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Getting the model right – Trusts working with primary care

For this issue’s interview, we talk to Dr Berge Balian who is Medical Director of Symphony Healthcare Services (SHS), an NHS organisation that operates and supports 20 GP surgeries covered by 16 GP contracts in Somerset and Devon.

B Balian
Berge Balian

Berge has been a GP in Somerset for 26 years and for 25 of those years has been representing GP practices through the Local Medical Committee (LMC). He has also held several roles bringing Somerset GPs and hospital consultants together with the aim of improving operational relationships and referral pathways in the area. He currently chairs the Somerset general practice provider board.

Can you tell us a little about how Symphony Healthcare Services (SHS) come about?

About 10 years ago Yeovil District Hospital NHS Foundation Trust recognised the need to work more closely with general practice and established an associate director for primary care role which I applied for and was fortunate to be offered.

We identified ways that general practice and the Trust could work together and put some resource into care for specific groups of complex patients with comorbidities who often revolve in and out of the hospital.  We created a comprehensive data set (called the Symphony data set) of health and social care activity and commissioned the University of York to do a really in-depth analysis of patients and identify the most appropriate care pathways to better support high users of the health and social care system in South Somerset. We created a complex care team to support these patients, and this led to us becoming part of a nationally funded PACS (Primary and Acute Care System) Vanguard programme which was the Symphony Vanguard program.

We set up a board for the program with representatives from all but one GP practice in South Somerset (17 practices in total, covering a population of approximately 110,000 patients), alongside representatives from the Acute Trust, but with general practice representatives forming a majority on the Board through me being one of the Trust representatives and chairing the Board.  This allowed us to use the vanguard funding to develop new care models directly supporting general practice but with the aim of both improving practice resilience and reducing hospital-based activity. One of the things we identified was that roughly one seventh of the money that was spent in South Somerset was spent in primary care, but this provider sector provided more than 50% of total patient activity, and 80% of all healthcare activity. Additionally, much of the other activity was influenced by primary care through the decisions it makes on a daily basis.  The Symphony Vanguard developed new models of working including the introduction of health coaches and care coordinators, in addition to expanding the existing complex care teams, and through them demonstrated that we could make the whole health and social care system more cost efficient.

Halfway through the vanguard program, three practices who were part of the program but were struggling with the traditional partnership model of general practice approached the Trust and asked if it would be interested in taking on their contracts.   

After speaking to other local practices, the Trust Executive and Board, and some of the hospital consultants about the potential impact of these practices either closing or being re-procured, potentially from private providers that we would be less able to influence, we realised that actually the impact on the health economy in South Somerset could be quite significant so we decided it would be worthwhile looking into the feasibility in more depth. 

How did you go about establishing SHS as an organisation?

We recognised that, because hospitals and GP practices are run in a completely different way with completely different governance processes and contracting models, we couldn’t simply integrate practices as a division of the Trust. So, we developed a model that established a company that is an arm’s length NHS organisation run by people with knowledge and experience of general practice, but owned by the Trust, which holds the risk associated with those contracts.

We created SHS as a separate entity that has one shareholder, which is Yeovil Hospital Foundation Trust, but has its own board with voting members from the Trust and from General Practice, with the latter forming the voting majority on the SHS Board.

The other thing that we recognised was that it had to not only look and feel as much like general practice as possible, but it also had to have complete openness and transparency to the other practices so that they could see that this is neither a predatory organisation that’s going to take them over, nor an organisation that is privileged by its links to the hospital and being differentially funded. The SHS Board consequently has a voting GP member representing the independent practices, and the vanguard models of care continue to be deployed across both the integrated and independent practices. 

Other local practices were also concerned that we could simply bring in GP contracts into one entity and then sell them off to one of the big corporates.  To allay this fear, we spent time with a legal team looking at how you bring GMS and PMS contracts into an organisation that is not a Trust, but is linked to the Trust, and give it the ability to hold these contracts.

 In order to be able to hold GMS Contracts, we created a novel role called the ‘Nominee GP contract holder’. This is where each practice contract is held by a nominal GP Partnership that has me as the common Partner (in my role as SHS medical director), the other being the lead GP in the practice. These GPs hold the GMS contract and then subcontract it to SHS.

