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Vulnerable practices 'to be allowed to fail and wither', says NHS England director

Exclusive A senior NHS England official has said vulnerable practices must ‘transform…or be allowed to fail and wither’, a leaked document obtained by Pulse and the BBC has revealed.

Paul Twomey, medical director of the Yorkshire and Humber area team, made the claim in a briefing sent to NHS managers and GP leaders in the region.

He said that NHS England is ‘no longer in a position’ to continue supporting vulnerable practices ‘irrespective of their willingness or ability’ to transform.

GP leaders said that NHS England were taking on ‘Orwellian tones’ with this latest statement.

NHS England has been urging practices to federate and merge, but this is the most explicit a medical director has been about allowing practices to fail.

It comes as Pulse has revealed that a £10 million fund to support vulnerable practices announced 14 months ago has had very little impact, with many area teams having failed to even identify the practices that will receive funding.

Pulse has revealed through its Stop Practice Closures campaign that practices are closing across the UK, and reported today that partners of a practice in Warwickshire are having to take out personal loans to pay for redundancies after the local CCG blocked its attempts to merge. 

Other notable recent practices in danger include an 18,000-patient practice in Oxfordshire, and another closing while it was waiting for vulnerable practice funding, while the local trust is taking temporary charge over four GP practices in Lincolnshire, and four practices in Brighton and Hove servicing over 10,000 patients had to close after funding was pulled through the review of PMS contract.

NHS England has previously said that practice closures are ‘not always a problem’ and ‘happen all the time’, and occur through mergers, new premises and death of a single-handed practitioner.

But the comments by Mr Twomey go further than this, indicating that NHS England would actually allow practices to fail.

In the briefing note, he wrote: ‘The message we need to communicate to general practice is the GP Practice Forward View must be about transformation and in that sense is not like a pilot.

‘This is what we do need to explore I think in particular with the LMCs, who on the whole across Yorkshire do have a commitment and focus of quality, and appreciate that vulnerable practices must either transform and deliver a quality service or be allowed to fail and wither by the system.

‘We are no longer in a position to continue supporting practices irrespective of their willingness or ability as a provider to transform appropriately.’

But GP leaders reacted angrily.

Dr Richard Vautrey, deputy chair of the GPC, said: ‘The term transformation seems to be taking on Orwellian tones when used in this way. There are many practices who were previously performing well and valued by their patients but are now vulnerable because of spiralling workload and recruitment problems beyond their control.

‘Such practices should not be written off. The whole basis of the practice resilience scheme is to provide appropriate support to practices and NHS England and CCGs should be trying to do all they can to utilise this resource.’

Dr Peter Swinyard, chair of the Family Doctor Association, said: ‘Starve the practices of resources. Micromanage them into the ground. Over inspect and over criticise. Then stamp on them.

‘It is hard to be transformative when you cannot recruit doctors or nurses and are under the cosh of all the stresses we know, then have your income and resources reduced making it even more likely that you cannot manage change and adapt.’

He added: ‘This is the most desperate and negative policy I have heard.’

Mr Twomey declined to comment, but an NHS England spokesperson said his comments ’do not reflect national policy whatsoever’.

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Readers' comments (47)

  • Is anyone surprised ?. The phrase "wither on the vine " keeps cropping up from our "leaders" . Feels like we're on a runaway (virgin) train

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  • cd...it's the ordinary people who will be falling like flies.

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  • Thing is he's right. The GP Forward View says exactly the same thing.

    There is NO proper help for individual small (or large) practices. We must work together or die. There are significant resources for collaboration.

    There is no doubt of this.

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  • It doesn't reflect national policy, IT IS NATIONAL POLICY.

    Do as we say or die.

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  • Anonymous | GP Partner12 Oct 2016 12:00pm

    We need to be planning for the health service after the collapse of primary care . The demise of general practice is inevitable now . This is because those leaving ( in droves ) cannot be replaced . There is no one left to train anyone willing to take on the job. This government wants rid of a state funded service and the best way to pull it down is to undermine the foundations . There is an orchestrated assault on primary care . Even our receptionists are getting a kicking now . No help can be expected from the establishment because the quicker things fail the better for them . Any direct action from us will allow them to blame us . Time to take to life boats and save what you can . This ship is going down .

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  • Nhsfatcat

    Quo usque tandem abutere, NHS England, patientia nostra?

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  • This is correct. NHS England has to save money. How better than letting 1:4 Gp practices close by refusing to allow them to merge and not helping them access the transformation funds in time- with the partners personally taking all the liabilities for redundancies and leases etc at no extra cost to the NHS?
    Once the money is saved some can be redirected, they hope, to the remaining drowning Gp practices who can only cope with the increased demand by operating 8-10pm 7 days a week just as they had all planned. Saved rental and running costs by NHS England and public gets its extended hours. See it as increased efficiency. Job done. Except no continuity of care any more. No local GP practices and still the public never got to vote or debate this plan.
    Well done Hunt! Well done NHS England! At least if they can be honest about this now the public and media may start to support those left struggling and be a bit more sympathetic to the individuals caught up in this mess rather than vilifying us all the time. Hard to be painted as greedy GPs anymore now many of us face personal bankruptcy as a result of NHS policy.

