Policy Bite - September 2018

‘Working at scale’ – issues for family doctors


Family doctors define our discipline in part by our relationship with, and active knowledge of, our patients as people: also recommending an ongoing relationship with both individuals and their communities, so that we can be proactive about health needs and risks identified for the different populations within our reach.

Systems where care is anonymous, and where the next available appointment is randomly allocated to any doctor available, are less acceptable to patients, and also less effective – because prior knowledge and ongoing trust helps both the doctor and the patient to make good decisions, and to act on the advice given. Even within a primary health care team, efforts are made to keep some continuity where the patient wants or needs it, while a shared record allows ‘knowledge’ to travel between the clinic staff, and to be efficiently used for team care.

But there may be advantages to joining up some functions. A well run clinic will need administrative, human resource, financial and IT expertise, as well as clinical competence. Primary care services must interact with the hospital and social care sectors, as well as with the agencies who fund their work. If the clinic is owned by the doctors, they will need to make decisions about who to employ, how to organise the team, and infrastructure services such as cleaning and medical supplies. A serious commitment to community engagement needs staff to spend time in discussions with local stakeholders to create healthier environments. Leadership roles in teaching, research and service management will take staff time away from clinical services. And even the most centralised health systems benefit from some involvement of the family doctors in service development initiatives.

So there are discussions to be had about how to do this ‘at scale’ – that is, finding new ways of working that enable us to meet the increasing challenges and demands placed on our clinics, by working collaboratively with other practices and healthcare providers to achieve economies of scale and improve overall services; but still retaining local autonomy and ownership of the doctor-patient-community relationship.

This is a journey I have seen in the UK, New Zealand, Singapore, and Brazil – to name only a few.

Let me start with the UK When I was a child, I went to the GP’s house, where his wife checked the patients into the waiting room in the downstairs of their house, and he was the only clinician in the team. When I first went to work as a GP, my senior partner was still working from his family home with his children’s nanny as one receptionist - but the house had been extended into a small clinic, and we were four GPs, three receptionists, and two nurses. Soon we expanded all three parts of the team, became computerised, and also started to share some work and initiatives with eight other practices. We compared data on referrals and admissions, co-funded some innovative services for mental and occupational health problems, and shared out-of-hours cover.

Various experiments – including government-driven policies around funding and commissioning, plus the increasing needs for high calibre business and personnel expertise - have now led to many UK general practices merging their ‘back office functions’, in order to improve their purchasing power and market opportunities. The Nuffield Trust policy unit reported in 2017 that almost 75% of GPs were now linked into some kind of collaborative or federated network. This does not usually mean selling their businesses, but may take the form of a ‘not for profit’ organisation, or a network who have agreed to co-employ some staff and run some shared services. The ‘local face’ of the clinic remains unchanged in many of these models, but GPs can band together to negotiate with other service providers for improved models of care for patients. And leading for teaching, research, or clinical quality initiatives, can be done across practices - with more opportunities because of the larger patient base.

In New Zealand, these linkages have been driven in part by government policies to address quality and population health needs through setting up primary health organisations (PHOs). GPs were already moving to collaborative models – one of the most mature, Pegasus Health, in Canterbury, https://www.pegasus.health.nz/ has been in development for 25 years, and most GPs are now linked into PHOs. Cooperation for staffing and professional development has led into major service redevelopment and citywide cooperation – while keeping identifiable local practice teams. The national voice of GPs is also strong, with clear leadership and inputs to policy making through our WONCA member, the Royal New Zealand College of GPs.

Singapore has a different challenge – the public sector GPs and academic family medicine units are linked into three major clusters of health care providers and are often hospital based, running specific services (see for example singhealth https://www.singhealth.com.sg/Pages/home.aspx ). The need here is to ensure services are community oriented, and that some continuity of clinician contact is made possible. There are new ‘polyclinics’ being opened under GP leadership, and family medicine is making major impacts on care pathways - for example, an integrated care approach to older people’s care, to minimise hospital admissions and length of stay, and to increase home support. Another challenge is that there is a large private GP sector, with very different service models – the question of how to include these doctors in both service and professional development networks is also one of attaining ‘scale’.

So, key messages – while small is beautiful, and the personal relationship between patient and doctor one to be treasured for its therapeutic potential, most of us cannot survive economically or psychologically as a single person service.

Most patients value access to a modern team and a range of services, with reliable care available when needed, especially if their ‘own’ GP is away from frontline service. And we need capacity for nonclinical services – in a network of clinics, named individuals (both clinical and others) can play lead roles to develop teaching, research, extended services, and also act as advocates and managers for collaboration with other service providers. I personally recall the amateurish attempts we made as young GPs to secure a good practice manager – and how much more successful and enjoyable our practice became when we got a very experienced person. We had to offer a higher salary scale, but managed this by appointing them with another clinic, and the individual was more than skilful enough to run both practices – in fact, we ended up ‘lending’ her to some others!

So as family doctors we need to think both small and big – and not always feel we must ‘go it alone’. Some of the modern models of care offer effective support and capacity, while keeping the human face of family medicine.

Amanda Howe
WONCA President