The review of the NHS announced by Gordon Brown on 4 July 2007 included a requirement for focus on the delivery of more accessible and more convenient care integrated across primary and acute providers, reflecting best value for money and offering services in the most appropriate settings for patients.

This aspect of the review goes to the heart of the services offered by GP practices and the report’s conclusions may lead to further changes to the way in which providers of services are structured and the opportunities for the involvement of the independent sector in the provision of healthcare services.

This article looks as some of the opportunities which exist at the moment and argues that consideration should be given to further collaboration between GPs and other healthcare providers prior to the publication of the review so that GPs are in a position to take advantage of whatever opportunities the review presents.

The General Practice

The structure of GP practices throughout the United Kingdom has not changed for decades.  It is traditionally structured as a small (in relative terms) general partnership, with perhaps 5 partners, serving a small geographical locality.   The services provided by such practices will be similar, although additional services will be offered by some. However, very few practices have established themselves as a genuine alternative to hospital referral except for minor operations and procedures.

The Government appears to remain keen to direct as many patients as possible away from expensive acute care and is looking for innovative solutions to assist this. The Department of Health has tried its own solutions, including the NHS Direct phone line service and its "walk-in" centres, but is expecting the independent sector, including GPs, to generate its own initiatives.

Future Possibilities for Collaboration

It is well known that a number of independent healthcare providers are talking to GP practices about the possibility of joining one or more practices in joint ventures of different kinds. They are also beginning to talk to PCTs as to whether some of the services currently provided by NHS Trusts would be more efficiently and economically provided by the independent sector, with or without the use of hospital facilities, consultant time and access to key clinical staff. The opportunities for GPs to expand their services already exist since the introduction of the APMS contract in April 2004, but so far there does not appear to be a consensus as to what collaborations or structures will work best in the future.

The provision of modern equipment for diagnosis and for the treatment of long-term illness and the expertise to properly use that equipment is usually beyond the financial range of GP practices, but if that equipment can only be funded by the acute care sector, then moving patients away from hospitals and into primary care will not be easy to achieve.

The future may therefore be in greater collaboration between GP practices, perhaps in conjunction with independent healthcare or equipment providers, so that specialist units can be funded and operated for the benefit of patients over a wider geography. If that sort of collaboration is possible to add services and expertise to a GP practice, is there not a future for much wider collaboration between practices leading towards the "Polyclinics" trailed by Sir Ara Darzi?

One of the perceived disadvantages of the partnership structure used by most GPs is that it is a very "flat" structure, ie the ownership is broadly the same as the management, with most GPs believing that they have and should have a right to decide on most aspects of the practice. In many cases the practices do not have up to date partnership agreements and are vulnerable to instant dissolution. The introduction of professional practice managers has helped to move practices forward and to take away some decision making from the GPs themselves.  However there is a long way to go to convince GP partners to give up or reduce their decision making rights. At the moment there is little pressure to change from this structure because the rewards for the partners are relatively high. However, if competition, or Government pressure, reduces the income of a practice, it may no longer support the present number of partners and this may lead to practices having fewer partners and more employed doctors and staff. Once this happens, the freedom of GP practices to join consortia or come to other arrangements will increase because the decision making process to do so will involve less partners.

Imagine therefore a scenario under which 10 GP practices in a locality collaborate together to form a consortium of those practices with a view to providing the sort of services that the Polyclinics might provide. Those practices could agree a structure in respect of the services provided by the Polyclinic under which all decisions were made by a Board consisting of a representative of each practice, with a majority of say 75% of the practices able to bind the other practices within pre-set limits. The Polyclinic would then have a life of its own and could move at a much faster pace, independent of the individual practices, to take advantage of whatever encouragement the Department of Health and the PCT is able to give.  However, for those 10 practices to agree, their individual decision making processes, as set out in their partnership agreements, must be clear and solid.

If collaboration is taken one stage further, and particularly if the number of partners in a practice reduces over time, the individual practices could become absorbed by the Polyclinic which would have its own legal structure rather than simply providing services to it. The reduction in numbers of partners could happen by the natural retirement of senior GPs and a decision not to replace them, with the remaining partners becoming owners of, or employed by, the Polyclinic. Equally the current partners could make a strategic decision to accept a small share in the ownership of a Polyclinic, and an employment contract from it, in exchange for their share in the present partnership.

What now?

Many will argue that they need to know the result of Gordon Brown’s review before committing themselves to discussions with other practices or independent health providers. In my view it would wise to consider those possibilities now and to ensure that the arrangements within practices are clear.  Many GP practices are already beginning this sort of approach and it is doubtful, having been encouraged to think big, that the review will fundamentally change the direction which the Government has taken in looking for innovation from GPs and the independent sector. If practices delay they may find that they are left behind and will have less and less control over their own destiny.

Key Points

• Ensure that you have an up to date partnership agreement with clarity over the decision making process and voting majorities
• Consider the future structure of your practice and in particular whether the practice should become owned by fewer partners
• Be prepared to begin discussions with other practices to explore the benefits of co-operation or merger

John Cole heads the partnership law team at Morgan Cole Solicitors and is a member of the firm's Health and Social Care Team. John can be contacted on 01865 262650 or john.cole@morgan-cole.com.