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  • There has never been any real understanding from anyone other than primary care exactly how primary care works. The drivers are not financial but money is important to pay the bills. I have had many instances where senior NHS people and politicians believe GP's are on huge salaries as they believe the media rhetoric. There is little reward for good practice nor for long service. With the introduction of the £10 per patient per contact as described by the Kings Fund discussion paper there may be some respite from the relentless demand. There certainly won't be any help from NHSE before the cards come tumbling down.

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  • If you are over 50 don't worry. There is still just enough game left to play. If you are 30-40 then you should prepare for a portfolio career. You need to gain further skills either in or out of medicine.
    If you are 40-50 I grieve for you. This is not what you bought into.

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  • so if that lot are not in a position to support practices, why are we still in a position to provide unfunded services?

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  • Vinci Ho

    Finally.
    Ministry of Plenty, of course is Orwellian.
    Like to listen to Auntie May's response to this.

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  • The implication that vulnerable practices are those that are 'below par' or that offer poor quality care is not true. Any practice can become vulnerable to closure as a result of illness, retirement or resignation. As workload spirals, it becomes increasingly impossible to attract or recruit replacements - who would choose to join a failing partnership? Training practices and practices formerly rated as 'good' or 'excellent' by the CQC can be just as vulnerable to a change in circumstances as any other practice.

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  • Nothing we didn't know already.

    Ditch the contract comrades.

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  • Dear friends , surely no one is surprised...

    Wake up and smell the roses, our NHS is systematically being dismantled and will be offered to the likes of virgin health on a plate once the concept of at scale working within the public sector is firmly established. STP's are the vehicle being used to force us to engage with placed base care.. once placed base care entities have had some time to mature they'll be tendered off to the private sector. As STP's aren't a statutory body or indeed covered by any legislature they cannot be held to account- as a profession we need to take a stand to protect our NHS from this inevitable fate.

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  • Vinci Ho

    True face of NHSE
    For those who have been telling the truth ,nothing but the truth , are always condemned to be negative and not helping the situation . Oh dear, we and Pulse are so so guilty .......
    By the way , how much taxpayer money is used to pay these 'senior NHS officials'?

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  • Practices fail. Surrounding practices are destroyed with a sudden increase pressure . The wave ripples outward and others collapse in its wake. Soon only a few desperate outposts remain which implode under the workload. The foundations are gone and the NHS goes with them. This is the plan . Pity they couldn't let the banks fail . All our money has gone to support those hunts.

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  • The Tories have always hated the NHS . This is their revenge .

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  • NHSE thinks that GP at large scale is workable. It is NOT.

    It is difficult to do this even in hospital e.g. 'Any Gastroenterologist in a DGH, or increasingly across DGHs will see any new patient or follow up'. This means that all Gastroenterologists have to work with joint protocols, but vague GI symptoms do not fall into protocols and patients respond individually to different treatments and clinician 'styles'. At least the hospital Doctors get a lot more consultation time to do this for only 'one' disease area

    Now going back to GP at scale. We will need common protocols for ALL disease areas, not just one, as above. We will also need common patient access portals, one referral centre, one repeat medication centre, one centre for actioning letters and results, one centre for complaints. As to patients having any on going clinical relationship with a named clinician, dream on. And all in 10 minutes!

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  • I do think we should try and see both sides to this. I agree that colleagues livelihoods and stress levels are crucial. However, the question has to arise - when do you stop trying to fix/maintain something that isn't working?

    Consider a favorite 15-year old car, where each month something else goes wrong. At some point you have to say - well thanks old friend but it's time to let you go. Same applies to some of these "failing" (I hate that word) practices.

    Can't just keep the "old ways" going indefinitely.

    Need more honesty from our politicians, and a proper discussion about this. Trouble is, they will just do it through the back door and underhand.

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  • The need to scale is entirely due to the impact of centralised NHS requirements to control, collect data and create bureaucracy. Many dentists work at a similar or smaller size (per site) than GP surgeries without and they are subject to the more honest funding of patient self pay.

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  • GIVE TAX ALLOWANCE FOR PRIVATE HEALTH COVER AND REDUCE INCOME TAX. NHS IS UNAFFORDABLE IN LONG RUN.

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  • Follow up Dr Sanjeev Juneja's excellent comments, I wonder if these draconian measures apply to surgeries run by GPs who are also members of CCG governing bodies and LMCs.
    PULSE might like to do some research on the matter, or, are those super-GPs immune?

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  • "GIVE TAX ALLOWANCE FOR PRIVATE HEALTH COVER AND REDUCE INCOME TAX. NHS IS UNAFFORDABLE IN LONG RUN."

    Spoken like a true Tory. Any idea what to do with patients who can't afford private healthcare due to proliferation of Minimum Wage/Zero Hour Contracts abusers?

    No, I thought not but then again you probably couldn't care less.

