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Practice Mergers

Advice for practices thinking about merging and top tips.

Be prepared to eat, drink and sleep mergers but remember that the majority of your staff won’t be at the same level as you so will need to hear information many more times than you might think is reasonable! Also, be aware that if there is a void in information, staff will make up gossip to fill it so give regular updates on what is happening, even if it is that there is no news.

Your practice team will all reach a point of acceptance about the change in their own time-frame. Some staff will be sad, many in denial, some may be angry about having to work in different ways and may feel a sense of loss at the prospect of losing autonomy. You do have to accept that they will all have to find their own way through the process with you there as a constant in the background. I sent out a document about managing change to the team which some staff found very helpful:

http://www.exeter.ac.uk/media/universityofexeter/humanresources/documents/learningdevelopment/the_change_curve.pdf

Before going out to the wider public, talk to your PPG and seek support to the principle of merging. If you are rolling out more services over longer hours, therefore improving patient access, it is easier to pitch as everyone will benefit but you may need to undertake a full public consultation if there is a net loss to services through premises being closed, which the Area Team will be able to guide you through.

As you still have a day job to manage, think about freeing up key members of your team to support some of your work, e.g. you may consider employing a deputy on a short-term contract, or extra admin staff to help with information gathering.

Electing a Merger Team with two of the partners working with the PMs is a more efficient way of encouraging decisions to be made as with a larger group, there are many more opinions to hear and more chances of disagreement!

Although ultimately it is a partnership decision to merge, the relationship between the two PMs is fundamental.

Talk to the LMC early in the process, as well as the CCG, particularly if you are facing a recruitment crisis and key members of the practice leave, as it is important both organisations are aware so that measures of support can be put in place if necessary.

Engage a solicitor early in the discussions to draft a Merger Deed, which will protect and guide the merger process in terms of indemnity, due diligence and timescale. This is particularly important if premises are to change ownership and one of the partnerships will effectively dissolve to create the new business. It is very important to have an understanding of the legal framework to support the process, particularly if there is any possibility of staff redundancy or contractual change required.

Try to have an idea fairly early in the process of how your appointments system might be set up as this will guide how the IT/telephone systems will need to be configured, which may potentially be your biggest areas of expense. Discuss any costs with the CCG and the AT to establish whether there might be any capital funding available to help.

Be prepared for not all of the partners to be on board with the plans, and for some to be challenging. Give yourself time to fact-find before presenting proposals and seek support from the partners who are more closely involved however, make sure that ultimately, they are behind the plans so that you don’t end up being the scapegoat if things don’t come together as anticipated.

Understand and accept very early on that with every good intention and a lot of hard graft, many things will not be in place before the merger and may not be for months afterwards.

SUMMARY

Mergers

  • Rationalise premises, where possible
  • Rationalise services/equipment to one site (even where maintaining more than one site) e.g. cryotherapy
  • Some issues around continuity of care if staff in different places
  • It is possible to undertake a slow, gradual merger but is there a point? Get on and reap benefits as early as possible.

Actions

  • Get clarity on fundamentals
  • Contract value differences - medical accountants will supply this
  • MPIG / PMS Premium if appropriate
  • Partnership income differences
  • Premises
  • Staffing
  • IT

If decision in principle made to merge then:

  • Discuss plans with CCG
  • Consult LMC for help, as needed
  • Produce Business Case
  • PPG consultation (ideally 90 days required)
  • Consider which bank, accountants and solicitors once merged
  • Decide which J number will be retained – check for issues around dispensing and rural practice payments first

Local flavour

  • Access is a big issue – extended opening shared from one building – less admin/reception staff needed – reduce costs of premises and staffing
  • Recruitment issues – shared – fewer partners, more salaried/locums or less locums as cover available and more likely to attract other healthcare professionals.
  • Public Health departments in local authorities – bidding to provide services

NB: IF 2 GMS practices wish to merge they do not need NHSE/CCG approval

Issues re timescales

  • The optimum merger date is 1st April as this aligns with the beginning of the NHS financial year. However, this is not always possible due to the numbers of practices opting for this and the resources to do it. Sometimes, the practices also can’t meet this deadline. Where this is the case, it is preferable to opt for the 1st day of a quarter e.g. 1st January, 1st July or 1st October.
  • PCSE has to merge the practice lists onto the one chosen J code and are behind with this – worth checking if your chosen deadline can be met.
  • IT – even if both practices are on the same clinical system the lead in time is around 14 weeks in many cases. If different clinical systems it may even be longer if GPSoC has to be worked through too to get both practices onto one system.
  • Screening – PH (NHSE) need to align cervical cancer and breast screening programmes which takes time.

Always notify and discuss your potential merger with your CCG and NHSE as soon as possible. They will offer a meeting to explore all of the above and the timescales involved. The LMC can be invited to those meetings to help and support

Options for merger:

  1. Running 2 or more contracts but with some sharing of partners and staff in each contract for further economies of scale.
  2. Merge in to one contract

Information which should be considered when completing the “Application for Consideration of a Contractual Merger”

  • Demographics
  • List sizes
  • Practice distances
  • Accessibility – bus routes, distance from practice to practice,
  • Parking?
  • Distribution of patients of two practices, post code areas etc
  • Merger Benefits
  • Sites for delivery of services
  • Increased services?
  • Choice of female GPs?
  • Longer opening hours?
  • Benefits for the CCG? Local Authority?
  • Staff benefits
  • Merged practice boundary and outer boundary map
  • Pharmacies – request/ collection service
  • Premises old to new?
  • Training / research Practice
  • Single hander to merge with larger practice?
  • Extended hours
  • Local or on-site access to Pharmacy? Home delivery?

Staffing

For each practice detail, how many:

  • Partners
  • Salaried GPs
  • Long term locums
  • GPRs
  • Nursing team
  • Admin and management
  • Have preliminary investigations into TUPE taken place.

Finance

  • Savings?
  • Investment required? Area Team, Practice etc?
  • Potential TUPE cost pressures?
  • Have IT merger costs been considered?

Stakeholder Engagement

  • Have plans been shared with CCGs and public health teams? If so, include whether the merger is supported and why?
  • How will practice engage with stakeholders? Eg patients, staff, community services, media, MP, Councillor, local practices, etc
  • Will there be any potential adverse reaction from stakeholders? How will this be managed?
  • If a site closure is envisaged have Healthwatch/health and wellbeing board been consulted?

Premises

  • Will all remain open?
  • Changes to opening times?
  • Notice period?
  • Premises improvement to accommodate?

IT

  • Added benefits or disadvantages?
  • Different clinical systems? How will they merge?

Screening Programmes

Provide details for any provider / location differences between the following screening programmes for the merging Practices

  • Antenatal and new-born (includes 6 programmes but most are done by maternity)
  • Cervical
  • Breast
  • Bowel cancer
  • Diabetic eye screening
  • Abdominal aortic aneurysms

Indicate if there are any differences between the practices with regard to immunisations. For example, if one practice has not signed up to any particular immunisation Enhanced Service.

Contacts:

LLR LMC office

E: enquiries@llrlmc.co.uk

T: 0116 2962950

Updated on 16 October 2017, 450 views