Efficiency, effectiveness, and communities of practice

Ben Hoban is a GP in Exeter.

The number of GP surgeries in the UK is falling, through either mergers or outright closures, and those that remain are becoming larger.¹ This growth in practice size is a significant change, for which I would like to suggest three potential explanations. The first is that once the number of practices closing in a given area exceeds the number opening, the only option for patients and staff is to join an existing one, so that the change merely reflects the ongoing pressures on general practice. The second is that larger practices may provide a better service, prompting those that can to grow, even at the expense of smaller neighbours. The third is that regardless of quality, larger practices may simply be better at surviving. More than one of these explanations might apply: practices do many different things, some of which are likely to work better on a larger or smaller scale, and all of which could affect their financial viability as well as the care they provide; and even in hard times, small differences between practices may allow some to stay open, while others close. The powers that be certainly seem to equate bigger with better, viewing Primary Care Networks of at least thirty thousand patients as optimal for the purposes of funding and service provision. Patients take the opposite view, with a negative correlation between size and satisfaction, and the highest level of satisfaction found in practices with a list size of less than ten thousand.² How can we make sense of both these views?

It is well recognised that businesses of different sizes have contrasting advantages. Larger ones tend to be associated with a higher degree of specialisation, more clearly defined structures and hierarchies, and economies of scale; smaller ones, with less role differentiation, a more flexible and cooperative structure, and greater agility. It is easy to see this reflected in general practice. Larger surgeries will tend to experience more predictable demand, giving them the stability to provide specific services in areas like acute illness, musculoskeletal problems and mental ill health. They will be able to access funding for such services through their PCN and will be well-suited to adopting the multi-professional team model promoted by NHS England, with arms-length initial contact followed by the allocation of patients to specific clinicians based on the nature of their problem.³ Those working in smaller practices, on the other hand, will find it easier to maintain relationships with each other and with their patients, favouring a more collaborative and generalist way of working, and benefitting from greater personal continuity of care, although they will find it more difficult to pay for these things.⁴ Perhaps we can characterise these two kinds of practice as representing either efficiency in providing a high volume of appointments or effectiveness in making each appointment count for more. As a practice grows, we can expect it to become more efficient, although there is likely to come a point, beyond which further gains in efficiency come at the expense of reduced effectiveness.

To see why this might be the case, it may help to consider the idea of a community of practice. The term describes a group of people working in pursuit of the same goals, using the same tools, and working out together what needs to be done and how to go about it.⁴ Such a community relies on arrangements which maximise interactions between its members, including adjoining work spaces, communal areas, and rotas that guarantee overlapping work and break times. Its members are neither specialists with distinct roles, nor duplicates enacting a standard set of procedures, but colleagues, each bringing to the table their own experience and perspective. Whereas practitioners working in isolation follow national or international guidelines, communities of practice create their own mindlines, which fulfil a similar purpose, but are locally negotiated and owned, and sensitive to local contexts.⁵ In this sense, communities of practice become specialised in dealing with their constituency rather than a particular problem.

.linicians in a practice represent one such community, while administrators make up another, and patients have the potential to form a third. How well these three communities interact internally and with each other depends at least partly on the layout of a given surgery, including the reception, waiting room and adjacent consulting rooms, office space, and shared staff area. Even with an ideal layout, and taking into account the impact of remote working and patient access, the level of interaction needed for communities of practice to function effectively will only take place up to a certain size. Beyond this, a larger building containing signposted corridors and numbered doors to identical, hygienically optimised cubicles becomes conceptually more like a hospital, even if it contains GPs, inasmuch as it represents the privileging of process over meaningful personal interaction.

Economies of scale and the ability to provide more specialised services in return for increased funding will tend to favour a growth in practice size, while the requirements of interpersonal care and the communities of practice with which it is associated, probably mandate an upper limit to this. Given the current realities of general practice, however, it seems likeliest that we will simply see a continued shift towards larger and more efficient surgeries, providing ever-more appointments, but perhaps achieving less of what patients really need or want. Let us beware of seeking efficiency in isolation, and at the expense of effectiveness.

References

1. NHS Digital, General Practice Trends in the UK to 2017 digital.nhs.uk/data-and-information/areas-of-interest/workforce/technical-steering-committee-tsc/technical-steering-committee-tsc-archive
2. Peter J Edwards, Bigger practices are associated with decreased patient satisfaction and perceptions of access, British Journal of General Practice 2022; 72 (722): 420-421 DOI:3399/bjgp22X720521
3. NHS England, Modern General Practice Model england.nhs.uk/gp/national-general-practice-improvement-programme/modern-general-practice-model/
4. Denis Pereira Gray, Kate Sidaway-Lee, Pippa Whitaker, Philip Evans, Adverse effects for patients in big group practices, British Journal of General Practice 2022;  72 (724): 518  DOI: 10.3399/bjgp22X720989
5. Practice-based evidence for healthcare: Clinical Mindlines, John Gabbay and Andreé le May, Routledge, 2011
6. Communities of Practice: Learning, Meaning, and Identity, Etienne Wenger, Cambridge University Press, 1998

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