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Sharp rise in GP mergers as smaller practices struggle to stay above water

Exclusive The decline of the smaller GP practice is accelerating, with double the rate of practice mergers in the first half of this year, compared with last year.

Figures obtained by Pulse show 93 practices have been involved in mergers in the first five months of this financial year in England, with a further 76 pending.

This compares with 80 overall in 2013/14.

The figures, supplied by NHS England’s area teams under a Freedom of Information Act request, have confirmed reports from accountants that the number of practices looking to merge is sharply rising.

Accountants and LMC leaders have said a merger is often the ‘last option’ for a practice to avoid having to close amid challenges such as a squeeze on funding or partners retiring,

The news comes at a time when various bodies are developing plans for GPs to work in larger organisations, with the chief executive of NHS England, Simon Stevens, claiming that the ‘corner shop’ model of general practice was finished, and that GPs will form ‘expanded group practices’ that employ – or take on as partners – hospital consultants, pharmacists and social care workers.

The Labour Party has also announced plans for every hospital to become an ‘integrated care organisation’ with ‘GPs at the centre’, which the GPC has warned could lead to the ‘destruction of practices’.

GP leaders have said there is ‘no time to waste’ for practices to merge, saying it is the only way ‘GP-partner led general practice can… survive’, but others have warned of the unintended consequences that this may have for average list sizes, an important determining factor for the value of QOF payments.

In the year to date, 12 practices have merged in Birmingham, Solihull and the Black Country – the second most of any area, after Derbyshire and Nottinghamshire – to create six practices, while a further 14 practices are involved in pending mergers expected to result in five practices, the area team said.

Birmingham LMC executive secretary and chair of the GPC’s contracts and regulation subcommittee, Dr Robert Morley, said practices had not made the decision on the basis of funding pressures.

He said: ‘I am not aware of any local mergers specifically because of funding pressures, they have been more for strategic and operational reasons.’

Dr Morley added that the GP partnership model can survive ‘only if GP partnerships merge into significantly larger partnerships and as soon as possible. There is no time to waste. GP-partner led general practice can only survive within a radically different business model.’

Dr Nigel Watson, chief executive of Wessex LMC, which has seen 10 practices merge into five to date this year and has a further six mergers pending, said locally practices were taking the step proactively in anticipation of future consolidation of GP providers.

He said: ‘We have quite a few [practices merging] but most have made an active choice to protect their future rather than be forced into an unhappy alliance.’

Dr Guy Watkins, chief executive of Cambridgeshire LMC said he suspected more practices than cited by NHS England were looking at merging.

But he warned there could be unintended consequences, saying: ‘We have got more mergers pending than the area team has confirmed to you. I think the practices believe it will make them more stable and ready for the future, and it might do. But it also has some consequences to the average list size, which affects QOF payments, so the math of mergers becomes very complicated.’

Former RCGP chair Professor Clare Gerada said: ‘Small, single-handed practices have had problems with viability for years. The model is, for all sorts of reasons, impossible to maintain.

‘Where I worry, though, is if practices are merging just because they can’t keep their doors open because of financial constraints – if the decision to merge is based solely on financial grounds, rather than because it is in the best interest of patients.’

It also comes as the Government admitted that there are now 518 fewer GP practices since five years ago, with some of the decline resulting from mergers and practice takeovers.

Readers' comments (27)

  • The Great British Public will thank neither the Government nor the Profession for admitting these changes. These are not inevitable developments but more the result of human folly and failure.

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  • Ivan Benett

    I very much disagree with David Brownridge. It is inevitable that surgeries will merge as the workforce of smaller and single-handed practices come to retire. In Central Manchester we have gone from 42 practices to about 34 (figure changing all the time) in just a couple of years.
    This allows for economies of scale, sharing staff more efficiently, more flexible hours, stretching the working day to meet requirements for extended hours (8-8 and at weekends) and to use premises most effectively (sweating your assets, as the business men say).
    It is also better for salaried doctors who will have a wider range of hours to work within, to better fit with work-life demands.
    Of course, we still need to fill the workforce gap, and need more investment in Primary care, but these bigger practices will be better placed to respond to the changing needs of the NH Service.
    The age of Dr Findlay is over, thank goodness! I value continuity of care, but I don't want to be up all night and working the next day, as we used to, and people knocking on my door for help.
    So too has the day passed, when most GPs are partners. Younger doctors are voting with their feet and don’t want to settle into a life of partnership anymore. Some need to become partners, those interested in practice management. For most us want to see patients and get on with the rest of our interests and lives, without have to wade through the bureaucracy of running a practice.

