Across the country, groups of healthcare professionals are joining forces to develop different forms of group practices and then selling their services back to their local PCT.

Nigel Edwards, Director of Policy at the NHS Confederation, looks at both the benefits and challenges of this approach to healthcare provision.

One reaction to some of the turbulence caused by the current reforms being rolled out across the NHS has been a resurgence of interest in the group practice model of provision. A number of companies have already formed and signed up healthcare professionals.

The attractions include greater autonomy, freedom from some of the less desirable aspects of the NHS and possibly the potential to increase earnings.

There are both problems and opportunities with this group practice approach to healthcare provision - especially the 'chambers model which I will address later in the article. However, there may also be powerful clinical reasons for looking at the less common group practice models which are often ignored and could, in fact, massively improve the delivery of patient care.

Models based on doctors and other healthcare professionals working together in group practice create a real opportunity to form a system that is designed around the needs of patients - a step forward from the current unhelpful rhetoric of shifting work from the acute sector to primary care.

I recently visited Central Middlesex Hospital and learnt about their model for COPD management. Its approach uses specialist nurses and consultants to support patients at home - intervening earlier and supporting primary care. The hospital's work is an excellent example of an integrated service that crosses the so called primary secondary care divide.

There are many examples of this sort of service around the country that prevent hospital admissions and outpatient attendances by deploying the expertise in the hospital to support services out side of it. Unfortunately, in the current financial regime of Payment by Results this sort of imaginative model costs the hospital valuable income.

An integrated clinical group which brought together hospital specialists, GPs and other primary care staff could design and deliver care in new and imaginative ways that could avoid this problem.

To use an international comparison; General Health Co-operative (GHC) in Seattle, USA, is a group practice of this sort. Its integrated approach to care, particularly for patients with chronic diseases, has allowed it to make major reductions in the use of hospitals.

It is likely that in the near future GHC will be providing care to over 500,000 people and conducting world class research without owning any of its own hospital provision. Its patients are cared for in facilities owned by other organisations leaving GHC to concentrate on designing and delivering better care.

GHC's approach seems to me to be a more exciting model than the rather outdated idea of 'barristers' chambers'. In my opinion this does not comfortably transfer across to healthcare provision. This is because barristers do not work in teams. The chambers model was designed to support barristers in terms of accommodation, scheduling, fee negotiation and billing.

There is little advantage to a hospital or PCT contracting with a 'chambers' style organisation unless it is able to offer standardised approaches to routine care, quality assurance frameworks, audit evidence, shared information systems and a range of other quality and governance arrangements.

Each PCT or hospital trust will need to know how the 'chambers' will be able to guarantee the quality of the individuals practising with them. This means that the 'chambers' model provides no escape from the fact that in modern medicine the price of autonomy is accountability. A second implication is that a 'chambers' style organisation may not offer membership to those doctors that do not accept its values and approach.

If Practice Based Commissioning is successful it seems very likely that groups of GPs will come together to create co-operatives or companies to undertake the work. At some point they will notice that if they had hospital specialists as partners or co-owners they could make better use of their resources and will start to take advantage of these opportunities.

The model which may emerge from this might look more like the John Lewis Partnership than a barristers' chambers. Done well, this could produce some significant benefits for patients.

For the professionals who run traditional hospitals, and for the specialties which are exclusively hospital based, this type of integrated model of provision is likely to be more challenging and some careful thought will be needed.

Creating models that allow primary and secondary care to work in an integrated way to meet the needs of patients is the key task and some of these models could make a real difference.

Medicine should perhaps avoid being sucked into the NHS mania for restructuring and keep sight of the objective of improving patient care.

Nigel Edwards will be talking further on the subject of health co-ops at the forthcoming NHS Confederation conference 'Shaping the future' in London on Thursday 6 April. He will be joined by Tony Blair's special advisor, Paul Corrigan and Health Minister Lord Norman Warner.

For more details about the conference please visit www.nhsconfed.org/events.

Hospital Doctor - 6th April, 2006