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Are singlehanders reaching the end of the line?

Alan Johnson's remark that some singlehanders are not at 1948 standards reflects a wider drive to phase them out. By Steve Nowottny investigates

By Steve Nowottny

Alan Johnson's remark that some singlehanders are not at 1948 standards reflects a wider drive to phase them out. By Steve Nowottny investigates

For a Health Secretary with a reputation as a diplomatic type, it was not a particularly diplomatic remark.

Opening the country's first GP-led health centre at the end of last month, Alan Johnson was scathingly critical of single-handed GPs.

‘Some don't even reach 1948 standards,' he claimed, as he cut the ribbon on the Government's vision of 21st century general practice.

A dismissive, off-the-cuff remark perhaps – but one which immediately infuriated not only hundreds of single-handed GPs, but many others who saw it as a dismissal of the core values of traditional general practice.

And the battle against solo GPs seems much more than a war of words, with PCTs now working quite openly to close down singlehanded practices.

A Pulse investigation suggests one in 10 single-handed practices has disappeared in the last year alone, as practices have in a few cases been persuaded to take on new partners, or more often closed down following retirement or a GP's death.

Trusts are careful to distance themselves from Mr Johnson's comments, with most insisting they have no particular concerns about small or single-handed practices, and that all performance issues will be treated equally regardless of practice size.

Yet at least half of the PCTs Pulse contacted admitted to having policies in place explicitly designed to phase out single-handers, with patients often distributed among neighbouring practices on a singlehander's retirement.

In Birmingham East and North, where 39 of 82 practices are single-handed, the PCT is working towards list sizes of 10–15,000 patients ‘to give resilience of cover and continuity of care'.

NHS West Kent is ‘reducing isolation for GPs through a reduction in single-handed practices'.

A spokesperson for Westminster PCT puts it even more bluntly – by invoking the ‘S-word' that continues to hang over single-handed GPs, 10 years after Harold Shipman was brought to justice [check].

‘With changes to governance and closer monitoring of clinical activity following the Shipman case, sole practice will not be encouraged in future,' a spokesperson says.

If the trend among PCTs is clear, there's no doubt Mr Johnson's remarks caused outrage among single-handed GPs. Dr Laurence Buckman – GPC chair, and a single-handed GP in Finchley, led the charge.

‘He'd better back that up, hadn't he?' he says in response. ‘It's a very cheap thing to say. If you're going to attack a large number of doctors, you ought to have some evidence.'

In the corridors of power, however, it's likely Mr Johnson's remark was seen as somewhat less controversial.

For years, politicians have been predicting the demise of singlehanders. In 2002, Tony Blair called for ‘a move over time away from single-handed practices to improve quality of care', while in February this year Lord Darzi said ‘I have no doubt we are going to see a critical mass of GPs working together, rather than what we used to see in the past, which were practices with a single-handed clinician.'

These incantations in Whitehall are starting to take effect. While the figures for the last year suggest a sharp drop, they have now been coming down gradually for a few years. In 2007, the last year with official figures, there were 2,125 single-handers, with 1,594 working without even the support of a salaried colleague. In 2004, the figures were 2,285 and 1,949 respectively.

There's no doubt the pressures of running a single-handed practice are unique. Earlier this year a Health and Safety Executive study found single-handed GPs were the unhappiest group, with 72% saying time constraints meant they were unable to get involved in wider aspects of the GP role such as LMCs.

Dr Lis Rodgers, a single-handed GP in Doncaster with 14 years' experience, says: ‘Single-handed practice is incredibly rewarding and the patients love it, but the pressures of daily practice are such that to carry that load on your own is becoming harder.'

‘Locum cover is becoming more difficult and more expensive – and you worry about what's happening to your patients when you're not there.'

While the added stress of running a practice single-handedly is hard to quantify, there is anecdotal evidence it can take a toll on GPs' health. In Hillingdon, PCT bosses are worried after seeing two single-handed GPs die while in post in the past 14 months.

‘We are concerned at the workload for single-handed GPs, given the current demands of general practice,' a spokesperson says.

Running a practice single-handedly may add to a GP's stress, but those who do so are adamant that – contrary to Mr Johnson's claims – there is no evidence quality suffers. They point to various studies finding exactly the opposite – an Audit Commission report in 2002, for instance, found ‘access to care, continuity and some aspects of communication tend to be better in smaller practices'.

One GP in Luton, who asked not to be named, said the number of local single-handed practices had been cut in the past year from nine to just six.

‘Our practice is achieving maximum QOF points, we are meeting all our immunisation targets, we are saving on our drugs budget,' he says.

‘Single-handed GPs know each patient. But they think all single-handers are bad – and it's because single-handers are expensive.'

This they certainly are. Recent earnings and expenses figures found single-handed GPs make the highest net profits, averaging £132,010 in 2005/6. By contrast GPs working with six or more partners had the lowest net profit, averaging £105,769.

Bob Senior, vice-chair of the Association of Independent Specialist Medical Accountants, says: ‘There's no doubt it is more expensive per patient to run in small units.

‘There is a minimum number of staff you need to look after 2,000 patients – reception, admin, nursing staff. The staffing to look after 4,000 patients would not be double that.'

‘In urban areas the Government is trying to address that by saying if we put lots of single GPs into a polyclinic or Darzi centre, maybe we can help them achieve some economies of scale – but it's a big if that they're willing to do that.'

‘It wouldn't be astonishing - though slightly ridiculous - to walk into a GP-led health centre with 10 single-handed GPs and find they all have their own receptionist.'

Independent, or bloody-minded, depending on your point of view, single-handers may have to embrace change if they are to survive. GP leaders talks of collaborative working, PBC clusters and federated networks as the way ahead – all attempts to drive up standards and reduce isolation.

Dr Michael Dixon, chair of the NHS Alliance, says: ‘You can't have an isolated GP these days. Part of improved clinical governance in primary care is to do with the fact we all know each others' business, whether it's looking at a partner's entry on the computer or signing their repeat prescriptions. It is the end of practice isolation – which doesn't necessarily mean the end of single-handed practices.'

Faced with a Government critical of the quality of single-handed care – and PCTs' reluctance to pay for it – some grassroots GPs are less sure.

Dr Krishna Chaturvedi, a GP in Southend in Essex, is part of the Space consortium of 16 single-handers, which exchange best practice and collaborate on practice-based commissioning.

Set up in 2002, it is exactly the kind of collaborative working encouraged by GP leaders as a model for the future. Yet even so, two single-handed surgeries were recently closed down after their GPs stopped practising.

‘With small practices, any opportunity to close it, they will close it,' he says.

FAQs: Singlehanders

How many singlehanded GPs are there?
The most recent figures from the Information Centre show that in 2007 there were 2,125 single-partner practices in England - and 1,594 of these were GPs practising without salaried GP support. But numbers have been falling for years and Pulse's investigation suggests one singlehanded practice in 10 has disappeared in the past year.

Why are they under threat?
Ministers and PCTs have concerns over the quality of singlehanded practices. Despite some evidence pointing to higher standards at smaller practices, they fear isolated GPs lack peer scrutiny. Also, singlehanded practices lack economies of scale, and are costly per patient.

How are PCTs phasing them out?
In a few cases where there were quality concerns, singlehanded GPs have been removed from performers' lists. More commonly, PCTs wait for GPs to retire. Patients are then distributed among neighbouring surgeries.

Are many singlehanders really not meeting 1948 standards now?

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