Originally published in the HSJ, 1 December 2020
General practice in the UK has shown just how adaptable it can be during the covid-19 pandemic, and how rapidly it can respond. This is reassuring for all those who depend on their local primary care practice for healthcare. Yet a familiar problem remains: the supply of doctors in primary care – known as “GPs” in the UK – is falling behind a growing demand for their services. GPs continue to leave general practice in large numbers and those entering the profession have a greater preference to work part-time and to do so outside the traditional partner-led practice model.
One way to help struggling GP practices could be “vertical integration” which occurs when healthcare organisations operating at different stages along the patient pathway combine, such as when the organisation running a hospital takes responsibility for running some GP practices. This is happening in a few places but is not yet widespread.
Researchers at the BRACE Centre examined the rationale and implementation of this type of vertical integration for a National Institute of Health Research-funded study. The aim was to understand the early impact of acute hospitals running GP practices and to see whether the arrangement could resolve the challenges facing modern day primary care.
According to the small amount of previous literature on this, the main reason for this approach would be to better integrate care for patients. But as the study progressed and we interviewed many clinical and non-clinical staff, including senior directors and managers, observed meetings and reviewed documents, it became clear that the dominant force driving vertical integration at the sites we studied was the need to sustain GP practices facing severe recruitment difficulties.
Our initial evaluation of three case study sites, two in England (one urban location, one rural) and one in Wales (rural/coastal), found that the single most important driver of vertical integration was to keep primary medical care local to where patients live, when GP practices would otherwise probably have closed.
Vertical integration has, in these places, provided a more stable financial platform for primary care than the model based on individual practices run as separate businesses. At the same time, these NHS trust-backed or local health board-backed GP practices can offer staff training and career development opportunities as part of a larger organisation, as well as greater job security, which increases their chances of recruiting and retaining primary care staff.
This organisational model enables primary care practices to remain open for their patients. Achieving that is a necessary first step, which then provides opportunities for better integration and innovation in care to follow. Also, the local acute hospital to which most of those practices’ patients are referred can be better assured that demand can be managed, and that patients can continue to be treated outside hospital when that is more appropriate.
One unintended consequence of vertical integration, however, was that some GPs then left their practices sooner than they might otherwise have done. The vertical integration meant that they could exit knowing that the practice would continue, and without personal financial risk. Some GPs remained at the practice for only a short period of time after it transitioned to vertical integration with an acute hospital, before leaving.
The recruitment of GPs is not easy, even for vertically integrated organisations. All sites we studied encountered high costs associated with continued employment of locums; despite fast-tracking the development of more multi-disciplinary teams in primary care.
Vertical integration has grown alongside the development of primary care networks in England and primary care clusters in Wales – which are forms of “horizontal integration”, a collaboration between organisations at the same point in the patient pathway. The two types of integration coexist and can complement one another.
Vertical integration does not suit everyone, however, as many local GP practices choose to remain outside available vertical integration arrangements, even though they would be free to join. This is despite being in areas where recruitment of GP colleagues and/or other practice staff may be difficult.
As such, vertical integration is not an option that should be imposed from the top down. It is however, a potentially valuable option to consider when GP practices look likely to fail in future – no matter how resilient some have been throughout the ongoing covid pandemi