Practice Merger Considerations for Practice Managers
An Operational Guide by a Practice Manager who has survived one!
Written by: Alex Kimber, Managing Partner, The Grove Medical Centre
LMC Documents: Dawn Chalcraft, Deputy Director of Primary Care
The key to remember is that no one task in a merger is particularly that difficult; they are all sortable. The sheer volume of work needed in a short space of time is the biggest challenge. Make lists and lots of them as things will change and priorities rejigged very regularly! As a PM expect to feel overwhelmed and under pressure at times. This is the ultimate test in plate spinning. Make sure you look after yourself during this process, talk to your GP partners when it’s all getting a bit too much, don’t try to do it all yourself, you HAVE to delegate. Book a holiday away now (right this moment!) for a few weeks after the merger where you will be uncontactable and can recuperate!
For reference, my experience is based on two similar sized practices merging who occupied two halves of the same building. Both practices were dispensing. Parts of this document will reflect the decisions we had to make and may or may not be relevant to your situation.
There are two bits to the merger:
- The actual formal business merger in terms of legal, paperwork, contracts, financial and more..
- The operational in terms of hearts and minds, processes, people, emotions, ethos, teamwork and ensuring the day job.
Neither A or B are easy, and you will find yourself desperately trying to do the paperwork but being continually drawn into the operational. You do need to do both but when you need to concentrate on A without B then find a way, work from home, rearrange your working week if you need to but ensure you get the concentration you need on A.
For B expect low level politics within the partnerships and expect that to fluctuate. You will need to hone your diplomacy and facilitation skills. Expect people’s engagement to be differing but try not to lose anyone along the way. Be understanding and accepting that sometimes people just need a bit of time to think. If need be, slow certain decisions down by changing tack or looking at something completely different to re-engage the stragglers. It will be exasperating!
Good luck! Alex
Decisions to make early…
Decision making as a new partnership must be number one – what requires unanimous vote and what requires a majority. Stick to it – expect some vote outcomes, even if agreed on a majority vote, to be unpopular with some individuals and the fallout to potentially get emotional and heated. Get independent facilitation if needed and consider getting this early on – you may find you will not need this later once the partnership has established but an independent in the mix helps ensure everyone feels like it’s fair play.
Consider how to structure the decision making during the merger. Not all decisions can come back to a full partnership meeting. Do you have a small executive team that make the day-to-day decisions and meet (much) more regularly? What decisions can that team make and what needs to be brought back to the full partnership? Do you have small working groups for specific areas such as merging clinical ways of working or looking at the premises to involve more partners and spread the load?
What type of business are you wanting to create? Decide your type of merger – full blown or a variety of differing variations of a merger with one or more contracts. Plenty of advice and guidance out there. LMC, your specialist medical accountant and various other internet sites have lots of info.
- Get agreement early on which legal firm to use. For independence it may be worth considering one that neither practice has used before if there could be contested issues regarding fairness towards one practice or
- The lawyers will be able to advise on avoiding legal pitfalls of a merger. Worth considering paying for to put in place a merger agreement that is legally binding to all parties and not just a gentlemen’s agreement. Depends on levels of trust already established.
- Ensure you get a merger agreement in place (whether by a lawyer or not) regarding sharing of information such as accounts and staff and what happens to the finance and costs should the merger fail. There are templates on the internet you could use for this but consider the point above. This is to protect each partner and is a worst-case scenario but crucial should things not go to
- A new partnership agreement will likely be needed. Get the ball rolling on this early, get agreement to share current partnership agreements if you can. Expect challenging discussions on annual leave, sickness, workload parity etc. The more discussion and agreement that can be reached before a lawyer gets involved and the less iterations of the agreement going back and forth between lawyer and partnership, the cheaper it will be. Ensure all partners understand the costs involved in querying clauses. Encourage partners to obtain their own personal legal advice (at their own cost) if they wish for clarity on contentious points.
- If you are merging with more than one contract type PMS or GMS, then you need to choose carefully if you don’t intend to keep them separate and take advice from your accountant.
- Practice boundary – you will need to discuss this with NHSE/ICB if you wish to change it and go through the approval
Which ODS Practice Code to Use
- It is simpler, once you choose the contract type, that you use the ODS code for that practice.
- Beware that whatever decision, staff (and some patients) will perceive this a decision that one practice is taking over the other even if it’s not. They will get territorial – need to explain and reassure!
