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Wednesday 28 September 2016
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Future-proofing your practice

Insight: Finance

The pressure is on: costs are rising year on year, outstripping any small increases in core practice income; the primary care trust (PCT) and the wider NHS are demanding more from general practice than ever before for that same income; commissioning involvement is sapping time our GPs simply don’t have; and let’s not forget the increasing expectations of patients.

It’s tempting to batten down the hatches, do the bare minimum expected of us and try to weather the storm, hoping all this will pass by and things will one day get better. But is this the right approach? To my mind this is a dangerous and potentially very risky mindset. So what should we be doing now instead to prepare for the future and ensure that our practice is still here and indeed thriving in five years’ time – and 10?

Think big
Size will undoubtedly help; it is going to become increasingly untenable to be too small. Increasing patient numbers is one of the few sustainable ways to be able to increase income and will provide that bit of extra income that is required.

However, the key is to put in place a business strategy that allows practices to make this growth and maintain (or even improve) the level of patient care you offer without a corresponding increase in overheads and costs. Key to this are the economies of scale that you will start to achieve within your practice team once you get larger.

While some practices treasure their smaller status and feel the lower list size and provision of patient continuity is so important, this will become increasingly unsustainable. Practices would be advised to work towards expansion now, devising a growth strategy that keeps and protects the important things but finds new ways to deliver them from within a larger organisation.

Some practices may find it harder than others to grow if there is not an increasing population in their area, but most should be possible to grow the patient list if desired. While you cannot directly advertise for new patients, there is plenty you can do to raise your practice’s profile locally – for instance, by courting the local press and getting them to publicise health promotion campaigns you are running or launching something new that lets the community know this is the practice to be at.

Make sure that the quality of service you deliver is the best in your area and you will grow by recommendation from existing patients. If you are fortunate enough to move to a new building this is also a good opportunity for publicity and to attract new patients. Don’t ignore opportunities outside of organic growth that exist, such as merging with other local practices, bidding for practices via tender if they come up and perhaps even working in a federated manner with other local practices to shares risks and resources.

A key ingredient in future-proofing your practice is to diversify. As well as core general practice, offer a range of extended services wherever possible to bring in additional income, and ensure that each of these is profitable (they don’t have to be hugely so, but make sure you aren’t operating at a loss!).

While some of these services may not be guaranteed to run for ever, having a range in your portfolio would mean you are unlikely to lose them all at once. Having a good range of extended-care services available in the practice, including intermediate care and GPs with a Special Interest (GPwSI) services, will also attract patients.

Change needs to be an ever-present constant in our practices from year to year. Rather than seeing change as something that we do occasionally as part of a major project, we instead need to operate our practices in an environment that is continually embracing incremental change in everything we do, constantly looking for the small changes that will help us along the route of our desired strategy. If this attitude is embedded in the culture of the organisation, it will make if far easier for the practice to respond and adapt to the changes of the moment.

Another important facet of your organisation needs to be one of flexibility and responsiveness. While some of this is an extension of the readiness to embrace change as outlined above, it goes beyond this to being an organisation that has in place structures and processes that allow flexibility and can easily absorb and respond to new challenges as they arise – often with increasingly less notice than general practice has been used to in the past.

This means being able to respond not only to a new project that may arise and need to run for a month or two, but also to a new Quality and Outcomes Framework (QOF) target or direct enhanced service (DES) set up in a new financial year, as well as the ability to respond in the very short term to variable daily access demand placed on the practice. Having the ethos and team structure that can continually respond to such pressures is an essential part of being able to maintain the level of service provided to patients, without just throwing more GP resources (in short supply) at it.

No time to lose
So, you want to grow, you want to diversify and you want to future-proof your practice – where and when do you start? The answer to the latter is: right now! There will always be excuses as to why you shouldn’t do it now – you are struggling for access, everyone seems too stressed just now, other changes are going on, etc – but this position is unlikely to change any time soon: there will always be more to do than the resource that is available.

