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We are gathered here today to mourn the death of small business

Dr Sarah Merrifield

Once upon a time there was a village. Its residents consisted of a small, consistent group who lived harmoniously as a community. Life circulated around the village centre. The greengrocer, butcher and fishmonger were well known figures to all who lived there. The butcher knew exactly how Mrs Jones from Number 22 liked her meat prepared. The greengrocer had her carrots ready for her to collect them every Thursday at 5 o’clock as she walked home from her weekly trip to the library.

Another well respected member of the community was Dr Past, the village GP. Known to all its residents he had seen families through births and deaths. Villagers knew who to call if they had an overnight emergency but were keen not to bother Dr Past unless they really needed to. A strong sense of community support and family care carried the residents through.

Sounds great doesn’t it? But sadly, a great departure from modern life. Gone are the greengrocers and butchers, replaced by sprawling superstores with high turnover employees and low priced, mass produced goods. The modern community is also vastly different. Communication and infrastructure mean residents move year on year, often with long distance family connections.

So whilst the concept of the local village GP is a great one it cannot, alas, continue in the same small business fashion. Doctors and receptionists come and go in an era where information and products can be bought and sold in an instant. Many newly qualified GPs favour the flexibility of locum or salaried posts, shunning longer-term partnerships.

I’m not saying this a good thing. As a young’un I bought into this world, observing the contribution a family doctor can give to a community. I feel saddened that the environment I now work in will be vastly different. But reminiscing will not change the reality.

As more and more businesses have to work at scale, so must we. Yes, it’s not the way it used to be, but if we do not embrace it we will be left behind. We need to find ways to make general practice work in a larger business model whilst still providing personalised care. I don’t claim to know how this will work but collaborative working would be a good start. Single handed practices are dropping off left, right and centre. Let’s at least try and work at scale the way that we want to. If we don’t I have no doubt that Virgin and Tesco will do it for us.

Modern times aren’t all bad. We have more treatments and technology now than ever before and the population are living longer and longer.

But no matter how much technology advances and businesses mass produce there is one thing that will never change. People will always need clinicians to care for them. An avoidance of change is letting ourselves and our patients down.

Dr Sarah Merrifield is a GP leadership fellow in Yorkshire

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Readers' comments (9)

  • I do not see how a large GP Federation/PLC will be able to deliver personalised care. Just take a look at any large organisation, whether that is a supermarket chain or any other large body. Do any of them deliver personalised care/service? Of course patients will adapt as they have done with other large bodies. Without personalised knowledge of patients there will be huge extra cost due to over investigation. And of course patients will not like it. There is a big difference between receiving service from a local butcher or fishmonger and receiving care from a local family GP. As a result there will be a reasonably large market for private personalised healthcare for those that can afford it. As far as I am aware there is no country in the world that has healthcare delivered to anybody by anybody with no patient choice. This includes private and state controlled healthcare. In countries without or little general practice patients develop close relationships with secondary care doctors. Just look at the number of our patients who say they cannot get an appointment with us, but when you analyse this it is normally about getting an appointment with a specific GP or nurse that they like and trust.

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  • GP Federations with multiple part-time assistants/locums cannot offer "personalised continuity care"as in the past.Young GP's seem to favour the "flexibility"offered in these circumstances.Different expectations are needed for these Models of Care.Private General Practice will have an increasing role.Society will need to adapt.

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  • Cobblers

    "but if we do not embrace it we will be left behind"

    I am an oldie. How many many times have I heard that mantra above?

    Pray left behind what?

    There are patient benefits such as more on site services but the massive impersonal juggernaut it is rolls over the patient. No continuity. Take it or leave it. Feck off if you don't like it.

    There are alternatives. You mention one. Independent doctoring with or without self arranged groups.

    As this Primary Care Home (seriously?) concept takes off there will be an increasing market for the smaller independants.

    Do you wish to run with the sheep or the wolves?

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  • Sarah - I'm afraid I have to disagree with a lot of what you say.

    Firstly, my experience of a recent Trainee Conference I delivered in Bristol, shows that trainees value continuity as much as their predecessors. They were not at all impressed with working at scale and had grave reservations about other HCPs performing bits of our role.

    Secondly, and without wishing to sound patronising, it is only through experience you realise the immense significance of continuity of care.

    It prevents over-referral, over-diagnosis, over-treatment and SAVES LIVES. And if you are interested in evidence - Sir Denis Pereira Gray has produced lots of research papers on it.

    The small business model has provided amazing care for so many years. Of course we need to constantly improve it, but getting rid of it and replacing it with a mass Tesco is definitely not the answer.

