Policymakers should focus on tackling the underlying problems facing general practice instead.
General practice in England is under extreme strain. People are finding it harder to book GP appointments,1 patient satisfaction is falling,2 professional wellbeing is under threat3 and there are challenges offering continuity of care to people with complex conditions.4 Appointments in general practice are at a record high5 but the number of full-time equivalent qualified GPs has fallen since 2015.6
Some policymakers are suggesting reforms to the way general practice is organised to help address these pressures, including scrapping the GP partnership model in favour of GPs becoming salaried NHS employees. Some NHS trusts in England are already playing a greater role in managing GP services. We summarise these approaches, evidence on impact and what it might mean for policymakers considering options for the future.
There is a longstanding separation of primary care and hospital services in the UK dating back to the beginning of the NHS. Unlike hospital consultants, GPs have traditionally held independent contractor status and not been NHS employees, although almost all their funding comes from public sources. A recurring debate is whether GPs will retain this model of employment given that around a third are now salaried doctors.7 There is an increasingly diverse range of employers of salaried GPs, including local GP practices, large-scale primary care-based organisations,8 or even John Lewis-type mutual GP organisations.9
Some acute NHS trusts are now acquiring general practices and employing GPs – for example, to staff urgent treatment centres. What is proving more controversial is hospitals employing GPs to deliver a fuller range of GP services, such as the Royal Wolverhampton NHS Trust, Northumbria Healthcare NHS Foundation Trust and others.10 Some have suggested this might be an organisational and employment model for the future11 and the idea appears to have some political support from senior Conservative MPs.12 The Labour party has also proposed scrapping the independent contractor model, with GPs becoming salaried NHS staff13 – and one option for doing this could involve NHS trusts employing GPs.
This is not a purely UK phenomenon. Similar merging of some general practice and community services with hospital care has happened in Spain, the US, New Zealand and Denmark.14,15,16,17 The stated rationale includes improving collaboration between services, better management of the population’s health needs, sharing back-office support such as premises and IT, making general practices more sustainable and accommodating changing career paths and GP training preferences.
Emerging approaches to integration
In the UK, there is a range of models of NHS trust integration with general practice, including approaches being developed in Somerset, Wolverhampton, Northumberland and North Wales. This sometimes involves acute hospital trusts managing general practices (vertical integration), but also community or combined acute and community trusts (horizontal integration), such as in Derbyshire Community Health Services NHS Foundation Trust.
The Royal Wolverhampton NHS Trust, a large acute and community health services provider, currently has eight directly integrated general practices, governed by a designated division in the trust comprised of primary care clinicians and secondary care managers. The trust has established links between its community health services and GP practices, creating a rapid intervention team intended to improve health in the area and reduce unnecessary demand for emergency care services. Work is under way to establish a ‘command centre’ that handles calls to all practices. GP practices owned by the trust also have access to a live dataset showing their patients’ contacts with acute, primary and community services.18
In Somerset, the acute hospital trust owns a limited company, called Symphony Healthcare Services, which is currently running GP services for a group of 16 practices, covering a total registered population of approximately 117,000.19 The primary care company reports directly to Yeovil District Hospital NHS Foundation Trust. Symphony Healthcare Services has established several multidisciplinary care teams focusing on patients with complex and multiple conditions who have high health and care needs. The trust uses a mix of data to assign each patient a score for how complex their health needs are and monitors their wellbeing and risk for potential hospitalisation. It has also implemented a centralised hub to process medication requests across primary and secondary care.
Evidence on impact
UK studies of vertical integration of acute trusts and general practice are limited, but research is starting to emerge.20,21 Early evidence on the professional and management effects of these new models21 points to a mix of potential challenges, such as:
- fear of loss of GP and practice autonomy
- increased bureaucracy associated with larger NHS bodies
- a reduction in local patient and community attachment to their practice
- potential damage to relationships with other local GP practices
- threats to existing multidisciplinary team working
- staff leaving if they feel ‘taken over’.
But the research also identified potential advantages of these new ways of working, including:
- better links between GPs and secondary care services and colleagues
- less management and regulatory pressure for GPs
- more training and development opportunities and resources for all in the primary care team
- new career pathways for practice managers
- greater potential for service innovation.
