12 Aug 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?