As a nominal partnership, the Partners get no benefit from the contract and so in turn the Trust agreed to indemnify those Partners from the risks and liabilities associated with holding the contract.

To further allay the fears of some form of sell off of the contracts to non-NHS organisations, we also added a clause to the integration contract that would allow former Partners the option to request to take back the contract if this situation were to happen (that option has never been exercised).

How did you deal with the issue of subcontracting and its effect on NHS pensions?

We were fortunate because of the vanguard status that we had at the time.  We were granted open direction by the secretary of state for health allowing all our staff working in GMS practices indefinite access to the NHS Pension Scheme for the duration of our lifetime, and we have retained the ability to have our staff on the Scheme.

What has happened since you became established?

In the first two years that we were in existence we moved from three practices to eight practices.  Some practices made a strategic decision to integrate with SHS (having decided that the Partnership model was not viable for them in the long term), whilst others were encouraged to do so by the commissioners as they were struggling with their contracts or workforce or care quality, and this has continued to be the case with other practices regularly joining us over the course of the past six years.

The latest four practices to join had already integrated with two other Trusts in Somerset (who subsequently merged), but using a different model involving direct integration into the Trusts. Following a proposal for that merged Trust to also merge with Yeovil Hospital Foundation Trust (SHS’s owner), it was agreed that these practices should also become part of SHS.  This was partly driven by the practices who recognised the benefit of SHS having established its own central team specifically dedicated to general practice, as opposed to having integrated directly into the Trust and its support structures.

How have ex-partners been incentivised?

We created something called the Performance Incentive, which recognises the additional hours, responsibility and work Partners working in traditional practices put in.  We set it based on how much an average salaried doctor earns compared to average Partner drawings in the area (decreased to recognise that the risks associated with being a Partner in terms of income and contract risks no longer exist, as I mentioned earlier). 

The model is continually being revised to reflect what is happening in general practice and we now have a multi-tier model to reflect the amount of leadership responsibility an individual GP has, ranging from purely salaried GPs to GP consultants who effectively work as Partners do in the independent GP Partnerships.

What do you see as your successes?

Firstly, every one of our 20 practices (covered by the 16 contracts) is now rated ‘good’ by CQC although two thirds of them were rated ‘requires improvement’ for various reasons at the time they came into SHS.  CQC initially viewed SHS with some suspicion and it took us three years to develop trusting relationships with our local inspectors, who now recognise that we have got robust governance structures and invest a lot of our energy into continually improving the quality of our services, including looking at how we standardise protocols and processes within the practices as well as developing quality improvement programs we can implement at scale.

Much of this occurs because we recognised the need for SHS to be clinically led.  We have a medical director, a clinical director, and a team of clinical leads (one in each practice, some of whom are nurses or paramedics by background) who come together through our clinical forum and set the strategy and the clinical policies for SHS.  We then have a central team that enacts these policies across our practices, but also sets the operational strategy supported by the practice managers in our practices, and the clinical leads in turn help to enact that strategy.  The operational model is effectively a “hub and spokes” model. The central team sets the overall ambition, which is that we need to move to a multidisciplinary team (MDT) care model and an “at scale” provider model, but allows each practice to run as autonomously as possible on a day-to-day basis, including how the practice interacts with patients and the workforce model they put in place.  This is developed by the clinical lead and the practice manager in each practice and that’s worked well from the point of view of still keeping that individuality in the practices. This also helps to ensure patient choice, particularly in the areas of the county where all the practices are now part of SHS.

The downside to that is that we haven’t been able to push forward with standardisation and achieving economies of scale as rapidly as we would have liked.

The hub and spokes model is continually being adjusted, but another thing that we’ve done successfully is to develop some support hubs for the Symphony practices. So, we have a prescribing hub that manages most of our prescribing for the majority of our practices depending on the stage of integration they are at. 

We have a workflow hub that manages all of the clinical admin workflow into the majority of the practices.  In my practice, I’ve gone from roughly seeing 85% of the correspondence that comes into the practice to seeing about 20%.