CQC Registration and CQC Registered Manager
- Consider using one (or both) of the registered managers already listed – less paperwork and probably no need for redoing CQC
- If using one, then consider using the registered manager of the practice with the ODS code you are using. You can then amend your CQC registration for that practice rather than setting up a new
- Start CQC paperwork early. There is plenty of it! Any GPs not from the practice of the ODS code you are using will have to have to be added as ‘new partner’ and will need a new CQC DBS check carried out if their current DBS is more than 12 months old. You cannot add them to the practice partnership for CQC until you have this DBS certificate number. This can take a good few weeks to get through the system. My advice to GPs would be that they do not need to write reams on their form. Just enough so CQC know they intend to support the practice in upholding their CQC registration. It can all be done via the portal although the steps are a little cumbersome as you can’t move on to the next step until the previous one is fully complete. The CQC helpline I found to be pretty good and they will talk you through your own situation and what ream of forms needs completing. You will need to also do a separate form for changing the practice name and need to do one for changing the location (even if it’s not changing address) as the provider name will have changed. Oh and you also need to confirm/change your statement of purpose (another form or two!) which has to also be uploaded on another form because they don’t seem to be able to link them! And don’t forget to shut down the CQC registration of the practice you are moving the partners from (if that practice is no longer holding its own contract) – you don’t want 2 inspections! You will then get back a raft of email from CQC approving you or telling that one bit of the form is incorrect and incomplete!
New Partnership Name and Practice Logo
- This will likely be contentious – agree on a voting mechanism early on (for everything not just this). Staff and / or patients will possibly feel like they should have some input – will need managing whether the partnership lets them be involved or not!
- A logo will need designing. Unless you have someone who is a complete whizz at Photoshop, you will likely need some professional help (costs of course) to ensure you have the design in various printable formats even if the logo design itself is done by someone non-professional.
- NHSE/ICB will have a process you need to follow to get confirmation/approval (depending on whether you’re GMS or PMS) of your merger. Follow this. It will take longer than it should with ‘approval’ having to go to the various ICB committee meetings before you get
- There is a wealth of forms to complete and these are well documented. Your ICB primary care team will have the latest Do them as soon you can and send them as soon as you have agreement from the partners (and probably a good idea to have got a merger agreement in place by that point). PCSE unfortunately are likely to lose your forms, say they aren’t completed correctly or aren’t signed in the right spot so make sure you keep copies of them all.
- ICB will also want regular face to face update meetings to go through the plan you have provided as part of the My experience was that although they offered support for the merger, these meetings didn’t add a huge amount as they only focus on point A and not point B when you actually need help with B!
- You will need to do NPL3 forms for all GPs in the partnership and upload to PCSE – expect to chase!
- Get your accountant to do an estimate of pensionable profits form for the merged practice GPs and upload that to PCSE – expect to chase!
- Expect to chase PCSE pre and post-merger (to be expected I know!) – they won’t have amended your bank account details, won’t have added your GPs to the new practice, won’t have sorted the local prescribing codes, they might have managed to change the practice name and do the list merger at the right time if you’re lucky (that bit was the only PCSE involved bit that has gone successfully and on time!), there will be issues with the partners pensions despite all the forms having gone in on time – but then I probably didn’t need to tell you all that… I’m hoping you are luckier than I was on this one!
My advice: Speak to your accountants early.
- Do you use the same accountant? If not, a decision on which accountant to use for the merger needs to be
- Are your year ends the same?
- How similar are practice profits?
- Get comparisons and projections done and if your time frame for merger is over a year end of any practice, revisit this to ensure you have up to date info. The partners will not want any
- What contracts do each practice hold beyond the GMS/PMS? Do these differ? What LES differ? What other income is there?
- VAT registration considerations if appropriate?
- Bear in mind that over the merger period, finance will be complex as there will be need to effectively close two businesses and start another one up. You may wish to consider having a new bank account in the new partnership name. Money will end up in the wrong accounts so need to keep clear records of what’s been done to
- Don’t forget to let suppliers know any changes to bank details, name change or partnership details and to redo all direct debits and standing Some suppliers will require you to open new accounts with the new partnership which may take a few weeks for any credit to be allowed. Beware if you are a dispensing practice as I found the drugs suppliers the most complex to deal with. And don’t forget to close old accounts as staff will inevitably order from the wrong account by accident.
- There will be costs to a merger – do not expect this to be done on a shoestring. And plenty of costs that will just appear as you go along, no matter how carefully you
- Agree how to finance the merger early on:
- Have a joint pot/separate bank account that can be easily
- Consider a loan, divert some current partnership profits (will likely mean a hit to the partners’ bottom line), equity out the building – must be a fair split between the merging practices. Do this up
- Consider what external finance may be available, talk to your ICB and the There are little pots out there if you dig enough and have the right criteria for accessing.