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  • I have just resigned my (senior) partnership and I am not yet 50. A head in the sand approach extending from partnership via LMC to CCG and even the Area Team was a very big factor. The need /justification/ benefits for merger or chambers or confederation is obvious to even the simplest of outside views! NO,NONE OF THE FUTURE GOVERNMENTS want the status quo so wake up or perish!

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  • This comment has been removed by the moderator.

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  • GP practices have to lose their cornershop mentality, mergers make perfect sense to support the new model of heath and social care combined.

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  • some good points Ivan, the day of the single handed practice should be gone, as it is inefficient and offers restricted patient choice.
    I am not sure what the' ideal size' is for a practice-has anyone ever looked at this from economic or patient choice /satisfaction aspects?
    Turning the service entirely salaried , would be prohibitively expensive and an excuse to pay us less.

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  • Ivan Benett

    12.06pm (I wish people would say who they are), I don't think there needs to be a move to make the whole service salaried, and so I don't see it being prohibitively expensive (for the Government/tax payer). It can happen naturally. Practices will remain independant providers with a small group of partners managing the income, expenditure and bureaucracy. They will employ the salaried doctors who are not interested in that sort of stuff.
    As for optimal size, there needs to be a balance between continuity of care and efficiency of care. This leads me to suspect that an optimal population size will be about 50,000...funnily enough the same size as our Localities in Central Manchester currently of 6-8 practices. These super practices will operate from several sites in the locality (maybe 3-5) and provide a range of services that currently come under urgent and planned care heading.
    For example, for urgent care they will provide same day access for same day problems, extended availability (8-8 & some hours at weekend), minor injuries centre.
    For planned care, long term conditions management including complex frail elderly and mental health, minor surgery, diagnostics, secondary care services like new outpatients and follow ups (all 8-8 and weekends).
    Those entrepreneurial GPs can be the partners, and be paid accordingly. The rest of us see patients and leave admin to them (and support staff).
    Everyone’s a winner. Not more expensive. Everyone’s collaborating. Patients get a better service.
    I don't care which Political party does this. I think this is apolitical

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  • Why?

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  • Will be very expensive for you when NHSE retenders it and you lose.

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  • So many "leaders" and other interested parties are reiterating the "fact" that small practices cannot survive, that the small business model is "impossible to maintain" but why?
    The essentials of the job are unchanged. The factors making life more difficult are generally not patient-related. Changes seem to have been imposed with the aim of forcing small practices under so announcements of the possible result are perhaps merely the same people furthering that agenda.

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  • Economies of scale suit a financial model of supply in cities. They do not suit rural areas where a 40 minute round trip to a distant farmhouse is a massively inefficient but inevitably necessary daily occurrence (lessened by good continuity). Think about any of the large economy of scale businesses that you have tried to contact for "customer service" - if this becomes how we administer general practice to the frail and vulnerable we have lost the plot. Can we please stop pretending that one size fits all. Which super-practice will the remote rural or island GP's join? Or could someone perhaps admit that some areas are just more expensive to administer primary care.

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  • It is not Practices that need to merge but there should be a system of sharing good practice manager s. It is not cost effective having a few highly paid professionals doing the same job in a small geographical area.
    This also goes for Prescribing Leads and Clinical Governance Leads

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  • STOP PRESS - pensions newsletter suggests that income derived from federation activity eg enhanced services will not be pensionable . A good way for the government to cut down their pension liability as increasing amounts of our income is likely to come from enhanced services .

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  • And it was never ever about keeping practices open, it is all about good patient care. not clinical need, but clinical want. no matter how unrealistic the want is. free at the point of abuse. Go NHS. RIP.

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  • News to me . Surely any NHS work is eligible for a pension . A federation is an NHS body ?? If not then collaborative working may be better than federating because pay for our core services is so crap it would massively reduce our pensions . We really need to include enhanced service income.

