Case Study- GMS Partnership/Practice Merger: Midlands Medical Partnership (MMP) A Model for Future-Proofing General Practice Bob Morley December 2012 Background and Context The advent of APMS in 2004 with the subsequent deregulation and commercialisation of general practice and the obvious implications of this for the future of traditional general practice led a group of like minded GPs from various practices across Birmingham to search for a solution to preserve the benefits of the existing GP partnership-led model within the new threatening and competitive environment. Whilst alternatives such as federations and consortia were considered, it became clear that these had significant drawbacks and had none of the advantages of building upon what we already had- GMS partnerships and contracts and that the way forward therefore was through partnership and practice merger. We also recognised the opportunities this could provide us, rather than just being a response to the threats to the profession. Goal,Vision and Purpose To develop corporate independent contractor general practice, merging our GMS partnerships and contracts to form a larger, more corporate business structure, allowing us and our patients to benefit from the resources, economies and efficiencies of a larger organisation in order to survive, compete and prosper in the new and evolving competitive landscape. At the same time we would improve and develop all that is excellent about traditional GP services - local GPs leading and working in local surgeries to provide long-term doctor/patient relationships based on the established values of trust and personalised care; enabling us to improve the range and quality of patient services, access, patient responsiveness and organisational learning. It was clear that the only way to achieve our goals was through the security of the nationally negotiated and non-time limited GMS contract. When, as initially seven separate practices, we first discussed our plans with our two PCTs they were, unsurprisingly, very keen to allow us to merge under a single APMS contract. But regardless of any possible practical advantages, as well as any short-term financial incentives, and more importantly as a matter of principle, we refused to abandon GMS.
Process The process involved obtaining PCT consent and support for practice mergers via robust business cases, engaging specialist legal and financial advisors, who also provided project management, and conducting a full feasibility study and due diligence on the merging practices. The key point was merger into a single partnership, run as one business, and holding the various GMS contracts. Decisions on whether constituent practices should merge contracts or stay separate were based on practical and logistical issues such as the size of the merged list, geographical location of surgeries and computer systems. We developed a comprehensive partnership constitution including various deeds, management and profit-sharing principles and policies which acts templates for any future mergers or new partner appointments. The initial merger of the seven founder practices took place in April 2009 and subsequently three more practices have joined. The model allows for straightforward expansion and increase of size to whatever we feel will best suit future needs. Subsequent Development The period since formation has been one of constant development and improvement of our business, infrastructure and management systems. As a new and enlarging organisation operating in a constantly changing environment we are well aware that this will be an ongoing process. Even whilst the merger was progressing new NHS policies and initiatives confirmed our belief that our strategy was right with a Darzi centre commissioned and two new APMS practices procured very close to three of our practices. The Darzi centre was seen as a particular threat and because of this we formed a joint venture with our local GP co-op and successfully bid for it. I have no doubt that had we not merged and formed MMP and been in a position to put in such a strong joint local GP bid it would have been won by a commercial provider. Everything that has happened since then, including the Health and Social Care Act, the advent of the CCG agenda, revalidation, CCQ registration, and the government treatment of the profession, culminating with the 2013/14 threatened contract imposition, has reinforced our view that our corporate partnership model is the right one. The Future As GP partnerships go we are large but, we believe, not yet anywhere near large enough to be best-placed to face all of our future challenges. The appalling financial situation, including the current contract imposition, together with all other recent and likely future changes for general practice
paint a compelling argument for larger partnerships and practices- for business/economic reasons, in order to have the required influence with the Commissioning Board and CCGs and to ensure survival against commercial providers ( and potentially Foundation Trusts too) who will inevitably gain more GP contracts, particularly with the increasing number of single-handers retiring. There is also the spectre of procurement with practices having to bid against large commercial firms to provide enhanced and potentially even core services. A large corporate partnership gives the capacity and expertise to do this, as well as better positioning to take more opportunities for new work generated through secondary to primary shift etc. The biggest threat of all is that the current GMS contract itself will be lost. Amongst all the recent destructive NHS changes, it seems inconceivable that the GMS contract for life will be allowed to continue. If it does go, that would be a tragedy for general practice, our patients and the NHS. However, we believe our corporate partnership model is the one best positioned to secure its future, and that of GP-led general practice. Midlands Medical Partnership (MMP): December 2012 www.mmpmedical.com 34 partners; seven salaried GPs. Circa 130 employees. 61,000 patients. Ten surgeries. Four GMS contracts with two PCTs. Five-partner management board. Single general manager; ten surgery/office managers. Specialist managers for finance/it/hr/quality GP training, including advanced training. Medical student teaching. Full range of enhanced services including invasive minor surgery, uro-gynaecology, IUCD/implant, drug abuse, nurse-led extended hours. Lead nurse Outside posts of partners include LMC secretary, subdean, VTS course organiser, urogynaecology clinical assistant, local authority medical adviser, CCG board member. Joint venture with GP co-op out-of-hours provider to run local Darzi centre.
