In the second of his blogs looking at the questions that will determine the future of general practice Ben asks

At What Scale Will General Practice Operate?

I find the answer “general practice needs to operate at greater scale” often precedes the question. Indeed, in many cases there is no sign of a question, it is simply presented as a statement of fact, as though 70 years of effective working at the current scale counts for nothing and there is no need to even make a case to support the statement.

As I have previously been at pains to point out, scale does not, of itself, automatically generate benefits for general practice. We only need to look at the graveyard of federation failures to know this to be true. Equally, the Nuffield Trust report “Is Bigger Better?” found instances where the quality of general practice reduced with increased size.

The authors of that report ultimately felt scale was better for general practice, but only where it is led by high quality leaders who understand the value general practice provides and work hard to preserve it. I have been fortunate enough through the podcast to be able to discuss with some of those leaders the rationale that sat behind their move to scale. What is striking is how different those rationales are. This is important, as it means there is not a single basis for general practice operating at scale. Further, it is the rationale for operating at scale that ultimately determines the answer to the question of at what scale general practice should operate.

There are seemingly two ends of the spectrum. At one end, the question is, “how do we create the efficiencies, voice and shared infrastructure to preserve and strengthen independent general practice”? This, for example, is broadly the question the super-practice Our Health Partnership (OHP) is seeking to answer.

They believe the optimum population coverage for their model is c500,000. This is based on each member practice contributing £2 per head, which creates a £1m budget to fund a management team. This is the size they believe is necessary to deliver real value. What is impressive about the model is it is maintaining a focus on working for the member practices (efficiencies), while at the same time creating a strong position within the local STP (voice).

At the other end of the spectrum, proponents of NAPC’s primary care home model advocate strongly for a population size of 30-50,000. Here the question is, “How can general practice really understand and best meet the specific needs of local communities, and retain and build on the sense of belonging that local communities have”? They believe if general practice operates beyond that size it cannot maintain the personal relationships fundamental to its success. Local needs vary so much that a service providing an average of the needs of two communities is in fact not meeting the needs of either.

Of course these two perspectives are not mutually exclusive. OHP want to build their organisation around specific geographical localities. Nav Chana, GP Chair of the NAPC, is clear a bigger population size might be required to create the infrastructure needed for these individual primary care home sites to deliver.

Futures are journeys not destinations. Beacon Medical Group is a great example of a practice on a journey. Already at 30,000, they have plans to scale significantly beyond that. But they understand what is important about general practice is continuity of care, and the ability for local areas to tailor services to the needs of their local population. So as they grow they are building on units of around 30,000, each with some degree of local freedom. Imposing a one size fits all operating model is not, in their view, going to work, even within a single practice.

General practice may be heading to a place where it operates at a large scale (over 100,000 population, maybe higher than 500,000) to create the new infrastructure it requires, while at the same time finding a way to retain some level of autonomy at individual locality level (30-50,000 population). But this concept of the journey, like the one that OHP and the Primary Care Home sites and Beacon Medical Group are all on, is the one that Rebecca Rosen and the authors of the “Is Bigger Better?” report believe to be critical. The most important question is not what size general practice is going to be, but rather how it is going to get there.

If you’d like to find out more about the future of general practice and meet some of the key voices in contemporary general practice (including Mark Newbold from OHP, Nav Chana Chair of the NAPC and Jonathan Cope from Beacon Medical Group) then why not buy a ticket to our first General Podcast LIVE event? For more information including a full programme and how to buy tickets visit our website here.