How to get practice mergers right first time
30 August 2017
Primary care at scale is a key part of the NHS response to crises in both finances and GP recruitment and retention.
PCC has supported practices and CCGs facing a range of those pressures or changed circumstances. Having worked in commissioning and primary care for many years, our associates can communicate effectively with both commissioners and providers. PCC adviser Charlotte Goodson says a range of local circumstances can trigger merger decisions.
“Many areas are finding it very difficult to recruit and retain GPs and the number of doctors retiring from general practice is unprecedented. We’ve worked with several practices that began thinking about merging when one or more partners announced they planned to retire early – partly because of contract changes. Sudden retirements for ill-health or other reasons can hit almost any practice. Partners today often earn little more than salaried GPs but have massive additional responsibilities in areas such as employment, premises and care quality.”
Those responsibilities are complicated by the difficulties recruiting salaried colleagues and other practice staff, ever-rising demand and changes in the funding formula for primary medical services contracts.
However, Goodson notes that clinical commissioning groups (CCGs) are also taking a keen interest in the quality and flexibility of the services practices deliver as they seek to shift more care and services from hospitals into the community.
“As we’ve seen with the rise of federations and primary care home structures, there’s widespread recognition that we need a new primary care organisational model predominantly based on practices coming together.”
PCC associate Frances O’Sullivan recently supported two practices in north Warwickshire to merge, creating the largest practice in the area.
“The practice managers appreciated that I spoke their language as well as that of the commissioner so I could clarify issues quickly. We can act as the interface or honest broker between the practices and the commissioner. For example, I was quite clear about the reasons for requesting additional funding from NHS England for a specific piece of work relating to the merger which was proving unexpectedly difficult to resolve.”
Jenni Northcote, chief strategy and primary care officer with NHS Warwickshire North Clinical Commissioning Group, says: “Having an identified project manager gave a focus to the workand Frances was able to co-ordinate the actions in the project plan. She also arranged weekly tele-conferences – and identified people from key agencies who it was useful to have joining in particular calls. I think Frances’s primary care management experience was crucial.”
Practice manager Elizabeth Gilbey says: “Although the practice had been proactively holding weekly planning meetings, Frances was invaluable in highlighting areas and risks that needed action. She identified key people within NHS England and PCSE and generally kept the momentum going when we were juggling so many tasks.
She cautions that it’s easy to underestimate the work-load of the practice manager of the practice that is losing its individual identity in the merger.
“They have to keep the practice running each day while ultimately closing a business, planning the logistics of the physical merge and trying to keep staff morale upbeat throughout the TUPE process.”
O’Sullivan agrees about the need for the softer form of support during what can be a stressful process: “It can be important just to provide encouragement and emotional support for practice managers feeling overwhelmed by the demands of the merger process while still doing the day job.”
PCC support for practices negotiating mergers typically includes:
- Project management
- Capacity and expertise
- Providing structured plans and reporting mechanisms
- Acting as the interface between all the parties involved
- Providing reassurance to the commissioners about the process being followed.
Goodson says that an outside perspective such as that provided by PCC can also act as a catalyst to kick-start the merger process.
“In one area in the East of England three practices had been talking about merger for a while as recruiting new partners was proving difficult especially with the squeeze on practice finances. The premises are reaching capacity and the pressure on the partners as the business owners is spiralling. It got to the point where they could carry on talking about merger as an interesting philosophical exercise or they could take practical action to move the merger along. We’re practical people with a practical approach.
“Their early discussions led them to realise that they had very similar views around the type and quality of services they wanted to provide. I have provided one day a week project management support to them and I’m now handing over to a project manager who can work four days a week over the next eight months up to the merger.”
LESSONS FROM THE COALFACE
Here are just a few of the 60 or so issues around mergers that practices and CCGs need to think about.
- The parties need to understand the reasons for the merger, the complexity of the task and allow sufficient time to both plan and execute the project plan
- They should factor in possible delayed responses from other organisations such as NHS Property Services, the Care Quality Commission and IT providers. Communicate with these groups early on
- Find out at the start what funding the commissioner can provide to support the merger – this could cover project management fees and the cost of integrating or upgrading IT systems
- Complications can arise if any partners are retiring as they may prioritise their own interests over those of a merged practice that they have no stake in. This can be a particular issue if partners own some of the premises
- Allow a number of months to update the partnership agreement as the format of new agreements will be comprehensive and run to hundreds of pages
- Keep patient participation groups informed and involved
- Seek third party advice on the TUPE process to reduce any risks around the transfer of staff.
Download the full edition of Commissioning Excellence September 2017.
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