The NHS Confederation document Supporting General Practice At Scale: Fit for 2024/25 and beyond recommends that Limited Liability Partnerships (LLPs) should be able to hold GMS and PMS contracts and limit GP partner liability “helping to modernise the partnership offer”.  But this, and the document’s use of the use of the word ‘devolution’, got me thinking.

In 1985 the optical market was deregulated – meaning that you no longer had to be an optician to run an optical business, and Doug and Mary Perkins set up Specsavers. By 2012 they represented 42% of the UK market, and the top three multiples held 66% of the market. With a growing online offer, independent businesses had already shrunk to 28% of services.

In 1999 the same thing happened to Vets, with Vets4Pets, the in-store service for Pets at Home, scooping up a vast market share amid a scramble of venture capital investment.

In 2003 Dentists were next, and Oasis Dental consolidated much of the market, aided by a team of senior leaders and investors who’d cut their teeth in the earlier professional market consolidations.

Similar stories play out in Pharmacy, Accountancy and Solicitors, with traditional models swept aside by larger corporates with a near identical structure;

• A Joint venture partnership model at local branch level, where the professionals delivering the service are partners with the ‘head office’ in owning and sharing the profits of the site, often as an LLP.
• A powerful head office function, with a strong brand, buying power to drive the cost of stock and consumables down and a franchise-like approach, drawing profits from being a partner at local level.
• Separate estates arms held as a real estate investment trust (REIT), allowing the property element of the business to be funded by stock exchange investors.

In 2013 it appeared our time in General Practice had come. The shift in NHS pensions directions and a decision by NHSE that all future contracts would go out as APMS, rather than GMS certainly looked like a deregulation event. Plenty of corporates have tried in the decade since. A number of major players have come and gone, though none with joint venture partnership models to retain the professional involvement at practice level. Some have seen pretty ugly examples of quality and safety. The number of practices owned by ‘multiples’ has grown, the average size of practices has doubled in the last decade, and the number of practices open in England has slumped by a quarter in the last five years. Is this a slow burn or a false dawn? We would do well to watch for signs of history repeating itself, and whether LLPs might be the spark.

But context is everything. The Confed piece is overwhelmingly more focused on vertical integration with existing NHS providers – the acute trusts that make up the traditional core of their membership. And Acute trusts are as likely to benefit from LLPs and indeed, the Specsavers approach as corporates, with JVPs as a useful way for Foundation Trusts to extract value, leverage their purchasing power and burnish their brands. The approach doesn’t stipulate who the consolidator will be, just how it has previously been structured. Perhaps the theoretical independence of Foundation Trusts will come to the fore at this point – ironically when we are supposed to be moving away from the internal market.

But it was the use of the word ‘devolution’ that really caught my eye. Call me a cynic, but it seems to me the political examples of devolution in Wales, Scotland and the English cities and regions have largely been about outsourcing the blame for financial control that doesn’t follow with the responsibility. As talk of localising the GP contract and removing QoF in favour of local priorities grows, we must keep an eye on who becomes the scapegoat for the cuts that inevitably follow from stalling investment in services.

Paul Conroy

Practice Business Manager, Denmark Street Surgery, Darlington