MMP- How It Works Management and Decision Making Comprehensive partnership deal details financial, managerial and decision-making processes. Five- partner management board including chair; elected by entire partnership; three yr.staggered terms.one board member is finance/managing partner; another has lead responsibility for clinical governance and quality. Board has authority for day-to day decision making affecting the entire partnership. Major policy decisions eg appointment/expulsion of partner, taking on a new practice which CCG to join, changes to the deed, formal approval of accounts etc are reserved for the entire partnership. Local decision-making affecting a single surgery and within agreed spending limits is delegated locally. Ethos To maintain GP-partner based general practice. What makes us different is that we have no desire to be a small rump of partners employing a large number of SGPs. All our surgeries and practices must remain led by local partner. Not only do we value the principle of partner-led general practice but we increasingly recognise the benefits of appointing partners in terms of value for money and valueadded. The preferred default position on a partner retirement is to recruit a replacement partner. However we also recognise the reality that many of the best applicants for vacancies are not seeking partnerships, at least not currently and therefore that the balance of partners to SGPs may well decrease over time. We therefore seek to appoint the best candidates for vacancies regardless of status, wording our adverts accordingly, and hope that we can persuade suitable candidates to join the partnership. Patient Care We have multi-site practices with common lists/records access, and recognise that registered patients may have a choice of which surgery in the practice they attend for appointments. However we also value continuity of care and encourage practices to attend their usual surgery unless unavoidable. In general this is well respected by patients and works well. It does however give us the option of offering appointments at other surgeries within the practice to better manage capacity and access; processes in respect of this are still being improved and developed. Patients are also able to freely access extended hours appointments at any surgery within the practice together with any enhanced
service that may not be generally available at their local surgery( eg invasive minor surgery, IUCD, Implanon, diabetes LES) This ability to be able to roll out all enhanced services across an extended practice list has been a significant advantage of our mergers. Staffing Inevitably individual surgery staff(both medical and non-medical) have loyalties to the historical practice ( and particularly and unsurprisingly so with the practice managers) rather than to the new partnership. This is naturally reducing over time but has caused some issues which have had to be managed. All new recruitments are put on partnership contracts and terms and conditions which clearly helps engender loyalty to the new merged organisation. This includes flexible working clauses so they can be asked to work at any site. Some pre-existing staff have anyway chosen to switch to new contracts post-merger as part of their TUPE process. Most nursing staff have been very keen to work across sites and practices, particularly to provide extended hours and certain chronic disease services eg enhanced diabetes care, spirometry. The appointment of a lead nurse and regular nurses meetings across the organisation has helped facilitate the process. However there is no doubt that the biggest factor of all in helping to achieve panorganisational loyalty and working has been the appointment of an excellent general manager. Relationships There is no doubt that our size and therefore clout has helped our cause by giving us a voice and influence in respect of key partners eg PCT, secondary care providers, CCG. PCT responsiveness and speed and positivity of decision making towards us has improved immeasurably compared to our experience as smaller practices. Examples include decisions over how we deliver extended hours, IT system switches, approval to provide consultations in a local supermarket pharmacy and numerous others. Local hospitals, up to chief executive level have been very responsive to issues and complaints, with CEOs making personal commitments to resolve issues for us ( not that that guarantees they will always be successful of course). We had absolutely no difficulty in getting a change of CCG for a practice which joined us earlier this year, even though it then cut across the geographical fit as it then was ( now not an issue since the
CCGs merged anyway) but we don t think would have been agreed had they not joined us. We anticipate our size will give us considerable influence in all sorts of matters in respect of the CCG agenda( though clearly we need to ensure that this does not in any way impact unfairly on other practices). We have also found that our CQC registration process has proceeded smoothly and without problem, indeed CQC seem to have bent over backwards to help and advise us, allowing us to register as one legal entity despite running four practices. And of course, we have been able have one manager leading the entire registration process across our four practices/ten surgeries, amply demonstrating the value of our scale in reducing work and duplication across the organisation.