- What happens if more funding is needed?
- We started off with a pot of £55k for a 2-practice merger and topped it up as was required but each merger is different and will have different costs. Whatever you do be under no illusion that the partners need to invest in this, not just in terms of effort but also financially as
- There will be need for additional staff costs, significant overtime as the day job is still to be done, recruiting to vacant posts (as you are likely to lose staff however careful you are), HR support, possibly redundancy or settlement agreements, pay considerations through staff job
- A new account requires forms, a lot of signatures and takes a little time to set Speak to your bank relationship manager. They will likely require some due diligence themselves regarding the new partnership, particularly if there are premises mortgages involved. Worth doing early on.
- Get your key policies in place and agreed early and working even before the merger. Agree a date premerger when all practices work from the same significant events, complaints logs and policies for example. Find a list of the policies most recently asked for by CQC in an inspection and use that as a starter for ten. The biggies are of course: – safeguarding, significant events, complaints, infection control, HR policies and staff handbook, H&S, fire, information governance, etc.
- Look at clinical policies one by one and agree practice
Project Management Support
- The practice manager(s) will need additional resource of some form to manage the day job as well as this mammoth change project. Even the best practice managers will not be able to just add it on top of what they already do without something else dropping. This does incur costs and PMs should have a conversation with their partners about how extra hours are recognised if that hasn’t already been agreed. As a PM you are likely to need to pull some extra hours, evening and even the odd weekend stint to meet
- Consider purchasing a project manager or project workers to take some of the workload and/or specialist HR advice with experience in merging businesses. The likelihood of there being enough capacity already within the practices is As PMs we know this only too well, but the partners need to understand the substantial incoming workload on PMs around the merger too.
- The partners need to be involved too; this is their business. It cannot be done without them. We had a clear out Sunday evening for partners, where they all agreed to drop in for an hour or so in their jeans, build some new flat pack furniture and ditch the rubbish we’d all accumulated. It turned out to be a good bonding time without the day job or the staff in the mix and not being an enforced meeting about the future. Little steps!
Communications with Staff, HR, TUPE etc
The staff will want to know decisions on how things are going to be as soon as you tell them this merger is happening so sort some answers before you tell them.
- What is the management and team plan for a structure? Don’t think what you’ve got now – consider what it is that the merged practice needs.
- Are you going to be merging existing teams? Job match staff into roles?
- Is there a possibility of staff redundancies? Do not rule this out too early as, as things flex further down the line, it may be what is needed. You need to follow proper HR law and process on this. Take advice and act on it. Expensive mistake if things end up in an employment
- Ensure every partner understands the basic TUPE implications and that they cannot make statements such as ‘no redundancies’ and then retract it later without it causing (potentially costly)
Biggest challenge of all the merger will be the staff. If you can do this well, and bring the ethos of the practices together, you’re on to something.
- Tell all staff at once together and absolutely before any patients get wind of
- Suggest you provide a written statement for them to mull over after the meeting that they can take away. We also filmed a (cheesy) video (introduced all PMs to staff that way) and agreed to show it at the same time in our practices. Then shared it on the intranet so staff could go back and take it in later. Also recommend talking to any staff that missed it personally to nip any rumours/concerns in the bud. Just keep talking to them, even if you have nothing to new to impart, any silence they will make up conspiracy theories as to what is going on. Even then some won’t believe it will actually happen until you do actually merge and it directly affects
- Ensure you let staff know when and what patients are going to be
- Timing of this announcement is crucial as it will cause anxiety and worry to even the most robust teams. Try to get all partners to give a positive and joint message from the outset even if they don’t yet quite feel it. Staff from each practice will immediately build a wall around themselves to defend off the ‘other’ The “them” and “us” will start… keep talking and be patient. This will be trying as every little thing will be scrutinised and analysed as to what it means for them personally. They will jump to conclusions and assumptions on things you haven’t even thought about yet.
- Bear in mind that as soon as you announce the intention to merge you have then started the TUPE process. Get support and advice on this if you need to and even consider it if you’re fully HR competent, as having an outsider support staff, review job descriptions and match to roles with you seems reassuring to staff and partners that it is all fair and above board. Staff can be suspicious beasts and if you can get that HR bod to review all your HR policies, staff handbook, staff HR folders and have those waiting to go at merge point, it makes life a lot
- Staff will immediately want to know if they still have a job, what that job will be, what’s going to change, will there be job matching carried out, do they have to reapply for their own jobs, what is the process going to be, who their line manager will be, will they still get the same holiday, will overtime still work in the same way, can they still have their booked holiday, is pay going to be reviewed, are they going to be unfairly treated and much more. Suggest if you can that the bones of this at the very least are agreed prior to telling the
- Encourage your staff to be advocates for the practice so give them enough information at appropriate times to reassure patients. Suggest honesty and openness with them as much as possible regarding the reasons for merger and what they should and shouldn’t tell patients. They are the ones on the front line and will be taking phone calls from patients the minute there is a sniff of things
- Staff will want to know how the merge will affect their Will their hours of work have to change? What is in their contracts? Make sure you don’t get the wrong side of TUPE regulations if you wish to make changes.