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  • In NI GP share of NHS funds is a 50% reduction from 11 to 5.5% is 12 years, at the same time work has gone up 50%. Chaand was given a clear mandate to call for mass resignation. He has ignored the average GP and let the failing ones just die, without doing anything.
    He should resign because he is not doing his job.
    Hunt is right, give them a few gongs, they are anybody's.

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  • |Anonymous | NHS Manager|13 Oct 2016 12:29pm

    "Spoken like a true Tory" isn't an insult although I am sure you wanted it to be.

    Btw that wasn't my post (about taxes) and nor do I vote Conservative myself. Live and let live though eh? Tories are proud to be called such. Ditto socialists, ecohippies etc. It's not offensive if one sees oneself within a given cohort. Mudslinging and name-calling is seldom helpful in debatee

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  • The ETC want the national health service to fail . They can bail out their mates with the banks . But for us a £10 million fund we can't access is supposed to fix the problem . To get this in perspective - channel 4 paid £75 million for the great brit bake off FFS. The ETC would just love it if we resigned . It would play right into their money grubbing little claws.

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  • Of course the 'Powers that be' want/ensure that the current NHS will fail so that they can provide a 'better, cleaner, brighter, whiter' NHS. It's not a case now of 'do as we say or die' but 'do as we say and die'!

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  • agree with 5 .38 - they're just a bunch of jeremy hunts

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  • I have had the pleasure to work with Dr Twomey and a more dedicated and caring GP would be hard to find. The comments above do not do GPs justice and maybe they too should start to focus on how best to deliver service quality rather than just maintain the status quo. We all know there is a range of practice out there and surely it is right to work to improve it, for the benefit of all.

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  • The assumption is that a vulnerable practice is a bad practice and nothing could be further from the truth.

    Reasons for vulnerability range from overnight funding reductions ( PMS review, service charges)to unscheduled recruitment issues (sickness or early retirement)

    But let's be clear - it is all of NHSE's doing. They created the funding crisis and they are also responsible for no-one going into general practice.

    How dare people suggest that it's time to move on to working a scale when we receive HALF of the NHS budget compared to some years ago.

    Working a scale is not the answer. But you will all find out the hard way when the NHS collapses.

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  • 8 years they have been killing good doctors pay and conditions now the poor doctors and their patients
    Always the weakest lose
    Civilisation is about ...

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  • Peter swinyard
    Why is he ignored as the small practice voice

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  • Daughters wedding
    Registrar fee £500 1 hour boournemouth
    We should wake up
    5 min with dentist £80

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  • I have to say better to get £300 per patient in Dorset
    Live the good life do some CCG work appraisal as well
    Small is a waste of time
    Remember Clare Gerada forget swinyard

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  • What do they assume is a vulnerable practice?
    If GP's do not want to be into NHS owned buildings and pay high rents, but deliver an excellent service in their old converted properties, with no complaints from patients, why should they be forced to merge ... other than to make the NHS properties service money?
    I belonged to oen of the new health centres where one of the GP's is chair of the CCG, and the service was appalling and appointments harder to find than gold dust.r
    I changed to a practice with just two Gp's working from a converted bungalow, the environment is invisible, what patients need is the best quality of care and that is what I get.
    Modern is not best, my GP is so good I would care if he ran his surgery from a tent!

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  • @Simon Ruffle | GP Partner12 Oct 2016 6:39pm

    Quo usque tandem abutere, NHS England, patientia nostra?
    =========
    patience or patients ?

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  • They're all SMEs
    It's the MARKET, stupid.

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  • Eventually when we have super practices the GPs in them will realize they have no autonomy.
    I am saddened by the current lack of support for GPs
    We have worked too hard for too long with ever increasing workloads
    We should all become salaried with the BMA contract terms or be self employed locums. GP partnership is just a slow form of self harm
    Let's wake up, somehow do less work so we can enjoy some social life and family life

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  • Amen 04:11 Amen to that

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  • 1. CQC should have shut down the poor and inadequate practices
    2. Why let good practices die from poor funding
    Ok .. If the workload has spiralled or there is a sudden staff shortage
    Allow the list to be shrunk to a manageable size
    Transfer patients to where they would go if the practice shut down
    The problem is that shrinking list means reduced income

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  • Where is the quantitative easing for General practice
    Bankers too big to fail
    General practice ...too valuable to fail
    Unappreciated until it is lost

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  • Peter Swinyard

    Thank you Dr Ruffle, for the erudite comment in Latin. I agree completely with your question.

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  • Allowing GP Practices to fail is not looking after the patients. NHS England does not know what it is talking about. NHSE or the CCG closed down my nearest GP practice which had a small list suitable perhaps for a single doctor, and they did the same thing closing down several small practices in North Brighton which served some isolated blocks of flats containing older folk with no cars and many infirm so would find it difficult or expensive to get to the next nearest practice. These closed practices did not wither and fail: they were closed down by NHSE or CCG because they did not try hard enough at getting replacement GPs. They asked local larger practices but offered no incentives such as money for an additional partner or nicer premises which might persuade the larger practice to take on one or more of these branch surgeries, and if they could not find any willing replacement GPs they should have asked in the EU, while we still have it, or further afield wherever GPs are well-trained.

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  • utter disgrace
    RESIGN!

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