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  • Could someone please clarify the situation viz federated income and pensions? It seems pretty fundamental to joining or not.

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  • Re is federated activity pensionable or not - perhaps the RCGP should seek a definitive opinion from
    Ross Matthieson at NHS Pensions

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  • Merging two struggling practices, in the expectation that things will improve, is absolutely stupid.
    When the number of partners dwindles (which it is bound to do, because of the recruitment crisis), the remaining partners will have a even greater number of patients and workload, and even greater staff redundancy liabilities, when things collapse.
    If a practice is struggling, it should simply close, and leave the problem for the department of health to sort out. Perhaps then, they might start helping, instead of punishing us.

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  • big practices for big cities maybe, but wont work in less densely populated areas.
    I don't see why the small practice cannot be maintained. The only benefit of larger practices is savings and perhaps more flexibility for extended hours. Unlikely to be better for the patient as continuity is more important in my view.

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  • Ivan Benett

    Yes, continuity needs to be preserved as much as possible but the days of 24/7 responsibility were given up by the profession a long time ago. So we need to find a balance. As I said Dr Findlay has long gone, however nostalgic some may be for those days (not me)
    Yes, there needs to be a more complex solution in sparsely populated areas. The principle of bigger practices using more salaried staff still applies. Perhaps more use of internet consultations and other local solutions.
    Look, we need to change! The current way of providing General Practice is not sustainable and young GPs don't want it.
    Better solutions on a postcard, and say who you are!

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  • Ivan "3 single handed GPs in Manchester should have retired long time ago" Benett (your words, not mine)

    Good of you to jump up on agenda which you have been pushing for months. As previous posters pointed out, where is your evidence?

    My local area showed a clear trend of better patient satisfaction, lower referral and AED attendance rate, inversely propotional to list size (i.e. smaller the better outcome).

    Many wannabie economist/politicians talk about economies of scale. But you might want to look for words like diseconomy of scale, horizontal vs vertical integration. Many will then realize the perceived benefit of the integration may not always materialize. And it is this assumption that by having a larger unit you'd achieve efficient service (and hence savings) leads to many failed mergers. In fact many large companies now separate parts of it's branches for this reason. It will also make the economy vulnarable and whilst it may be good for those in the exec chair, it may not be the case for the workers and customers - look at South Korea for example.

    It's all very well wanting change, I'm all for it - but don't try and sell us your vision with your agenda without factual evidence as "good change"

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  • Why so quiet about federations and pensions . Do they have something to hide?

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  • yes evidence would be welcome to this debate. as one poster has mentioned already. it is not patient related factors that are leading to pressure on small single handed/2 partner practices but the top down re organisation and endless hoops to jump through with 0 support.
    Unfortunately IMAO those who are pushing their agenda are usually owners of very large practices.

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  • I totally agree with Ivan , and the best way forward is to have a crystal clear understanding about the roles ,i.e whether one wants an entrepreneurial role or just a clinicians role. Once this basic requirement is completed ,why not go for the biggest merger and I am sure sure,all the indications are this will happen any way!!

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  • Re federations - it depends whether you are limited by shares or guarantee as to pension eligibility. Full guidance is here
    http://tinyurl.com/prw5mlm

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  • I loved working with my patients until the list grew past 1700 .nights and weekends were exciting and I could get to a suspected heart attack quicker than an ambulance as no speed cameras were around. I worked my patch like a ward and asked we all care for the area as our patients, without arguing about why should we do this for your patient . Sometimes it was tiring but with my wife's supoort the patient came first .
    Now even knowing when a patient is admitted trickles and I can't visit them in hospital.
    Once I rang about my patient and was told by 2 locum nurses she had an amputation but was on the eye ward.
    Wrong. She was fine but had anaemia and was an outlier.

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  • I should add the continuity helps.
    Yesterday a friend was in casualty with severe pain which occurred on standing after a 2 hr meeting
    He was 14 hrs In hospital saw 4 consultants with Xray 3 ultrasounds 2 prs several bloods and too late for pharmacy after his oramorph . I saw him fine and laughing. He has several recent scans pr etc as a private businessman

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