Written evidence submitted by Symphony Healthcare Services (FGP0321)


  1. About the Respondent


1.1   Symphony Healthcare Services Ltd (SHS) holds GMS and PMS contracts within Somerset (and 1 in Devon).

1.2   Serves a population on 117,000 patients (20% of the Somerset population) with 16 contracts over 20 General Practices

1.3   At arms length subsidiary of Yeovil District Hospital that reports in bimonthly

1.4   SHS was created in April 2016 and has grown substantially

1.5   SHS has practices within 10 PCNs

1.6   SHS is the host employer for 3 PCNs

1.7   500 staff

1.8 All practices are CQC rated ‘Good’*.

*Practices normally integrate when they are challenged or strategically determine that the partnership model does not have sustainable future for the practice. SHS has picked up contracts that would have otherwise meant the practice would have closed hence impacting on the rest of primary care and acute Trusts. Many of the practices were Requires Improvement or inadequate CQC rating when joining and following significant turnaround all SHS practice are currently ‘good’. 



  1. Key Messages


2.1   Within 5 years of SHS being created 20 practices have chosen to integrate into SHS as the partnership model has not been sustainable for them. This links both into the profitability of contracts and the inability to recruit into vacant posts. Those that join us no longer want the life-time commitment of responsibility for a practice including the mortgage, managing of staff and finances. This is especially true of the younger generation that are seeking a more like work balance rather than a vocation.


2.2   Demand in some of our practices has increased by over 20% since pre covid levels. We are paid per patient registered not demand. This takes a massive toll on staff hence the need to work differently.



2.3   Population health is a key determinant of the above as well as people taking responsibility for their own health and well being.


2.4   Narrative needs to change that primary care is not just about GPs we have a diverse workforce in every practice. This consists of nurses, advance nurse practitioners, pharmacists, physios, enhanced care practitioners, mental health etc.  This is a huge benefit to patients to get the support they need however the expectation form patient sis they are short changed if they do not see a GP.


2.5   Workforce is a real concern. A workforce strategy is needed that delivers on more GPs and GPs that are competent and confident. The gap of expectations from a registrar to first GP role is huge.


2.6   The issue of locums still having access to all the benefits of working within the NHS such as a NHS pension but none of the responsibility HAS to change. Committed GPs are now leaving to become locums. The tax on pensions is also a real concern as growth continues there is no incentive for  experienced staff to do more.



3.0  What are the main challenges facing general practice in the next 5 years?

3.1  Workforce – retention and recruitment of all staff. It is not just GPs where there is a shortage now. The GP contract does not pay enough to enable coverage by locums or to increase pay of essential staff. Within SHS we are now having admin staff leave as the retail sector is paying more without the responsibility and aggro.  We need a strong workforce strategy that encompasses the whole MDT. Make primary care an exciting place to train and work for nursing , physio etc. We need locums to not have the benefits of a NHS pension and to turn the tide of a preference to work within a practice.

3.2 Media and government communications – the recent media and government communications have felt like a knife in the back for the monumental effort that has gone on within general practice not only dealing with 20% demand, trying to embrace new technology to see more patients (this instead has been criticised as not face to face) and leading the covid vaccine effort.  This has been the straw for a number of staff that have left primary care. Hospitals have reduced face to face in outpatients to a similar extent to primary care however this has hardly been mentioned. As well as some of the good news stories that reducing face to face has been patient experience and more patients can be treated.

3.3 Managing patient expectations – not just GPs we have a whole MDT of staff, care can be provided by non face to face means. Patient responsibilities for their own health. Managing the backlog from Covid.


3.4 Governance – many of the practices we have taken on have not had robust governance and the benefits of at scale primary care is the governance procedures, data and monitoring that we input to drive up standards.


3.5 Contract – the Carr –Hill formulae is not fit for purpose in some urban practices where frailty is not an issue. One of our practices has 79% weighting and as a result can not work within the contract even with the leanest staff per patient ratio. They have huge demand of deprivation, mental illness and in equalities. 


3.6 PCN vs practice – there has been some benefits of PCNs and closer working between practices. The Covid vaccine hubs are testament to that. However as an at scale organisation we are grappling with developing our own vision and ambitions whereas we are also within 10 PCNs making it difficult to drive the organisation forward. Interestingly none of the PCNs in our area have supported any failing practice. There are also issues with lots of funding being pumped into PCNs to drive quality and this money being held by PCNs (each starting to develop quite a back office) but supporting the management of day to day demand has not been observed so widely.  More funding needs to go directly to practices. As an at acale organisation we would like to see more funding also come our way to support and innovate improved ways of working.


3.7 Estates and IT- Estates and IT in many cases is not fit for purpose. Estates often do not support modern healthcare and the IT is substandard with often slow internet connections.


3.9 Demand

Demand is 20% higher now within SHS than pre covid. Digitalisation to support managing access is really supporting primary care to deliver on this demand as well as provide safer signposting. Ensuring the right professional treats the patient. However this is now so negatively perceived by the media and is impacting patients expectations and rapport with us. With Ask My GP platform it asks patients how they would like to be contacted and we actually see more patients face to face than what they ask. The % requesting to see face to face is often under 10%.  


4.Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?


4.1 For partnerships that are working successfully they are cost effective. Partners will often work 12 hour day plus in order to reduce costs of securing locums and have ‘skin in the game’ to ensure deliver of targets and incentives ie QOF. However within 5 years in Somerset 20% of patients now come under SHS as an employed model as partnerships were at the stage of handing back contracts as financially unsustainable  or lack of workforce.  There have also been cause for concern for some practices we have integrated regarding their governance systems and the lack of peer review/monitoring to ensure safe systems and processes.


As an organisation we are in deficit but recognised by the system without us it would have cost a lot more with no practice provision and patients attending A&E etc instead. If the traditional partnership model does go then it is likely to cost the system more.


Primary care could do more with population health and supporting the move of care form hospital to community.


We do not know what the answer is whether it continues to be a patchwork of provision or all general practice needs to move to an employed model. As an organisation we would welcome NHS status in our own right and are proud of what we have delivered.


Dec 2021

Symphony Healthcare Services