    The very essence of general practice depends on our knowledge of patients, their families and their communities. Put us on a supermarket conveyer belt and you may as well start planning a funeral for the profession.

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  • AlanAlmond

    Theres nothing modern, new, now or fresh about 'working at scale' it's just an overused cliche...Stalin was very keen on centralised working at scale, it's known as Stalinism and is generally agree to have been a complete failure. Fetishising anything that's cynically been dressed up as 'new' is limp beyond belief. enormous all powerful individual crushing corporations aren't sexy and they aren't new...they are as old as the hills and steam roll you unless you conform ..I'm really sorry but this analysis is riddled with superficial 'copy and paste' cliched crap - lifted straight from someone else's stereotyped view of a past that never existed. Sorry to be harsh but this kind of thing gets my goat. Use your brain,come up with something original and stop regurgitating other people's sound bites.

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  • Ouch. I will not regurgitate the opinions expressed in reply to the article because they are clear and on-point.

    I would however like to state that the merits of the 'small business model', certainly as I experience it most days, and the issue of continuity of care is not all roses as has been suggested. Care, and its continuity, in my opinion, requires one to take the time to read the notes, look at investigations and hospital correspondence and then apply ones thinking faculties. This does undoubtedly take time, a commodity which is not in over-supply, but in this game one cannot defend oneself from the hazards which come from not practising thus. Getting away with it for 99% of the time will provide little solace when the crud hits the rotating device attached to the ceiling when ones failure to work in such a fashion catches up with you.

    One day this week I have come across 3 instances where a failure to work in the way outlined has made my working day longer, more stressful and seething with a degree of resentment towards my colleagues whose slap-dash approach presents me with the quandary of either 1.rectifying the issues with the resultant prolongation of my day and increase in stress levels, or 2.ignore the issues and becoming complicit. Without going into too much detail this involves a non-existent HbA1C result in someone who was pre-diabetic 18 months ago marked as 'Normal' with no moves made to get the test done,a cirrhotic with an iron deficiency anemia and signs of portal hypertension on U/S and no history of OGD being told to eat more protein to correct the low albumin and no thought to the issue of varices as the cause of the anemia, and lastly a cardiology opinion asking for a number of fully appropriate tests on a letter which was marked, and treated as, 'No action required'.

    This is the small business model at its finest and I can only see working to scale making such shoddiness more prevalent presenting those with a degree of diligence such quandaries of complicity or conscious dismissal, or the increased stress-levels which are already pretty unbearable.

    I don't have the answers but the above is not in any way hyperbole, and is something which plagues my work more days than not.Rant over-for now.

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  • Cobblers

    Idon'tgiveaF*** (IDGAF) there are holes in all models of doing medicine. A poorly performing doctor is poorly performing whatever business mode he is in.

    Surely the option here is choice? I may want the small business model where the GP has known me since birth and can recall my problems with minimal effort. Or I may want the more slick, more choice, less travel options (more in house investigations and clinics) of the MegaDoc down the road.

    Now the small surgeries are actively being exterminated. Mine being but one last year.

    The mantra is one size (large) fits all.

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  • Just Your Average Joe

    The police were slowly whittled down, getting rid of those with experience and replacing with cheaper new officers at first then the Plastic police community support officers. The tide pushed and numbers went from cut to wholesale slaughter.

    Now everyone turned around this last few months wondering were all the police officers have gone.

    You don't value something until it is lost, and once lost it is near impossible to return to.

    Stop the slaughter of GP partnerships and the slow APMSisation or privatisation of primary care, with its new staffing via salaried or locum colleagues.

    Yes they are voting with their feet to take on these roles, but its because the partners are left holding the responsibility and overflow of work and it is a bitter pill to swallow, harder as the numbers start to dwindle.

    BMA leaders force a return of the basic practice allowance and return of GMS contracts as standard with a refusal to co-operate on all commissioning unless they renege on the privatisation agenda.

    We can work to rule and the whole NHS would come to a grinding halt forcing U-turn May and the DOH to swallow the crap they have been trying to feed GPs and avoid a melt down to the NHS.

    We have the power - just be brave enough to challenge the changes.

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  • David Banner

    - The over 50s are merely clinging on until their financial advisers give them the nod to retire (and the twin torpedoes of defence subs and revalidation means they ain't coming back,not even part time
    - The under 40s (quite rightly) won't touch partnerships with a barge pole.
    - Those poor souls between 40-50 trapped in failing partnerships are herding into Federations because a drowning man clutches at a serpent. It delays the horror of unlimited liability, redundancy payments and bankruptcy for a few years, But that 25 year lease isn't going anywhere.........

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