There is some early evidence of impact on quality and service use associated with the integration of general practice with hospital trusts in the UK. A quantitative study found a modest reduction in emergency hospital admissions or readmissions for patients of vertically integrated practices compared with a ‘synthetic control’ group of non-integrated practices, perhaps due to the removal of some barriers to more effective coordination.20 The authors note the similarity of their findings with those of a study of vertical integration in Portugal.22
But research on patient experience and outcomes in these models is lacking. Building this evidence is not straightforward, as vertical integration rarely happens in isolation from other policy and organisational changes, such as the introduction of ICSs or trust mergers. An NIHR-funded study is underway to examine the impact of hospitals managing general practice on patients with multiple long-term conditions.23
Examples of vertical integration are also emerging in other countries, but differences in context mean evidence on their development and impact should be interpreted with caution. In Denmark, the Odense University Hospital has co-located primary and secondary care services (called the ‘cooperation model’) and introduced an on-call GP facility alongside the accident and emergency department.17 ln Spain, a single provider was contracted in the early 2000s to provide integrated access to primary care, acute and specialist hospital services in Valencia, but the approach did not appear to outperform services in other regions and the contract has since been withdrawn.19 These examples are often confined to specific areas or regions in response to particular local pressures – something that appears to be common to UK developments.
Establishing a clear vision for general practice
The move by some NHS trusts to take on the management of general practice has, so far, happened organically and not as a result of NHS policy or central mandate. A driver for these changes is often a pressing local problem, such as general practices facing closure21 and commissioners, NHS trusts and GPs working together to find a solution. This is happening in parallel to GPs developing new forms of employment to suit their career, work-life balance and other needs. But now politicians are exploring options for direct NHS management of GPs and suggesting more widespread adoption.
Evidence on the impact of these new organisational models is limited. Broader evidence shows that greater organisational integration does not necessarily lead to better service integration.24 And there are alternative options for GPs seeking additional management support to survive in the face of financial or other pressures, such as joining a GP federation or contracting with an NHS organisation to provide support services. The form and scale of any integration with NHS trusts will depend on local circumstances, and international evidence points to general practices preferring smaller scale initiatives.25,26 More evidence should be gathered on what models work, for whom and in what context.
Standing back, the underlying pressures facing general practice in England link to the fundamental mismatch between demand for care and available GPs.27 Broader policy action is needed to address these problems, including a long-term plan for NHS staffing and sufficient government investment in primary care and other services in the community. More NHS trusts managing general practice will not fix them.
GPs in England are in need of hope and support – not threats of radical changes in how they are organised. Policymakers seeking to improve general practice should start with a clear articulation of the vision, principles, scope of service and funding for general practice in the future. Giving GPs options for how they organise to help achieve this vision makes sense.28 But it is not clear how a wholesale shift to one organisational model for primary care would address the major problems facing GPs. Evidence from the long line of NHS reorganisations shows it would likely cause distraction, additional costs and unintended consequences,29,30 along with further loss of GPs, practice nurses and other staff – something that can be ill afforded.
Judith Smith (@DrJudithSmith) is Professor of Health Policy and Management in the Health Services Management Centre (HSMC) at the University of Birmingham.
Manni Sidhu is Associate Professor in the Health Services Management Centre (HSMC) at the University of Birmingham.
(1) NHS GP Patient Survey. Surveys and reports. NHS England and Ipsos; 2022 (https://www.gp-patient.co.uk/surveysandreports).
(2) Wellings D, Jefferies D et al. Public satisfaction with the NHS and social care in 2021: results from the British Social Attitudes Survey. The King’s Fund and Nuffield Trust; 2022.
(3) Beech J, Bottery S et al. Closing the gap: Key areas for action on the health and care workforce. The Health Foundation, King’s Fund and Nuffield Trust; 2019.
(4) Wiltshire A. Improving continuity of care in general practice: four lessons from the frontline. The Health Foundation; 2019 (https://www.health.org.uk/news-and-comment/blogs/improving-continuity-of-care-in-general-practice-four-lessons-from-the).
(5) Bostock N. Appointments hit record 32m in October as profession loses 400 GPs in a year. GP Online; 2022 (https://www.gponline.com/appointments-hit-record-32m-october-profession-loses-400-gps-year/article/1806197).
(6) Nuffield Trust. NHS Staffing Tracker. Nuffield Trust; 2022 (https://www.nuffieldtrust.org.uk/nhs-staffing-tracker/general-practice).
(7) RCGP. Fit for the future? Retaining the GP workforce; 2022 (https://www.rcgp.org.uk/getmedia/155e72a9-47b9-4fdd-a322-efc7d2c1deb4/retaining-gp-workforce-report.pdf).
(8) Pettigrew L, Kumpunen S, Rosen R, Posaner R and Mays N. Lessons for ‘large-scale’ general practice provider organisations in England from other inter-organisational healthcare collaborations. Health Policy 2019 123(1) pp 51-61/
(9) Harrison T, Morrow J and Scholtes S. The ‘John Lewis’ model can help save general practice. Health Service Journal; 2022 (https://www.hsj.co.uk/service-design/the-john-lewis-model-can-help-save-general-practice/7032158.article).