- Find ways to involve staff in the merger and merger decisions, however If merging teams, get them together as much as possible. Consider shift swapping, joint team meetings, process mapping tasks to learn of their differences together, staff get together without work getting in the way, etc. This is time and energy sapping and does come at a financial cost; the partners must understand the need for investing in overtime and cake, crucial if you wish to bring the staff with you along the journey.
- Expect that some staff will Some will be just too uncomfortable with the change to be willing to stick the challenging times. Some will have personal reasons for it being the right time to go. Hopefully these will be the staff that are the flaky ones and it will be better for the practice in the long run but expect that you will also have to recruit in the middle of all this too whilst doing the day job and the merger work. If it means you don’t have to make redundancies, then all well and good. Reduced staffing will be a challenge. Consider if the staff member leaving is stirring things and upsetting other staff, that it may be better to offer gardening leave for the remainder of their notice if you can cope with the hole. Make sure any recruitment fits in with the new practice and there are ways agreed to involve all that need to be from the merged practice.
- Practice managers – yep, likely that there will be at least 2 of you on this process. Take time to get to know each other, find out each other’s skill set and preferences, don’t always talk work! You will need each other through this. Work out how you can work together, who does what and when and if you can’t sort it then you need to speak to your partners sooner rather than later. Perhaps involve the LMC. Also remember to be tolerant of each other when things don’t go quite to plan, you both have your day jobs and you both are more than aware what curve balls come in daily to put you off course. Keep talking, that is easier said than done when everyone is so
- The partners will agree that this is the way forward, but they will have pretty much the same reaction as the staff as although they may have talked about it more, they will not probably have grasped what it means to them on a day to day basis and how things are going to change for them as an Expect similar questions as from the staff ….… I had, “where am I going to eat my lunch?”, “But if I’m not in that room there is nowhere to hang my spare shirt?”, “But I always do my <insert GP action here> at “X” pm, how am I going to fit that in?”. I even had “Why are the staff worried about their jobs?”. – GPs are human beings after all and do the “What about me” too!
- And I know it goes without saying but make sure you and the partners regularly thank the staff for coping with the upheaval, dealing with the patients, going the extra mile, carrying on with the day job. With all your own personal stress, this will be hard to do with a smile on your face when they’re moaning over the littlest thing, and you’ve been working your socks off with everything behind the scenes that they don’t know
Overall Internal Comms
- How are you going to communicate as a partnership and as a practice? Are you going to have an intranet? Use email or the clinical system comms methods for dissemination of info? Clarity TeamNet or other such provider?
- What practice governance and meeting structure are you going to have?
- How are you going to ensure all partners know what is going on in the merger project?
Perhaps use white boards to display or write up info as it gets people thinking. See my spider diagram and timeline below… scared the living daylights out of partners once they’d realised that it wasn’t just about clinical.
- Patient consultation and/or engagement – make sure you are clear on the difference between consulting and engaging and make sure you know what is required of you by your commissioner for your
- PPG – engage with them as soon as you can. Expect a lot of questions so have responses prepared. Ask for their help engaging the wider patient population. Listen to their ideas and perhaps let them lead on some. My personal experience has been that giving them a purpose has been a real positive and the group have become much more advocating and understanding rather than critical of the practice. Mine took the lead in writing and answering (with my support) patient information, newsletters, FAQs, press releases, monitoring social media and managing a practice open day. They took some of the load off which surprised me. Yep, had to invest some time in this that I didn’t really have but it did pay
- Also invite your local Healthwatch person to a meeting with your PPG (if they don’t come already), particularly one where you are talking about engaging patients. Tick on the CQC/ICB/NHSE box and they can be quite
- Patient information – get info out there often, new information reduces the patient chatter and misinformation on what’s already out there. Patients will assume that GPs are trying to make money and will profit from a merger, people will be losing their jobs and will generally be negative. You can’t change everyone’s automatic opinion but the more you have out there that you control, the less easy it is for the doubters, trolls and the ignorant to keep on
Managing the local press – engage rather than ignore is my advice. Give them press releases, copies of practice newsletters, statistics on call volumes, staffing levels, challenges, good news, etc. otherwise they will just go to social media threads and literally copy and paste the gripes whether they are true or not and make a story out of them. Your ICB comms team may be able to help you with this. They should at least be able to advise on good local contacts within publications/local news and might even take this on for you. It is worth to ask.
