Organising primary care that’s fit for purpose

12 April 2016

GP services have always been seen as part of the fixtures and fittings of the NHS. Something that is the context of the way in which the NHS works and something that we assume would always be there in the same way. Like so much in the NHS there was a moral confusion about a particular from of organisation – small, private practices – with the existence of the primary-care practice itself. There were those who assumed that if you questioned the organisational from of general practice, you must be questioning the importance of primary care as a whole. There was a conflation between a form of organisation of care and the nature of that care itself.

In fact, over the decades it has become increasingly clear that the particular organisational form of very small private partnerships hampers the way in which primary care might have developed to play a much bigger role in the NHS. For example, as the variety and quantity of diagnostic testing has developed within medicine, it might have been logical for more of those diagnostic tests to have been located within primary care. It would make sense, in many cases, for a GP to carry out tests themselves. But practices of one or two GPs do not have the size to invest in the equipment or staff to carry out the diagnostics. For that investment you need the one thing that small primary-care organisations do not have: scale.

Bigger organisations are needed to take on new services and the wide variety of primary-care staff required to supplement services. Nurses, physiotherapists and pharmacists can all add considerably to the nature of primary care and if these services are a part of what primary care regularly offered, patients would be kept out of expensive hospitals.

Ten years ago I wrote a pamphlet, Size Matters, which made the case for sizing up the organisation of primary care. This, as they say, was politiely received. But for most of the ensuing decade very little sizing up actually happened. Some smaller practices merged with others, but the basic organisational form set up by Nye Bevan and the BMA in 1948 was continued through its sixth and seventh decade. (But then again what do pamphlets ever do?)

But in 2016, at the time of the publication of this Reform pamphlet, there are some signs of radical changes in organisational form for primary care. Across the country there is a recognition that size in primary care does matter and nearly every practice has been formed into some part of a federation. Some federations have been shaped as a part of a sizing up of organisational forms which will enable these bigger organisations to bid for contracts to provide other primary-care services.

Some federations are formed to merge back office functions and some are formed in the recognition that primary care in small practices will not be able to deal with the increased demand for health care that is coming through the doors every day.

For me, the most significant of these organisational changes that create size has been the formation of super practices. The majority of staff in these super practices are employed – with a few senior partners. The idea behind the super practice is a recognition that if primary care is to thrive in the time of this extra demand from sicker older people, it will needs a strong standardisation of approach. Meeting greater demand needs much slicker organisation where the organisation is much more proactive in working with the potentially sicker patients than the previous reactive approach.

Super practices employ a wide range of other professionals to ensure that the highest skilled in primary care are only being used when and where those skills are necessary.

Over the last couple of years some very large organisations have emerged and I predict between now and 2018 we will have three or four GP organisations that will have over a quarter or a million registered patients. This means that we will be celebrating the 70th anniversary of the NHS with an organisational form of primary care which can make the most of the most modern technology. This technology will enable a much more collaborative set of health care relationships with patients. Because of the parts of the NHS will enter its eighth decade with a primary care fit for that decade.

Paul Corrigan is Adjunct Professor of Health Policy at Imperial College London and former Health Adviser to Tony Blair.

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