A decade ago, Willow Bank made a single decision that has insulated them from many of the concerns GPs face today. Traditional partnerships underpin the way GP provision is delivered in England. Yet as Dr Nigel Watson highlighted in his recent GP Partnership Review, issues around personal liability, increasing workload and ambivalence about becoming a partner are driving the need for alternatives.
Willow Bank began exploring one alternative, mutualisation, early. It’s a model that gives workers ownership and/or meaningful influence. Originally founded in 2003 as a new Primary Care Trust practice, they soon sought an alternative structure that would allow staff to be directly employed whilst enabling more autonomy, financial control and freedom.
“In Stoke on Trent it was recognised there was an ageing GP population due to retire soon,” explains Paul Roberts, former CEO and current Chair of the Board. “We had a small team set up as employees rather than partners and wished to keep it that way. Salaried doctors were still quite a new thing.”
What was special about Willow Bank that leant itself to salaried doctors specifically?
“We’d always looked after outliers as part of our provision – a large homeless population, some with substance misuse problems, etc. Because of this, we built up a coterie of multi-disciplinary folk including district nurses and health visitors, who were all an intrinsic part of our team. This diversity in skillset lends itself to a different model. Whilst in a partnership of GPs, there’s a certain agility in being able to make a decision on Friday and implement it on Monday, you’re also missing out on input from other key people. For our team, the social enterprise model looked sensible.”
With pathfinder funding from the government’s Social Enterprise Programme, support from local partners and advisors (Gingerbread Stoke and CTP) and around 2,000 patients, Willow Bank began delivering an APMS contract that meant they functioned as a regular GP practice but would need to recompete at the 10 year mark (coming up this year). It gave all their staff a voice, not just GPs, which was more fitting for their cross-disciplinary community-based approach.
Written into their APMS contact was the condition to keep growing, so this impetus was always present, resulting in Willow Bank eventually expanding to its current size serving 11,000 patients – about a third larger than the average practice in the UK.
“As a social enterprise, we’ve worked differently to other GP practices, at times being quite entrepreneurial,” explains Paul. “Even to the point it got us into trouble.” Chuckling at the memory, he explains how they offered free blood pressure checks inside the local Tesco until a rival GP objected and they were asked to leave.
This is something we’ve heard repeatedly from public service mutuals – that through the freedom to think freely and autonomously they tap into creative problem solving that would otherwise have been hampered by bureaucracy and system limitations. (See our spotlight on Thurrock Lifestyle Solutions.)
“We knew that if we grew in size fast enough, we would have a viable business, and so unlike some GPs, had a proper marketing policy. We asked ourselves what mattered to our patients. On one occasion we took some of the local community on a bus trip to buy fabric. Another time, we implemented hepatitis C screening as we hypothesised the silent disease could become a problem to the local community – though we found tens of cases, rather than hundreds.”
And how is this different to working in a GP partnership?
“As a CIC, we can take a ‘project’ approach. The profits are put back into the service, so personal financial gain isn’t a motivation. Our board is only interested in what serves the community and the people who work in it.”
Primary care faces a number of nuanced challenges, and personal investment and financial incentives historically have played into the drive to keep delivery standards high, at least in their intention. However, with GP numbers falling and a significant number retiring imminently, the partnership model will come up against barriers to buy-in that mutuals like Willow Bank don’t need to contend with.
“At Willow Bank, we were successful at recruiting doctors because they still have a voice in the mutual model, but don’t need to take it home at the end of the day. These days, people want ‘portfolio careers’. They want to come to work and do it passionately, but be able to draw a tight boundary around it, going home at the end of the day. Imagine the stress of being the last man standing. We didn’t want that.”
Here Paul is referring to what can happen in a partnership when just a few, or one single partner is left shouldering the responsibility and liability due to the lack of a robust succession solution in place. Furthermore, the split between partners and employed GPs can lead to a two-tier system, where some get to ‘switch off’ and others lose sleep over how the business is doing. This is even more complicated – and detrimental for communities – when premises are involved. An assumed growing lack of appetite for premises ownership was a contributing prompt for NHS England’s Review of GP Premises last year, all entwined with the complex struggle of getting primary care fit for the future.
The ambitions of the GP Forward View (2016)– as well as having to simply adapt and respond to evolving economic and social demands and challenges – has prompted a period of change for general practice. Analysis from The King’s Fund shows a down-turn trend in GP partners, whilst the number of salaried GPs has risen four-fold over the past decade to nearly 30%.
Mutuals present a response to this new reality, offering the ability to grow through diversification, freedom to innovate, and structure to engage and retain staff. Right across the sector, mutual providers take into consideration their communities’ gaps in service, tethering their approach very closely to need.
Primary Care Networks, super-practices and GP federations enable shared services, more tailored routes to appropriate care, shared learnings, back office efficiencies and other benefits. Mutuals fit particularly well into wider networks like these because, like Willow Bank, they often already incorporate multi-disciplinary teams and are focused on integrated services. They can carve roles in these wider healthscapes, helping staff to remain engaged and empowered within their localities. “Social enterprises play nicely into ‘place-based care’,” says Paul. “They bring people together so they can solve their own problems. People use care less when they are happier.”
That sounds like a good rallying call for GPs, when faced with problems of succession, engagement or recruitment, to take a good look at mutuals. They may provide a fertile middle ground that enables deep community engagement and innovation to thrive whilst keeping doctors and the staff that work in them, firmly at the helm.
We would like to thank Willow Bank for talking to us about their journey. They are also featured in a forthcoming report for DCMS about the replication of mutual models within health and social care.
Visit Willow Bank’s website.
If you’re interested in exploring new models of delivery in primary care, email firstname.lastname@example.org.