Are there really too many small GP practices?

The recent comments by Dr Arvind Madan have generated a heated debate, with most ire directed at his suggestion that ‘GPs should be pleased when small practices close’

The notion that GPs welcome the closure of a neighbouring practice, (presumably because it will generate more ‘business’ for them) is a bizarre one. Few, if any practices are looking to grow their lists, and most see closures of nearby surgeries as a significant risk. The analogy with the commercial world is not valid in a single healthcare system that is struggling to provide universal coverage.

Dr Madan also suggested it is the responsibility of GPs to adopt ‘at scale’ working arrangements, rather than ‘passively wait’ for change to be enforced. This is, arguably, a reasonable challenge to make. Most innovation in the NHS is conceived and delivered locally, and it must be better for GPs to drive change in their own sector. Time and resource are constraints but, generally, those who take control of their own destiny are most likely to receive system support.

This episode makes it clear that NHS England view large-scale general practice as the way forward. This is not new of course, as it was already signalled clearly in the GP Forward View.

The benefits of working at scale have been discussed here and elsewhere in some detail. Many GPs are finding it advantageous to work in large groups, despite the risk of losing practice autonomy and identity.

Small practices are most vulnerable to the severe shortage of new recruits, particularly for partner roles, and certainly, small practices are closing at an alarming rate. Perhaps Dr Madan was voicing an unpalatable truth, and was indeed trying to ‘provoke a balanced discussion about contentious issues’ as he stated when he resigned?

We are very far from a consensus on how general practice should develop in the coming period. It seems to be difficult to debate the matter calmly whilst pressures at the front line are so high, and trust in those setting policy is so low. Leading such a discussion is a key responsibility of the NHS England Director of Primary Care, and this feels like an opportunity missed.

This is not a binary issue. If small practices are struggling, then we should not be looking at whether they have a future, but at how they can be supported to adapt and change in order to survive and thrive, and to play their part in the development of improved services for patients. There are many ways in which small practices can work together to generate efficiencies and greater resilience, and some of these preserve the much-prized autonomy and culture of constituent practices. It is, demonstrably, not necessary to ‘throw the baby out with the bathwater’

When Simon Stevens took up post, he encouraged the imaginative development of small hospitals, because patients like them. The same encouragement should surely now be given to small general practices, for exactly the same reasons?

  • Umesh Prabhu
    Posted at 18:02h, 12 August Reply

    Dear Mark

    Good to read your article. It was sad that Arvind Madan had to resign for making such a comment. Please note, I am not saying he is right to make such a comment and he should have been careful making such a comment which upsets hard working sincere doctors who are trying their best to provide good care to their patients. Single handed GPs have kept the Primary care going for many years and kept the cost of NHS so low. It is equally important that we have to move with time and we got accept change. There are some advantages with single handed or small practices but there are also disadvantages including work-life balance. locum arrangements and mostly working in isolation. NCAS and GMC data does suggest that working in isolation is a risk factor for patients and for doctors. So, we got to find much better way of providing Primary care and we must think radical way of providing Primary care and use skills mix, digital technology and so on. We all have to move with time and if not NHS will not survive for too long.

    As a profession we got to make sure we transform NHS and Social care and we doctors must take the lead. I am confident that we all work together we can transform and make NHS safest and the best and also reduce cost and save money and invest it in transformation of Primary care, new hospital buildings, new facilities for early and effective investigation facilities and make our NHS and Social care safest and the best.

    Transformation is not easy and many do not like change but without proper transformation we will not save NHS or Social care. or we may have to privatise some aspect of NHS and in my opinion this will be a sad day for NHS and for our patients and for all of us and our children’s’ future.

  • Mark Newbold
    Posted at 13:27h, 14 August Reply

    Thanks for commenting Umesh. Isolation is a clinical practice risk I agree but there are ways that small practices can come together to avoid this, without losing what is special about them. This incident highlights how important it is for us to find a way of debating transformation without alienating and disengaging people., because it is necessary as you say.

  • Dr Andrew Sixsmith
    Posted at 09:47h, 15 August Reply

    Dear Mark
    I enjoyed your article.
    I don’t think small practices have been excluded by these recent exchanges but I do think they have been offended.
    Our society is based upon classical liberal values such as freedom of speech and exchange of ideas. I think it is important that we as a community encourage free debate of ideas without fear of retribution.
    The mere fact that people feel the need to express their views anonymously is evidence that this value is being suppressed at a time when the NHS needs it more than ever.
    When I moved from a small practice to a large practice recently I received several very challenging comments which in spite of the tone I didn’t take offence to because I respected those views and was provided the opportunity to respond with reasoned argument as to why I decided to change practices.
    In general terms, how can we expect to agree on new ways forward for the NHS if we don’t listen to, tolerate nor actively encourage views from all sides without seeking to destroy those who may hold counter-conventional ideas?

  • Mark Newbold
    Posted at 20:52h, 19 August Reply

    Thank you Andrew. In short, the answer to your question is ‘we can’t’.

    In the NHS we really struggle with free and open debate, and very often those putting one side or the other feel the need to go incognito. This is not healthy as you suggest.

    Interestingly, most opprobrium tends to be directed towards those who express views that support the government or system line. The lack of trust I mentioned is a key factor here I think.

    The service faces a number of very significant challenges at present, and I completely agree that they cannot be solved without a free and open debate, and efforts to break down barriers, build trust, and encourage much wider engagement.

    Without these, it is unlikely that good solutions will be found, and even more unlikely that they will be taken up and implemented successfully.

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