(10) Pulse. The hospital GPs; 2022 (https://www.pulsetoday.co.uk/analysis/cover-feature/the-hospital-gps/).
(11) Phillips S, Ede R and Landau D. At your service: a proposal to reform general practice and enable digital healthcare at scale. Policy Exchange; 2022.
(12) Trivedi S. Javid backs report calling for GPs to be ‘directly employed’ by the NHS. London Health Service Journal; 2022 (https://www.hsj.co.uk/primary-care/javid-backs-report-calling-for-gps-to-be-directly-employed-by-the-nhs/7032012.article).
(13) Sylvester R. Wes Streeting: We must think radically – I want to phase out the existing GP system. The Times; 2022 (https://www.thetimes.co.uk/article/wes-streeting-we-must-think-radically-i-want-to-phase-out-the-existing-gp-system-tmpb0wqt6).
(14) Comendeiro-Maaløe M, Ridao-López M, Gorgemans S, Bernal-Delgado E. A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015. Health Policy 2019;123:412–8.
(15) Schwartz P M, Kelly C, Cheadle A, Pulver A, Solomon L. The Kaiser Permanente Community Health Initiative: a decade of implementing and evaluating community change. Am J Preventive Med 2018; 54: S105–9.
(16) Toop L. Steps towards more integrated care in New Zealand: a general practice perspective. BJGP Open 2017; 1 (1): bjgpopen17X100845. DOI: 10.3399/bjgpopen17X100845.
(17) Blom A, von Bulow LL (2013) Vertical integration across hospital acute care and on-call general practitioners: an evaluation of a cross sectional cooperation model at Odense University Hospital, Southern Region of Denmark. Int J Integrated Care; 2013;13:8 (https://www.ijic.org/articles/abstract/10.5334/ijic.1481/).
(18) The Royal Wolverhampton NHS Trust. Primary care vertical integration. (https://www.royalwolverhampton.nhs.uk/about-us/primary-care/).
(19) Symphony Healthcare Services (https://www.symphonyhealthcareservices.com/#).
(20) Yu V, Wyatt S, Woodall M, Mahmud S, Klaire V, Bailey K, Mohammed MA. Hospital admissions after vertical integration of general practices with an acute hospital: a retrospective synthetic matched controlled database study. Br J Gen Pract 2020; 70: e705–13 (https://doi.org/10.3399/bjgp20X712613).
(21) Sidhu M, Pollard J and Sussex J. Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation. Southampton, National Institute for Health and Care Research Journals Library; 2020 (https://www.journalslibrary.nihr.ac.uk/hsdr/TLLA3317/#/abstract).
(22) Lopes S, Brito Fernandes Ó, Santana R. Impact of vertical integration on frequency of hospital readmissions. Int J Integr Care; 2016 166A136 (https://ijic.org/articles/abstract/10.5334/ijic.3024/).
(23) Sidhu M, Davies C, Saunders C, McKenna G, Litchfield I, Wu F, Sussex J (Forthcoming). Vertical integration of GP practices with acute hospitals in England: rapid impact evaluation. National Institute for Health and Care Research.
(24) Lewis R Q, Checkland K, Durand M-A, Ling T, Mays N, Roland M, Smith J A. Integrated Care in England: what can we learn from a decade of national pilot programmes? International Journal of Integrated Care; 2021 vol 21(4): 5, pp 1–10 (https://www.ijic.org/articles/10.5334/ijic.5631/).
(25) Robinson J C, Miller K M. Total expenditures per patient in hospital-owned and physician-owned physician organizations in California. JAMA; 2014;312(16):1663–1669.
(26) Casalino L P, Pesko M F, Ryan A M, Mendelsohn J L, Copeland K R, Ramsay P P, et al. Small primary care physician practices have low rates of preventable hospital admissions. Health Affairs (Millwood). 2014: 33(9):1680–1688.
(27) Shembavnekar N, Buchan J, Bazeer N, Kelly E, Beech J, Charlesworth A, McConkey R and Fisher R. Projections: General practice workforce in England. The Health Foundation; 2022 (https://www.health.org.uk/publications/reports/projections-general-practice-workforce-in-england).
(28) Fisher B, Alderwick H. Reforming the GP partnership model? BMJ. 2023; (https://www.bmj.com/content/380/bmj.p134).
(29) Smith J A, Walshe, K M J and Hunter D J. The redisorganisation of the NHS. BMJ; 2001 vol 323, pp 1263–4.