- Practice open day or info event – holding an event where patients can come and ask questions is useful PR – time consuming whilst we have the day job to do I know and a pain to organise alongside everything else, but was one of the most successful things we did. We were surprised by just how many people turned up. And ensure that the partners are present – most of mine did a runner citing home visits/workload/childcare! Rather annoying but my nursing team were amazing!
- And expect that certain patients, no matter what you say will be against everything you are trying to do and that they will shout about it to anyone who will listen. Make your skin thicker and prepare your staff in handling these types of patients at the desk, in the waiting room and in Encourage your partners to intervene with receptionists being shouted at and encourage your staff to get back up. If the staff feel supported, then they will be more willing to come along for the ride rather than leave when it gets tricky. Also, we all know that patients are so much less likely to shout at a GP, than a young receptionist. Get your zero tolerance posters up and follow through if needed!
- Whether the partnership is owner-occupied or leased you will need to let the landlord or mortgage lender know the change of
- Owner-occupiers will need to consider if all partners own all premises, whether to re- mortgage or not. Get advice from your accountant and if necessary legal advice. Re-mortgaging of course attracts legal costs and fees and involves searches, land registry issues etc, and if you’re combining buildings then mortgage lender is likely to want up to date fire, legionella, asbestos and EPC assessments – costs!
- For leaseholders you will need to review the lease agreement as to what the requirements are for change of leaseholder. LMC can
- If you are merging teams within the building, then you may need to consider room moves and reallocating desks so they can physically be together. Project in itself! Will need to work out who moves first, and when and in what Are there IT implications? Phone implications? The physical desk space? How are teams going to function with one another? Does one team need to be co-located with or next to another? Do staff work across two or more teams and how will that work? Expect some staff to find this quite challenging personally and need some TLC and tissues when they find they can no longer sit in the desk that looks out of the window with the nicer view!
- Are you also intending on doing any building work and/or refurbishment to the premises as part of the merger? Why not add to the workload while you’re at it, and turn the practice completely upside down? (Yep, this is what we did!!) Consider getting premises grants if possible and getting someone else to take the project lead as you can’t do it all! In some ways getting all the change done at once is at least quicker but it is a bit painful for
- Consider all the in-house contracts each practice has. Things such as cleaning, maintenance contracts for fridges, water coolers, utilities, refuse collection, confidential waste etc. Which of these need merging or combining? They will all need informing of the change to the partnership and practice name at the very least. Most of the contract reviews can be addressed post-merger in slower time as is easier once the new organisation is in existence to transfer the contracts. Some will be more complicated than others to
- Notional or cost rent – confirm with the ICB what the changes (if any) will be and make sure that nothing changes until you have a new District Valuer assessment if they say things do need to change (for example combining two premises into one).
- Rates – the council will need to be informed of the merger and a rates review will possibly be triggered.
Do not expect to get these all sorted premerger! There are many things to think about.
- How and what clinical processes are you going to be bringing together? This can be a mammoth and daunting task so needs to be broken down and shared
- What are your GP rotas going to be like? This is a source of considerable discussion amongst partners to ensure it’s all fair. It is also hell to work out if they throw everything up in the air – suggest getting a GP to help sort it out to show them how challenging it is! Expect this to evolve and go through several iterations and be a source of complete frustration as the rest of the practice awaits the final version so they can work everyone around it. DO NOT UNDERESTIMATE HOW DRAINING THIS IS?
- What is your appointment system going to be? Does that need to change to adapt to your workforce and new structure?
- Are you going to have common ways of managing patients for certain pathways? Consider all your long-term conditions pathways individually? How is recall going to be managed?
- How are requesting and processing of pathology and other results going to be managed between the clinicians? How is the patient informed of their results? What are they told?
- Nursing appointments – do all nurses work to the same appointment lengths? What are their skillsets? Who is going to lead on diabetes or respiratory or sexual health? Are certain clinics going to be combined so patients will go to different treatment rooms? (We had a patient refuse to be seen by the same nurse they always saw in a different room because it was previously part of the other practice – he caused mayhem in the waiting room, receptionist in tears, nurse almost pinned to the wall with him shouting at her, other patients joining in, until his GP intervened (the smallest female GP we have!) took him aside and told him his behaviour was completely unacceptable, explained the reasons for merging or there wouldn’t be a practice for him to be seen in etc. etc. and he now brings in countless amounts of veg from his allotment and actually prefers the treatment rooms on the other side of the building!) One patient won round then…..
