The areas where general practice is on the brink of collapse
General practice in some parts of the UK is on the brink of collapse. As part of Pulse’s new ’Postcards from the edge’ series, Carolyn Wickware investigates the effect of surgery closures on GPs and patients
Practice closures have reached epidemic proportions across the UK.
Around 1.3 million patients have had to move surgeries as a result of closures over the past five years (see data below).
The pace of closures has quickened, as investment in general practice has fallen and GPs continue to leave the workforce at an alarming rate. Meanwhile patient demand continues to increase.
Last year alone, an estimated 458,000 patients had to find a new GP, after 134 surgeries shut their doors, either through partners handing back their contracts or deciding they were unable to sustain branch surgeries.
Such upheaval was unheard of as recently as 2013, when just 18 surgeries closed. But Pulse’s latest investigation shows another worrying trend: there are certain towns and cities where spates of closures have left general practice on the brink of collapse.
‘The current funding settlement means that most practices are operating on the edge of viability’
Dr Mark Sanford-Wood
These towns are suffering the full force of the domino effect, with a single practice closure triggering more, as the remaining practices are left to pick up the pieces until they can no longer survive themselves.
Local GPs, receiving little support from health commissioners, are having to take it upon themselves to come up with solutions, enlisting the help of MPs, patients and their colleagues in neighbouring towns.
The affected towns have strikingly similar profiles – they tend to be in coastal or rural locations, with an elderly patient and GP demographic, and a population size that changes according to the seasons.
Most importantly, they are almost invariably areas where it is impossible to attract new staff.
Among these places is Plymouth, where a fifth of practices have either closed or handed back their contract within the past three years, leaving 34,000 patients without a fixed GP.
Local GPs cited a ‘perfect storm’ of increasing patient demand, a deprived area and an inability to recruit and retain staff.
GPC deputy chair and Devon GP Dr Mark Sanford-Wood says that while the situation in Plymouth ‘may be particularly intense’, it should be ‘seen as a warning of what the rest of the country faces without urgent action to address the pressures in general practice’.
‘Without proper investment, the knock-on effects on the rest of the NHS…will cost the Government dearly’
Dr Richard Vautrey
Dr Sanford-Wood adds: ‘The current funding settlement means that most practices are operating on the edge of viability, and unless more is done by the Government and NHS England – which includes addressing the severe recruitment and retention crisis – the scenes in Plymouth could be repeated across the country.’
Indeed, the Plymouth effect is already being felt elsewhere. Brighton has seen nine practices close in the past four years as a result of GPs retiring, PMS contract changes and, in one case, the CQC withdrawing a practice’s registration – the desirability of the town not enough to overcome the effects of elderly and transient populations.
It’s happening right across the UK. North Wales – with its larger-than average elderly population – has been badly hit, with two practices recently shut and another taken over by the local health board.
Two areas in Northern Ireland – Portadown and Fermanagh – are also struggling, while in Scotland the Ayrshire town of West Kilbride has seen numerous practice list closures. Elsewhere, Essex and Cumbria, alongside many other areas, face their own mini-crises.
Commissioners are well aware of the problems. In the devolved nations, health boards have had to step in to take practices over – in Portadown, an unprecedented move even saw the local trust awarded the first APMS contract in Northern Ireland.
Read all our ‘Postcards from the Edge’
And there have been attempts by NHS England to rescue vulnerable practices, in part to pre-empt the domino effect.
The GP Forward View, launched two years ago, included a pledge of £40m to help practices teetering on the edge of viability – with £16m of this spent in the first year (see page 24)– on top of a separate £10m fund for 2016/17.
An NHS England spokesperson says: ‘More than 3,000 GP practices have received extra support thanks to a £27m investment over the past two years, with plans to help hundreds more this year.’
‘More than 3,000 GP practices have received extra support thanks to a £27m investment’
NHS England spokesperson
NHS England and the Scottish Government have also launched recruitment drives to attract GP trainees to rural areas by offering them £20,000 ‘golden hellos’.
The English scheme is having increasing success with 86% of these posts filled in 2016, and 92% in 2017.
But these attempts – national and local – have failed to stem the increase in practice closures. Freedom of information requests show that 136 surgeries closed across the UK in 2016 followed by another 134 in 2017.
But the 2017 figures are likely to be an underestimate, as CCGs were not able to provide full details of closures.
BMA GP Committee chair Dr Richard Vautrey believes rescue schemes ‘will take some time to produce results’, and says ‘long-term funding’ is needed.
‘Without proper investment in primary care, the knock-on effects on the rest of the NHS and society as a whole will cost the Government dearly in the long run.’
The failure of national funding schemes to deliver on their promises is also a danger. The Yorkshire coastal town of Bridlington faced its own domino effect, with all practices closing their lists because of unmanageable workloads.
GPs were counting on a new ‘health and wellbeing centre’, approved by NHS England through its £1bn Estates and Technology Transformation Fund set up to support practices.
But after the cost of the centre increased from £10.8m to £18m, with GPs in the area expected to pay for most of it, the plan was scrapped. Now, to make matters worse, practices have been forced to re-open their lists.
Dr Zoe Norris, the GPC’s lead on salaried and sessional GP issues, who works as a locum in nearby Hull, says Bridlington is ‘typical of places that are struggling at the moment’.
‘GPs have worked really hard to try and keep [Bridlington] going but are struggling’
Dr Zoe Norris
‘It has had problems with recruitment. GPs have worked really hard to try and keep it going but are struggling and I don’t know what the long-term viability of it will be without some help,’ she says.
With commissioners across the UK failing to help, GPs have been forced to take matters into their own hands.
Pulse has visited several parts of the country to talk to GPs about what they’re doing to ease pressure.
GPs in Plymouth arranged a meeting with NHS England chief executive Simon Stevens to discuss recruitment and have been promised up to 12 GPs from abroad.
Meanwhile, Brighton GP Dr Christa Beesley has helped set up a community interest company through the Wellsbourne Practice, which allows GPs to offer patients 15-minute appointments and set time aside for the clinicians and other staff to meet to raise issues and support each other.
Arguably the biggest success story is in West Kilbride, which could offer a template for other areas on the brink.
In 2017, a spate of resignations left the town with no full-time GP. But since NHS Ayrshire and Arran Health Board introduced GPSI salaried roles, designed to attract young doctors looking for flexible portfolio careers, four new GPs have been recruited – with another nine on the way.
Ayrshire and Arran LMC secretary Dr Chris Black says practices are ‘not out of the woods’, but the profession in the area is in a much better place.
There is no guarantee other areas, with their own localised problems, will be able to replicate even this partial success. But it seems likely that, in the absence of effective solutions from commissioners or the Government, the GPs themselves are their own most likely saviours.
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