Will large scale primary care services work?

The NHS Long Term Plan includes the intention to mandate GPs to work in primary care networks of 30-50,000 patients – but does the model work? In new research published in the Health Policy journal researchers have found that the proposed move to large-scale primary-care provision may not deliver the expected benefits for practices and patients. The independent researchers are urging policymakers to use ‘caution’ in shifting toward the direction of larger practices

Increasing collaboration among GPs is a central part of the NHS’s Long Term Plan. Working together, NHS England hopes to unlock savings through efficiencies and to offer patients a broader range of services in primary care. On paper, it makes sense but, in reality, there are likely to be some significant challenges.

In 2016 the average GP practice had 7,521 registered patients; however, the new, scaled-up providers would have list sizes of at least 30,000 – and in some cases approaching 100,000. The sheer scale of growth, and the expected timeframes, are worrying.

In the report the authors question whether scaling-up what they describe as the ‘corner-shop-model of general practice’ would actually deliver the economies of scale, workforce efficiencies and financial security the NHS claims. The researchers conclude that, ‘it is not a given that clinical outcomes, or patient experience, will improve nor that cost savings will be achieved.’

More importantly for the public, they challenge the prevailing view that larger practices will meet growing patient demand and deliver more consistent care quality that reduces unwarranted variation.

The bottom line

The researchers conducted an evidence review focusing on ‘specialist clinical networks, GP-led commissioning, out-of-hours GP co-operatives and integrated care initiatives in England and elsewhere.’ They paid particular attention to peer-reviewed journals and those authored by bodies like the Department of Health and NHS England. In total the team identified 1,516 papers that fitted their criteria.

The top-down approach adopted by NHS England has the potential to fail, the report finds, with a significant proportion of GPs likely to be against the change. The authors urge policymakers to be cautious, concluding that there is no clear relationship between the size of a healthcare organisation and its performance; rather, the optimal size is likely to depend on intended functions and how performance is measured. Inevitably, with organisations working together, there are likely to be trade-offs that could benefit some and disadvantage others.

Delving into the books, the economies of scale policymakers expect from a larger organisation may never materialise; so-called ‘diseconomies of scale’ are known to arise from more complex governance arrangements and management processes. There is also a question mark over how cost savings will be distributed; a fair and equitable system that reflects the commitment and work of GPs is essential in maintaining their motivation, the report suggests. Ultimately, it concludes that there is little evidence to suggest that integrated care initiatives have reduced the use of services or generated cost savings.

Patient focus

Larger practices and extended services are expected to increase patient access, but this isn’t always the case, the researchers caution. They point to the lack of uptake of weekend appointments, a move which the politicians expected would reduce the strain on primary care – something that has yet to materialise.

In fact, patients may be wedded to their current practice and find change difficult to cope with. This has been evidenced in other service areas, with patient satisfaction falling. Pointing to the available research on integrated care pilots in England, while there were reductions in outpatient attendances and elective admissions, there were no reductions in emergency admissions.

The current faith in technology may also be misplaced, as the costs of implementing new technology may outweigh the benefits it brings. Initially there may be a steep learning curve, with productivity falling during these periods. In larger-scale collaborations the importance of data security – and the number of potential points of failure – also increase.

The authors of the research are keen to point out that the failures of the past may not be replicated in the new approach to practice growth. The report is cautious, but retains optimism, encouraging change in the NHS. In one telling passage that defines the position, the researchers state that, ‘Whilst staff perceived a sense of improvement derived from new ways of working across professional groups, patients did not share this’.

Any new practice model needs to deliver for commissioners, practices and patients – something that is hard to achieve.

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