some time, is now in a critical situation with many practices having only one partner (often deferring retirement) and even national incentive schemes failing to persuade GPs to take on salaried positions. The area has historically low levels of investment in healthcare and infrastructure, making it more difficult to recruit staff in all roles when competing against other, higher profile areas.

We are a GP-owned CIC and in 2015 took on a small rural practice of around 2,500 patients when the single-handed partner retired.  Shortly after that a nearby branch surgery of another practice closed and our list size doubled.  Then, 12 months later, the main practice transferred to our management when the remaining partner retired bringing our list size to nearly 12,000. Many of our patients are frail elderly, living along a stretch of coastland with poor infrastructure and transport systems and high levels of deprivation – for example, many people live in mobile accommodation. In addition to the usual care and residential homes for the elderly we have residential homes for patients with severe disabilities, including some with severe neurological conditions.

Working at the top of professional capacity

We are managing both sites with a team of sessional GPs, nurse practitioners (independent prescribers), practice nurses, HCAs, clinical pharmacists and will soon be joined by a paramedic practitioner. All our clinical staff are led by a senior nurse and part-time GP clinical lead (who does not see patients) providing clinical oversight, governance and guidance. We have no salaried GPs or partners and we therefore need to invest time and effort to ensure that our sessional doctors work as part of a team and have time to engage with, for example, clinical governance. Our goal is that all clinical staff are working at the top of their professional capability.

Unlike more urban areas we do not have many patients with self-managed illnesses that can be diverted away from the practice. We therefore need to offer more support to manage and co-ordinate care and are working to develop our reception and admin staff to act as an interface and co-ordinators between patients and clinicians. The first phase of this is using short films around a range of chronic conditions that can help educate both patients and staff. We are also developing staff to take on as much of the clinic administration as is safely possible, using protocols and investment in training to reduce, for example, the amount of correspondence seen by GPs.

The cost of delivering primary care with sessional doctors is high as their hourly/daily rates are inflated by market forces and there is the additional expense of providing clinical oversight and management. We are fortunate to have been able to attract some excellent nurses, pharmacists and an experienced paramedic but, again, the salaries need to be competitive in order to retain them.

We also focus on developing our staff – especially HCAs – supported by an excellent local training scheme. For the future, we are hopeful that we will be able to manage with less GP input, especially when the backlog of demand and clinical governance issues have been addressed. In addition, all staff work across both practices and resources are shared so that we can exploit economies of scale; having the existing CIC with centralised functions such as finance and HR also helps to reduce costs as we are able to use common processes and protocols across all our services. Both practices are managed under APMS contracts but we have also sought support under the vulnerable practice scheme via NHSE and our CCG.

Delivering primary care without salaried GPs or partners is not easy – but it is possible!

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