- Medicines management and prescribing – do you use the same formularies? What about dressings and clinical sundry suppliers? How are you going to manage repeat prescription requests? What about EPS and paper script signing? For dispensing practices, repeat dispensing? Controlled drugs procedures? DRUMS?
- Communication between the clinical team – what meetings are you going to have, what about MDTs? How are you going to manage home visits? And urgent issues? What about safeguarding? Who is going to lead on what? How will you manage QOF? What is the practice clinical governance structure? Clinical supervision of staff?
I.T. Clinical systems
If this is merging, it is another project in itself!
- Make sure you take screen dumps of all reports for CQRS, LES, DES, QOF just before merger for all practices so you can ensure returns are correct.
- Ensure someone has access to all practices CQRS and Open Exeter logins and make sure all achievement reports, superann and pension reconciliation statements are downloaded pre-merger before they disappear. CQRS remains online for a bit of time so you can submit the last returns and check the automatic uploads (as they are likely to be wrong and require manual adjustments to be submitted but Open Exeter changes the minute the GPs are moved off the practice and accessing historical data seems then impossible.
- There will be processes that need doing premerger for clearing down the closing clinical system(s) such as e-referrals, tasks, results, letters, appointment book etc. and you will need to inform all providers who send things electronically directly into the system that they need to change their settings. Ensure staff are aware early and have the time to do it (whilst also doing the day job!); expect the need for overtime costs. Your ICB IT department and the Clinical System supplier will likely have written guidance and support available and actually my experience was that following all the required preparation meant it actually went very
- Book your IT merge date early with your system supplier to ensure it’s as close to your contract merge date as possible. This may not be possible to be the same day due to weekends – TPP for example, won’t do system mergers at weekends so you may have a merged list before or after your contract merge which confuses things no end! Also, someone will need to be logged into the system until the very last minute to deal with incoming reports, letters, results etc. that creep in despite having informed all providers of the merge in advance and to change their
- Consider how you intend to manage your future appointment book. Patients will likely need to book appointments in advance of your merger date for after the Consider getting all staff set up on both systems and creating a future appointment book on the system that is remaining. Receptionists will need training/support on how to book appointments.
- Consider that your clinical system will close early on the day of the IT merge and that clinicians will not have access to records. How are you going to manage this? Talk to your ICB about closing the practice for the afternoon perhaps and having 111 or another practice manage your calls. This is likely to
- Even if all merging practices are on the same system, it will have been set up in different ways in each. Decisions will be needed on how the practice is going to manage virtually every element of the system from incoming results to staff access. Consider how the clinical system What is your front screen going to contain? What shortcuts are you going to have? Does everyone have their own individual set up or do you have a practice setup? What is on your clinical and administrative tree or option lists? What button goes where? What referral letters and templates are you going to use? The address books? Communication issues such as use of instant messaging, task types, appointment rota templates, appointment types etc. etc. etc. (Don’t underestimate how people are wedded to their views on this!) If you can start getting both clinical systems to look the same before the merge, then this makes life easier post merge and one less thing at merger point to worry about (particularly if you have staff booking appointments on both systems).
- Consider your other clinical IT such as ECG machines, spirometry, etc. are they using the same software? Do they need to be able to be moved to rooms that haven’t had the IT installed? Do staff need training on any different systems? Also don’t forget the maintenance and calibration
I.T. Non-clinical Systems
Talk to your IT support provider (e.g., Healthcare computing) and the ICB IT team early.
- Talk them through the practical side such as room moves needing new cabling and even additional PCs/printers/scanners (this may cost if your ICB aren’t willing to fund). Ensure they understand your timelines, experience says that this is a challenge for them as they will have other IT projects on the go at the same time and a limited supply of engineers on the ground that are available when you need them as well as using third parties for installing
- Ask about their processes for your practice networks and email systems that are to be put in place. Can you get a new joint shared drive for instance? If they are combining networks, make sure not to forget to get them to sort the peripheral clinical systems such as ECGs, spirometry, INRStar, etc. so that your clinical system is still pointing to the correct place on the network to link to
- Ask for onsite support on the day of your IT merge (clinical and non-clinical). They can then deal with ensuring pathology is coming in correctly, all GPs are set up correctly for prescribing, the document workflow systems are set up and working and all the necessary links are put back in place and basically firefight the IT so you can concentrate on other bits.
- Don’t forget your generic email addresses for reception will likely need to be changed and shared with anyone who regularly uses them.
