Size Matters – could small be better?
By Francesco Carelli
Professor Family Medicine, Milan and Rome
EURACT Council Executive Board
Which is an ideal primary care structure and size? Some argue for large group practices, others say smaller practices are better, others that team work or salary payment is the key. There is no evidence about an optimum sized general practice for delivering safe quality care. By its very nature, general practice is served by practices of different sizes and contexts, the smallest being better concerning doctor – patient relationship and holistic approach, the bigger ones being associated with better evidence based processes of care and some clinical outcomes and economies of scale, but less accessible and with lower patient satisfaction ratings.
Having done research, scientifically managed, visiting different practices differently structured, does not resolve the questions, there is not great deal. Quality and size remain controversial, the different view and importance attributed to management or relationship go to opposite sizes. Some countries are more organized in large or extra large practices’ organizations, other European countries continue to see well managed primary care in small diffuse practices.
Patients seem to prefer and get advantage from smaller practices, whereas larger practices can manage better chronic care and prevention. Anyway, group practices don’t give evidence based evidence for better care, and over a dimension there is evidence for lower quality, surely lower quality from the patient’s prospective, over 200 patients for list the evidence is well known since years.
Quality of care seem correlated with support for preventive care or booking intervals, but at the same with time for single consultation, existence for listed / registered patients and, key point for family medicine, continuity of care.
We have little information on how much leadership, autonomy and peer pressure we would want family doctors and staff in practices to receive in order to foster better quality of care. From surveys, it is not clear if it would be better practices would offer more therapeutic and diagnostic services in primary care, if hierarchy would be better than egalitarian team structure, if part time job would be positive or interfering with practices’ processes, if audit would be don with peers with all the team or anything else.
Also the presence of extra team members such as pharmacists, social workers, physiotherapists and so on, does not definitively indicate better quality of care. The same no definitive answers from payments as salary or as capitation or private care providers. The research in this field, so important for the future design of premises, teams, services, contacts, is absolutely inconclusive.
Probably to get quality research, we need collect data from thousands of health centres and practices through a practice visit scheme using the same and coordinate format and indicators, investigating all relevant structural , process and outcome data.
Anyway, we can see that training practices are associated consistently with a broader scope of services, better managed with input, better patients satisfaction, less workload and job stress or dissatisfaction for family doctors.
In conclusion, the optimal size of practices is dependent on the aims, functions, and tasks of the organization, and last but not least, the way in different countries primary care is delivered to patients Other organizational factors, such as team climate, financial incentives, and time spent with the patients may have greater impact on the quality of care. Any search to identify the ideal practice size must not be at the expense of the focus on the individual patient or family doctor and on the longitudinal, continuous, personal, holistic approach: they are the key points for family medicine forever.