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General practice: does size really count?

Amanda Bryan
Med J Aust
Published online: 1 October 2012

Are large corporate-owned clinics better than the traditional small family practice? Doctors tell us how their experiences stack up.

A major shift in workplace dynamics is underway in Australian general practice. Clinics are getting bigger and ownership is becoming concentrated into fewer hands, thanks to the era of corporate ownership and the rise of the GP super clinic.

The figures confirm the trend: the number of doctors working in solo practice in Australia has halved over the past decade, and over half of all GPs now work in practices with five or more practitioners (see box). 

The premise is that a cluster of doctors and allied heath professionals can share resources more efficiently while collaborating to improve management of chronic conditions — but do the benefits of working in a larger clinic also extend to the medical workforce? 

Professor Mark Harris, executive director of the Centre for Primary Health Care and Equity at the University of NSW, points to the findings of their study on teamwork in practices five years ago.

“We found some interesting and complex results. Work satisfaction was not related to practice size. People could be satisfied in either”, Professor Harris says. “The message is that it is possible to be satisfied in a larger practice.”

When it comes to working in a small versus a larger practice, each has pros and cons. Here are some of the main differences for doctors weighing up their work options.

Small practice

The major advantage of working in a smaller privately owned practice is autonomy. Doctors who work in them say they tend to have more control over the way patients are managed and the way they practise.

Professor Harris says his research also suggests that continuity of care for individual patients and a sense of teamwork among staff are more achievable in a smaller practice.

Dr Anthony Mariampillai, who moved from a two-doctor practice to become director of medical services at Australia’s first GP super clinic in Ballan, Victoria, agrees that a smaller practice is more conducive to forging personal attachments.

“If a part-time GP works in large, 10-doctor practice with six nurses and lots of receptionists and visiting allied health, you won’t develop those close relationships”, he says.

However, he says he is now freer to focus on being a doctor. “Now I can concentrate on patient care rather than administration and computers.”

According to Professor Harris, because smaller clinics have fewer doctors and support staff and less equipment, doctors are also more likely to have to take work home and the hours are less predictable.

He also points to an international trend: increasingly, younger doctors don’t want to be practice principals. “Many doctors are quite happy for that not to be part of the deal”, he says.

Dr Rashmi Sharma, the owner of a 14-doctor Canberra medical practice and chair of the ACT Medicare Local, says the next generation of GPs could be better equipped for business ownership by including business skills in their training.

“It would be sad if all big practices were run by corporates”, she says.

Large practice

Efficiency is the big advantage of the larger practice, whether it’s private or corporate owned. The model makes support staff and equipment more affordable, which unshackles doctors from routine administrative and practice management tasks.

Dr Evan Jones, medical director of one of Australia’s first super clinics at Strathpine in Brisbane, says he can’t imagine how a practice can function without a full-time practice manager “given the amount of red tape and bureaucracy involved”.

He also says the super clinic model makes it easier to coordinate patient care with onsite allied health workers. “As a result, the levels of communication are much better”, he says.

According to Dr Jones, doctors benefit from the close proximity of allied health professionals. “The doctors can pick their brains, nut out clinical problems and interact with them, which is important for continuing education and professional development.”

Dr Jones says larger clinics can offer their staff greater work–life balance.

“If there are only two doctors and someone goes away, it places an impossible load on the remaining doctor. If there are 14 doctors, though, we have the capacity to deal with that.”

Dr Sharma agrees. “In a larger practice, staff don’t have to worry about going on holiday and that’s important because you don’t want burnout.”

One potential pitfall in the larger practice — especially if it’s corporate run — is lack of autonomy, Dr Sharma says.

“If doctors see something that needs changing but they have to go to head office to make changes, that can lead to disengagement. The risk with a corporate-run practice is you lose the bottom-up approach”, she says.

However, Dr Sharma notes that a larger practice, such as hers, can work to mitigate this risk by valuing the input of all its doctors.

“They have a say in our fee structure and how we run the practice. They all get involved and we listen to them.”

Moving with the times

For many years Dr Mariampillai worked out of his own two-doctor practice in Ballan, Victoria. Today he still practises in Ballan, but as the director of medical services at Australia’s first GP super clinic, which opened in 2009.

Ballan District Health and Care is a not-for-profit community-owned clinic that is administered by a board of directors. The clinic offers 29 health services — including five GPs — under one roof.

Dr Mariampillai says there was much more administration involved in running his small practice, but he can focus on patient care at the super clinic.

“That’s the advantage. What I do miss about owning my own practice was being able to make my own decisions.”

Also, his relationships with his patients tended to be a bit closer in the smaller practice, although the large practice still offers patients continuity of care. “Luckily patients can stay with their own doctors”, Dr Mariampillai says. “Some clinics are not like that.”

The big picture

The proportion of doctors working in solo practice halved between 1999–00 and 2006–07, and the proportion in smaller practices (2–4 GPs) also decreased considerably, according to a 2009 joint report by the University of Sydney and the Australian Institute of Health and Welfare. At the same time, there was an associated significant increase in the proportion of GPs working in practices with five or more doctors, from 35.8% in 1999–00 to 56.1% in 2006–07.

Asking the right questions

SMALL PRACTICE

Doctors should consider the viability of small practices, according to Professor Mark Harris, executive director of the Centre for Primary Health Care and Equity at the University of NSW.

While some small practices are well run and very effective, a doctor considering joining a small practice should find out if it has sufficient resources and if it is run sustainably. He suggests asking if the practice has a trained practice manager, and discuss with existing staff how they feel the practice functions as a team.

Professor Harris also suggests having a chat with the practice manager. “It’s not just a question of how you get on with principal but how open the practice manager is to improving things”, he says. “A dynamic practice manager can make an enormous difference to way the practice runs.”

LARGE PRACTICE

Professor Harris says that before a doctor joins a large practice, it’s worth asking whether staff are encouraged to provide input into how the practice is managed.

This is more likely in a privately owned clinic than a large corporate practice, especially in a large chain where decisions have to go up the corporate hierarchy”, he says. “Sometimes GPs say they find that aspect a bit irksome after a while.”

Professor Harris also suggests asking how easy is it for patients to see the doctor they want to see. “If you are always seeing different patients and not building continuity, that can be frustrating”, he says.

  • Amanda Bryan


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