Is bigger better? Lessons for large-scale general practice

This research report from The Nuffield Trust is drawn from a 15-month study of large-scale general practice organisations in England. The study examined the factors affecting their evolution and their impact on quality, staff and patient experience. It was informed by an extensive literature review, which will be published separately, and combined national surveys with in-depth case studies of contrasting, large-scale general practice organisations and analysis of 15 quality indicators.

Key findings are as follows:

  • This agenda is well underway across the country, with almost three-quarters of general practices already in some form of collaboration with others, almost half of which formed during 2014/15. The major reasons for forming were to ‘achieve efficiencies’ and ‘offer extended services in primary care’. 
  • Larger scale has the potential to sustain general practice through operational efficiency and standardised processes, maximising income, strengthening the workforce and deploying technology. 
  • However, scaling up will take a lot of hard work and cannot just be left to a few heroic leaders. All GPs will need to play a part in making these new organisations successful.
  • The evidence that these organisations can improve quality is mixed. Patients had differing views about the benefits of large-scale organisations. Some appreciated increased access, while others were concerned about losing the close relationship with their trusted GP.
  • The case study organisations had established high-quality specialist services in the community which were popular with patients, but were delivered at relatively small scale. Trust and close engagement between practitioners and commissioners were very important for successful implementation. Clinical commissioning groups (CCGs) had to manage the tension between supporting large-scale organisations to develop while also managing conflicts of interest.
  • In light of these findings, the authors argue that policy-makers and practitioners should be realistic in their expectations of the pace at which large-scale organisations can contribute to service transformation. The report offers a series of practical insights and lessons for general practitioners as well as important lessons for policy-makers, national leaders and commissioners.

The full report includes detailed insights about governance, leadership, management or change, staff perceptions and quality improvement methods used in each of our case study sites.

Full Report

Nuffield Trust Blog - Large-scale can help general practice weather the storm