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NICE damages its credibility with statins ruling

...Small practices are the future of quality care

Dr Dinah Roy, who left a group practice to become a singlehanded GP, explains why she thinks small is beautiful

I returned from a recent break to read in The Times that the Government is going to close me down1. 'Surgeries based around one or two doctors serving a local community are likely to be phased out in favour of super-surgeries and group practices of at least 10 doctors', the story said. Charming.

Thankfully, a statement from the Department of Health on the Small Practices Association website9 puts the record straight.

'We have no plans to scrap small family doctors, this is complete rubbish and is not Government policy.'

No need to start reading the careers section just yet, then.

But this isn't the first time I've read my days are numbered. A couple of years ago Tony Blair said: 'There has been a move over time away from singlehanded practices so as to improve the quality of care that people receive. That has been based on a great deal of evidence over a long time2.'

This blow was subsequently softened by a statement in NHS Magazine where Blair said: 'I don't believe any one practice model has a monopoly on quality of care. The importance of the personal aspects of care must not be underestimated ­ something that singlehanded practices are often very strong on.'

But why does the issue of singlehanded GPs keep coming up? We currently have 2,800 singlehanded practices in England, more than one in three practices4. And if you really want to improve care and morale then small practices are the way forward ­ not back.

I have worked in my current practice for 11 years, first as a singlehander and now as one of three (total 1.2 FTE). I came from a partnership of seven, where I had been unhappy and could no longer face working with other GPs. The group practice experience had left me feeling isolated, lonely and, quite honestly, a failure.

Colleagues and friends thought I was mad to go it alone. But I needed to prove something to myself. I needed to create a good practice.

I immediately felt part of a team in my new practice, where I took over from a retiring GP. I got to know patients very quickly and had a much more intense relationship with them than I had previously experienced. Now, I was dealing with many different conditions ­ not just 'women's problems'.

Clinical care is just as good

The practice was the first singlehanded practice in England to achieve the RCGP Quality Practice Award in 2000, and we achieved the maximum 1,050 points in the QOF.

And the evidence clearly suggests my small practice is not the exception in delivering such high-quality care.

New contract architect Professor Martin Roland in his observational study assessing variation in the quality of care in 60 randomly sampled general practices, to identify factors associated with high-quality care5, said that no single type of practice could claim a monopoly over high-quality care, and access to care was better in small practices.

Majeed's cross-sectional study of practices in Battersea Primary Care Group6, comparing methods of identifying patients with ischaemic heart disease, showed there was no association between practice size and quality of care.

Indeed, evidence given to the Shipman Inquiry8 suggested there was a greater degree of accountability and responsibility for patient care in a singlehanded practice: 'The doctor is individually responsible for the care of every patient and cannot pass on responsibility to anyone else8.'

We've already shown in year one of the QOF that we can quash the economies of scale argument by proving small practices can work together to deliver services.

Continuity of care is obviously much better in a singlehanded practice and this factor, along with accessibility, are the reasons why small practices have such high patient satisfaction rates. Many studies have shown patient satisfaction to be the major advantage of the small practice mode · 7, 8, 10.

The best critique of the advantages and disadvantages of singlehanded practice that I have read is chapter 13 of the fifth report of the Shipman Inquiry8. Following a review of literature published over the last 10 years, Dame Janet Smith, chair of the inquiry, concludes: 'Singlehanded practices vary in much the same way as do group practices. Some of each are good, bad or indifferent.

'Certainly, group practices do not have a monopoly on high-quality patient care. It seems to me that the policy of the DoH and of PCTs should be to focus on the resolution of the problems inherent in singlehanded or small practices rather than to try to reduce the numbers of them in existence.'

And, importantly, she adds: 'I do not think the fact that Shipman was a singlehanded practitioner should be used as a reason for preventing GPs from practising alone.'

The challenge to us all is to acknowledge the benefits offered by both models of practice at their best, and in particular that large practices have something to learn from us small-world colleagues: personalised, continuous care, accessible to patients with the patient perspective valued before organisational considerations, strong infrastructure and systematic, organised care10 ­ giving the best results for patients and practitioners.


1 The Times, March 28, 2005

2 Hansard July 3, 2002, Column 219

3 NHS magazine, February 2003

4 BMA website December2004. General practitioners ­ singlehanded GP practices

5 Roland M et al (2001). Identifying predictors of high-quality care in English general practice: observational study. BMJ, Vol 323: p 784

6 Majeed A et al (2003). Association between practice size and quality of care of patients with ischaemic heart disease: cross-sectional study, BMJ, Vol 326: p 371

7 Baker R and Streatfield J (1995).

What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction, British Journal of General Practice, Vol 45: p 654

8 Shipman Inquiry: Fifth report (2005)

9 Department of Health statement, Small Practices Association website

10 Pieter van den Hombergh et al.

Family Practice, February 2005,

vol. 22, no. 1, pp. 20-7(8)

Dinah Roy is a GP in

Sedgefield and PEC chair

of Sedgefield PCT

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