Dispensary (if applicable)
- If you are merging dispensing practices, then ensure you do not fall foul of the dispensing regulations in terms of where you can dispense from and to who you’re allowed to dispense.
- If there is only one dispensing practice in this merger then use this ODS code otherwise you risk losing dispensing
- If you are thinking of moving the dispensary to a different site, then this will require you to reapply for your dispensing rights and may cause you to lose them if unsuccessful. Take advice.
- If you are not already a member of the Dispensing Doctors Association then become one as they can provide a wealth of advice and support in regulations, help through any merger issues and they provide advice on being a better dispensing
- Don’t expect the ICB meds management team to be fully up to speed on dispensing regs and expect some ‘challenging’ questions from them which perhaps have little relevance. As this has (and technically still is) sat with NHSE, the ICBs have limited experience and knowledge. The NHSE pharmacy team at Oakley Road is very small and follows the regulations to the(ir) letter. DDA can offer support in challenging any responses and in asking the right
- Make decisions on SOPs for the new practice and ways of working, get these put into practice as soon as you
- Consider requirements if you have patients perhaps going to the ‘wrong’ dispensary to collect their medication or whether you are going to combine the dispensaries together physically. Costs will be involved and no funding available from ICB to help as is outside GMS/PMS premises funding regs. Requires partnership investment and informing/getting consent from NHSE as
- Consider stock management and if you’re combining stock into one dispensary then (in SystmOne) the stock levels will transfer with the IT merge (even if TPP says it won’t!!) but as each practice is likely to use different PIP codes then there will be multiple lines for the same stock item to sort and combine. Consider taking stock off one site system before merge – it may be quicker to do a stock take and add each item manually. Staff will likely need overtime to do this as well as trying to keep up with the day job when stock is all over the place. This was very challenging!
- Consider patient flows to dispensary. Do you have enough staff to man the front desk? Is there enough storage for collections? Do you have enough staff to answer the repeat prescription line? Deal with online or paper requests? All while still managing the dispensing and dealing with queries?
- Phone providers will need to be informed of change of
- Any current lease arrangements will need to change to new partnership
- Are you going to merge the phone systems?
- Does the phone system have enough capacity? Do you have enough staff to answer the incoming calls?
- What are your call volumes? Do you need call recording?
- What work needs doing for any upgrade or replacement? Upgrading cabling, appropriate internet connection outside of N3 if using VOIP calls, are the handsets in the right place? Are there enough? Expect
- Don’t forget to record new telephone answer
In-house Practicalities (with likely attached costs)
Contract requirement to have a website so needs to be addressed. Update an existing one or make a new one? Change of provider? Whatever decision, this takes time and resource to populate. A good website will help with the patient comms. Consider going live with it prior to the merger and consider arranging old websites to be forwarded for a period of time post- merger.
- Letterheads with all partners’ names on, compliments slips, whatever you use will need to be redesigned and
- Don’t forget your invoice templates for your sales ledger
Another contractual requirement. New patient pack will need updating and that opens a whole raft of decisions on the ground of practice boundary, out of area patients, managing new patients at the desk, paperwork, new patient checks, medication reviews etc.
Signage for the building
- Legal requirement to have a list of all partners displayed outside the Will need updating.
- Does the building signage need changing? Outside (new name plate?) and inside?
- Are you re-numbering consultation and/or treatment rooms?
- Do the clinicians need new room name plates?
- Fire exit signs may need checking, changing your evacuation point?
- Can patients find their way around ok?
- Health and Safety will all need updating or at least reviewing for new practice – think CQC! (for example, not an endless list…)
- Fire risk assessment
- Risk register
- Evacuation procedure
- Legionella checks
- Energy Performance Certificates if changes made to the building
- Electrical and Gas Safety Certificates
- New/updated H&S poster displayed in staff area
- First aid
Easy to forget
- Don’t forget to inform/re-register with the ICO, performing rights (if you use music), local authority, local schools, your local hospitals and other stakeholders, social services, safeguarding boards… your stakeholder list…
- Controlled drugs registers (if you have them) – you will need to transfer stock to the new practice and create a new book. Close but keep all old
- Management of safety alerts – needs to be sorted from day 1
- Returns for the old practices on CQRS need
- Manual returns for all DES/LES activity for the
- Review QoF figures post IT merger – make sure they look
- Merging the myriad of NHS IT that we have to report on, workforce, cervical smear database, DSP Toolkit and all the other websites used in practice!
