GP mergers are becoming increasingly popular. In this article we reflect on the pros and cons of merging and summarise the NHS guidelines for your convenience
In today’s primary care climate small and rural practices are struggling to sustain themselves. Issues surrounding GP and other practice employee recruitment and retention leave these surgeries under-staffed and pushed to their limits – and it is increasingly recognised that there is a great need for GP practices to collaborate to explore new, innovative ways of delivering primary care at scale. The 5 Year Forward View confirmed this view.
One solution to the constellation of problems facing practices is for them to form a merger. Mergers, typically, involve two or more neighbouring practices that are suffering from similar limitations and wish for innovative solutions, such as the desire for larger, fit-for-purpose premises or the opportunity to increase the patient list size and practice income.
A partnership agreement between partners of the practices is usually sufficient for a merger to take place, and the potential for pooling resources and sharing staff means that more and more surgeries are attracted to the idea of merging. However, the benefits of mergers must be weighed against the difficulties that can arise when several practices must quickly and efficiently work together to create an evolved, yet functioning, practice infrastructure and atmosphere.
The NHS England South (South West)’s guidance document, A Guide to Mergers for General Practice, outlines some of the pros and cons of mergers:
What benefits could merging deliver?
- Merging parties do not have to have equal viability.
- The model can be applied to multiple practices, e.g. Vitality Partnership in Birmingham; Whitstable Medical Practice in Kent.
- Can offer significant benefits through economies of scale.
- Enables rationalisation of quality frameworks and policies.
- Can establish joint ventures with other GP or NHS organisations.
What might the disadvantages be?
- Poor planning and preparation can lead to future splits following disintegration of relationships.
- Joining a larger GP organisation can lead to an initial decline in income due to profit-sharing arrangements.
- Involves a considerable amount of effort and motivation to establish large organisations.
- Individual GPs may have less influence in decision-making within a very large partnership.
- Risk of losing local connections and continuity with patients if staff become remote or too centralised.
The NHS offer further advice as to what to consider before merging:
- The development of a shared ‘vision’ for the merged organisation – perhaps limiting it, initially, to how the primary care service could be delivered differently/improved through a shared approach.
- Consideration and understanding of the potential barriers to achieving the ‘vision’ – a successful merger is only likely where there are perceived benefits for all participant practices/individuals. This will avoid any risk of participants perceiving the ‘vision as a ‘take-over’.
- Producing and agreeing a robust business case in order to establish benchmarks for measuring successful outcomes, document perceived benefits and risks and document the outcomes of benefit:cost analysis.
- Focus on the short-medium term – bringing practices together as a single business. Longer-term views, hopes or objectives can be referenced and documented for further consideration at a later date.
- Achieving consensus on the sharing of information and agreement on how issues will be handled – for example:
- Consideration of property-related issues and opportunities. For example, will all existing premises be required for future service delivery?
- Development of a clear business plan which will deliver the expected benefits, as specified in your business case.
- Achieving understanding and consensus on the potential immediate impact of merging – it may mean a change in the status quo to each individual’s and practice’s ways of working, with a consequent sense of loss. It may also have an impact on neighbouring practices not involved in the merger and this may need to be investigated during the discussion and planning phase.
- Consideration of, and consensus on, opportunities for wider service integration, as outlined in the Five Year Forward View. Key to initial thinking will be the anticipated future relationship with individual and groups of local community health and social care providers.
- Consideration of, and consensus on, whether you believe you are most likely to succeed in achieving the ‘vision’ through a collaborative or competitive relationship with those providers. Given the need for services to be improved within existing budgets/lack of new money it would, perhaps, be sensible to start a process with other providers to identify early win/win opportunities from joint-working, such as sharing of staff and premises.
- Consideration of how you are going to achieve the merger and realise its objectives – what resources will you need – e.g. effort, time, project management, facilitation, financial investment, legal and financial advice and guidance? What are your commissioners’ expectations and requirements?
There is no denying that mergers can breathe much needed vitality into struggling practices. Of course, you should consider your GP surgery’s local demographics to ensure a merger would be in the best interest of your patients.