So you will just need to get on with it. Bring in some of that flexibility, reprioritise what you are doing and look for things you can do more efficiently and effectively – and some things you can stop doing – so you can start to develop and then implement your plan.

It may sound very corporate but you need to form a clear vision of where you see the practice in five and 10 years’ time, and the sort of organisation, in terms of ethos and culture, you want to be when you get there. Inevitably reaching those goals is going to require a lot of change, so you need to bring your team along with you. To achieve that you need to be able to set out that clear ‘mission statement’ for the organisation that they can and will buy into.

Your practice team, which will necessarily grow larger as you develop your practice, is the most important ingredient to your success. We will always struggle to offer the best healthcare to our patient population without a skilled and motivated workforce. This is becoming an increasingly important factor as things get tough financially in the sector and we need staff to work under increased pressure, without the resources to reward them as perhaps we would like. If you are looking to go beyond this and radically alter the structure of your organisation as it increases, you will need to work harder in order for your team to maintain that level of enthusiasm for their jobs. A key ingredient in achieving this is involving the team in developing that strategy.

Once you have outlined a vision for your organisation you need to fill in a lot of the detail in your business plan. This should be a bottom-up, rather than top-down, process; engage with your team to develop the flesh on the bones of your strategic plan.

You will be surprised just how many ideas your team have for changes if only you ask them! Working every day in their own areas, they will know more about the inherent problems than the partners or the manager. They may also be closer to the patients and know what is important to them. Given the opportunity, staff will welcome the chance to suggest what could be done better, or to come up with totally new ideas for services. This also gives you the chance to find out about any special interests they may have – doing something new will increase their level of motivation if it fits in with their own specialist interests and provides a development opportunity.

In our practice we have an established ‘Staff Consultation Group’. This comprises representatives from each team (nursing, reception, admin, finance and salaried GPs) elected by their peers. This group meets every two months and provides a vehicle for any staff member to bring ideas, suggestions and issues to the group via their representative (anonymously if they wish) to be included in the business-planning process. It is within this group that much of the detail of the specific projects for our annual business plan are formulated so that by the time it reaches the full partnership team for approval (which also follows a discussion with our patient participation group) it is 90% complete.

Measure your progress
Building on the vision you have created for the practice five and 10 years’ hence, you will need to have milestones along the way to help measure your success going forward. In the early years, this will need to be increasingly detailed, identifying key projects and changes that will help you reach those milestones along the way. In the later years, those projects will only become clearer once the latest opportunities and developments within the NHS become clearer and the dusts starts to settle on the upheaval caused in the latest reorganisation.

It is important to be aware of what is happening in the wider NHS. Read a wide source of commentators for a mix of opinions regarding the future direction of travel, and form your own views from the various extremes out there! Remain close to those involved in commissioning locally and nationally. Attendance at a couple of conferences each year (some of the free ones are all you need) will give you an idea of how things may change.

Particularly important is to be involved locally – know and understand the challenges in your local health community. This will help you identify potential opportunities that may arise in the coming years. Ensure you have the capacity within your business plan to be able to respond to these opportunities.
As you progress, it is important to review and monitor your achievements against the business plan. Refresh your targets as required, add more detail to your plan for the next couple of years ahead, and continue to keep a five- and 10-year target (which will now be even further into the future than when you started!).

So, you are committed to growth and diversity and have created a vision that has been translated into a detailed business plan. Now you want to turn this into reality. A subsequent article will explore how to do this.

Nick Nurden is Business Partner at the Ridge Medical Practice in Bradford, a large practice (24,500 patients) operating out of four surgeries. The practice has an established reputation for quality and innovation, and offers a wide range of enhanced and GPwSI services in addition to core primary care. Nick has been with the practice for five years and has overseen growth in patient numbers of 40% since joining by organic growth and successful tendering for new contracts as well as project managing the design, build and relocation to a new £10m practice building for the main surgery.

Nick’s concluding article on this topic will be included in the Summer issue of Management in Practice. This article will provide some more detailed guidance on creating the team needed to deliver the business plan, how to manage change in the practice and risk-assessing the process to ensure the practice maintains its financial stability.