- Check the NHS website listing for the practices has been changed
- Do any of the old practices use other websites like Google Listing, I want Great care, best doctors near me, etc. Remove listings for now and replace with new sites later when you have
So, you’ve made it to the milestone of merger date and you’re one organisation. Yep, it’s a milestone and everyone will be patting themselves on the back for getting there. Looking forward to the brave new world. Remember the bit at the beginning where I said there is an A and a B part to the merger. So yep, you’ll have pretty much sorted A. With relief all (or nearly all) the paperwork will be sorted but don’t be under any illusion that you’ve sorted B. Yes, you’ve merged in name, but you’ll still have a way to go to getting the human element ironed out.
Post-merger things to watch out for…
- PCSE completing and actioning everything they should have done (still have over 10 outstanding calls logged 3 months later!) Keep an accurate log of all PCSE issues and escalate with ICB/LMC if
- GPs wanting to change their rotas almost immediately without it bedding in
- GPs wanting to change agreed processes almost immediately without them bedding
- Staff finding the changes hard going as they won’t have lived the merger as you have, will likely be in new teams with people they haven’t worked with before with new ways of working. And on top of it they will be dealing on the front line with patients who are not backward in coming forward about them not liking the change and how it must go back to how it used to You will need to do a lot of listening and a lot of supporting. Just when you’re exhausted from sorting all the paperwork.
- Your first GMS/PMS statement – this will very likely be wrong as will have been calculated pre-merge so your list size will be completely wrong and possibly only provide you with the finance of the practice who’s ODS code you are keeping. Ask ICB for a payment of the money you are owed as soon as you see this. Your cash flow will likely be all over the place and you need to ensure you have enough funds to pay the staff. Ensure you get a breakdown of exactly what funds they provide you in that interim payment so you (and/or your accountant) can reconcile against what is
- Your drugs/prescription payment on the first month is likely to be PCSE probably won’t have added some of the GPs to the new practice, but they won’t appear under the old one either on Open Exeter. You will need to check any manual adjustments made by PCSE/Open Exeter/NHS PPA.
- And if you’re a dispensing practice they are likely to screw up your drug advance and clawbacks as well. Seek support from the DDA if this is the
Things to watch on the following month or two’s GMS/PMS statement:
- MPIG/PMS premiums are all there for each practice depending on what you have agreed with your ICB/NHSE
- The global sum has been calculated correctly using the correct list size figure – the interim payment may very well have used a combined list size of the practices as at the beginning of the previous quarter not the actual list size as at the current quarter – particularly if you merge on the first day of the
- Temporary residents’ payments are not
- Childhood immunisation target payments are for all practices not just
- Any outstanding ICB/Public health payments relating to pre-merger for LES, CCLIP or other ICB/PH contracts are allocated to the right practice, and you have a breakdown from the ICB/PH of these figures as the remittance advice rarely gives you enough detail.
- Minor surgery payments (if you do them) are for all practices and that they have updated the budget figures to combine all
- OOH adjustments – ensure they’ve used the correct list
- Seniority – for those that get it, ensure it’s there for all those GPs (back to PCSE again!)
- Rent – ensure your rent payments reflect all practices as appropriate not just the one practice who’s ODS code you
- CQRS Aspiration payments (QOF) – ensure they’ve added all practice aspiration payments
- CQC fees and rates reimbursements will need to be reconciled and adjusted once they have been redone following
- And check that once they have rectified all the errors that they are all backdated appropriately to your merge
- You’ll need to check that PCSE have actioned the estimate of pensionable profits certificate you sent them which will hopefully show on your GMS/PMS statement as deductions against each GP/Partner but they won’t have done that yet because the pensions part of PCSE can’t do anything until the Performers list part have set the GPs up against the right practice (and no they can’t possibly speak to each other!)
- Expect to have to resend PCSE copies of all annual reconciliation and superannuation certificates for several years as well as the estimate of pensionable profits again. And make sure they are signed copies, PCSE refuses to deal with copies of certificates they already have (and lost) unless they can treat the resent ones as the originals and pretend they didn’t have them in the first place!
- A full inspection visit is likely within the first 12 months post merge. So start as you mean to go on with evidence gathering, policy updating and audit cycles. In fact, I spoke to our CQC inspector just before our merger and she said they are looking at coming around the 6-month post-merger mark these days. (Oh joy!)
- Don’t forget your complaints, complements, significant events etc. and get those policies up and working from day
- And if you can’t get everything sorted (who can) then at least have an action plan!
LMC Documents and Links
Click HERE for a timeline overview and useful links. Once open, click to download and it will drop into excel for ease of use.
The merger template also contains a link to a planning/checklist document that can be used as a working document for updating as the process evolves. This can also be accessed here