We also have a data team that is effectively a hub supporting both the practices and the central team.

Finally, we are continually developing relationships in the county so that the majority of the rest of the system in Somerset recognises the value that SHS brings, even if questions remain regarding the finances around it.  One of our concerns was that we would struggle to be recognised in the system as anything other than a turnaround organisation, but we’re increasingly seen as being a provider of quality services and focused on supporting the whole system including all general practice in the county.   

How have patients reacted to what you’ve done?

I think it’s fair to say that when we first approached patient participation groups (PPGs) at the time of integration, they initially saw SHS as a private provider, which is ironic given its ownership by an NHS statutory body.  Secondly, following integration it’s generally not their GPs providing their care anymore (partly because of our MDT model, and partly because some of the GPs inevitably retire or leave), and therefore we are viewed generally quite negatively at the beginning.  However, we spend a great deal of effort explaining the reasons underlying practice integrations and our care model to PPGs and other patient groups, and when we look at patient surveys a year after integration, the PPGs and the majority of patients view it positively because they see the changes that we make, they understand some of the stabilisation, and they realise that actually the model of care that they had before integration wasn’t necessarily either optimal or sustainable in the long term.

We’ve also created a PPG Group covering all the SHS practices; this group meet with our central team, led by our director of nursing and quality and we talk about SHS and the future and ensure that patients and their representatives have input into the future SHS strategy.  Consequently, we have a really good relationship with our PPGs and they in turn support us with our communication and relationship with the patient population.

Do you have any advice to other trusts thinking of looking at vertical integration?

There are some things that I would advise and the first is, unless you are going to take over the whole of general practice in your area, think very strongly before you integrate practices directly into your Trust because you will just be seen as a Trust taking over general practice and you will alienate the other independent practices that aren’t integrated. I think you would be better off thinking about creating a vehicle through which you provide primary care services and not thinking about that organisation as a division in the Trust.  This also supports more collaborative working across primary care networks (PCNs) and other practices.

The second is that you need to recognise that the way that secondary care and primary care are contracted and funded and actually operate, including the whole governance structures around them, are all are very different. 

In addition, particularly in HR and finance, you need to have people working within these areas who really have a true understanding of general practice, rather than just thinking you could do it within the resource and skill set that you’ve already got within your Trust.  If you don’t, you will increase your risk of failing, or at least really struggle to provide a good service and it will take you a long time to turn around any struggling practices that you integrate.

The last thing I would say is that if you’re going to think about integrating practices you need to understand that that you will inevitably end up having to invest some resources into those practices from within your budget allocation (or the system budget as we move into integrated care systems) or agree a separate pot of money over and above the core contract value. This is because you need to incentivise the clinicians you employ, especially the GPs, to provide the same level of input and workload that traditional GP Partners are inherently incentivised to provide through the Partnership contractual model.

I think it’s difficult for Trusts to integrate practices thinking that you could manage those practices within the national contractual envelope that those practices will bring in with them, based on our experience. This is not only related to the incentivisation problem I discuss above, but because although you do get some economies of scale, one of the lessons we’ve learned in Symphony is that unless you are operating at really big scale and also effectively impose single operating and clinical models, you won’t achieve sufficient economies of scale for your organisation to counteract the fact that there is inevitable transformation and turnaround that needs to happen in those practices, which is very costly and therefore very difficult to achieve within the existing financial envelope.

In summary, if I was the leader of a Trust being asked or thinking about taking on GP practices, I would not only spend time liaising with the other practices in the area with the aim of gaining their support and consent, but I would also be approaching the commissioner and trying to get some differential funding for the first three or four years that says, whilst we may not need (all of) it, we need to agree a pot of money that we can access if we find when we go into these practices that there are some governance, workforce and operational changes that we need to make, or find some quality issues that need to be improved on.

I will end on a positive note by saying that, in my opinion, Trusts supporting their local GP practices, whether through integration, deployment of Trust resources in practices, or sharing care models, can reap large dividends if approached with the appropriate motivations, focus on patients, and clarity regarding the intended outcomes.


Last Updated on 31 May 2022