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Independents' Day

Small practices must not be the collateral damage of reform

Editor’s blog

We are at a crucial point for the future of the profession. NHS England has said the GP contract is set for its biggest reform since 2004.

Much of this will be determined by the review of the partnership model, which is set to make its recommendations later this year.

We held a round table on the review with a group of leading GPs, and one of the points that struck me was how almost everyone was in favour of practices networking, federating, merging and all the other ways they can work together.

The ‘upscaling’ of general practice had much support from the newly qualified GPs present, who said opportunities to work flexibly and to pursue special interests were far more likely to arise in bigger practices.

In the drive to upscale we need to ensure no practice is left behind

This will be music to NHS England’s ears. It has made no secret of its plans to promote upscaling, incentivising practices to work together with promises of funding and staff

There are definite merits to this approach. Increased resources have to be the priority (although the pitiful GP funding award suggests the new health secretary hasn’t yet grasped this).

But, as I argued last month, even proper increases to pay are not enough in themselves to attract the next generation of GPs. We need to make sure the model is one that appeals to them, and I am starting to believe that working in larger practices is attractive to many young GPs.

However, I still have major reservations, and these came to the fore in our explosive interview with NHS England’s director of primary care, Dr Arvind Madan. It seems he is happy for small practices to be collateral damage in the march towards big general practice. He believes there are ‘too many small practices’ struggling to meet patients’ needs, and that GPs should be ‘pleased’ that the ‘rationalisation’ of the market makes ‘the remainder more viable’.

Plenty of GPs have attacked Dr Madan’s reported comments for applying the principles of the free market to general practice, and with good reason.

But there is also a practical consideration. Because it seems obvious to me that general practice relies on small practices. Unless there are potential patient safety issues, we simply can’t afford any more practices closing right now. We only have to look at the impact of closures in towns like Brighton and Plymouth to see how disastrous they are – regardless of the size of the practice.

We’re nowhere near the point where these ‘upscaled’ practices can absorb the shock of closures for the local health economy. I can’t imagine anyone close to these practices being ‘pleased’ when they shut.

Ah, the argument goes, practices should be willing to transform to prevent closure. But many smaller practices don’t have this option due to local factors. Practices in Bridlington – another town in crisis – had funding for a promised new health centre pulled, plunging them deeper into trouble. And, of course, many are too stretched to have the headspace to attend discussions about upscaling.

There are real benefits to working together, but for any model to work we need to ensure no practice is left behind. And that means valuing small practices as a vital part of the fabric of the profession.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at





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Readers' comments (9)

  • Vinci Ho

    Call me a conspiracy theorist:
    (1) Small practices are to be starved to extinction if they do not comply with grouping together .
    (2) The GP networking is the preliminary step towards forming mega- and super-practices . The currently formed networks are to compete against each other in a region for a relatively small amount of funding thrown out by NHSE:Cash chucked onto the middle of a motorway.The stronger networks win .
    (3) Winner takes it all : eventually the stronger networks take over the smaller ones as the latter will cease to survive. The strongest networks then take over the stronger networks.
    (4) The dream of 20-30 super-practices in the whole country will be fulfilled, as long as this government continues to starve the overall funding for general practice.
    (5) Still remember the Trilemma Theory: integration , sovereignty and democracy; you can only have two out of three but never all three together .

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  • Brilliantly articulated Jaimie.

    We need to allow cross fertilisation between practices, whilst retaining personal lists and autonomy of the smaller practices.

    This is the USP pf general practice. It is heartbreaking to see this overlooked

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  • Cobblers

    I was the last single hander in my area when I closed in 2016. (Thanet if you ask)

    Big joined up groups are the way forward.

    Until that changes, as it will.

    And then individual care, continuity and flexibility bring back the small practices again.

    Only this cycle I don't think so. The 'interoperability' of the new generation of GPs makes the individuality of the smaller practices daunting and might well put them off.

    This might be the last knockings of GP?


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  • General Practice has been stabbed multiple time by many traitors to the cause lies bleeding out its life blood on the floor of NHSEs head office.There is no saving this onests not if its when it ceases to function.Once it is dead the whole NHSE, tearing on the edge will collapse much quicker than it is already doing.Its turning out to be a very, very long and cold winter.

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  • NHSE= load of just out of university with no relevant qualifications just ‘blue sky thinking’ on £80,000 a year.

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  • National Hopeless Service

    In my area all the small practices are fully functional, fully staffed and good places to work. All the large practices are disintegrating with domino effects of staff losses and potentially unaffordable locum costs.

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  • Brilliant editorial Jaimie

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  • explosive interview:We can all take words out of context and put them in quotes. 'How' 'many' 'people' 'did' 'you' 'sell' 'your' 'story' 'to' '?'

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  • thats good you have diplomatically expressed some of the sentiment from the gp comments. If you read between the lines its the usual nastiness of utilising a GP whose ambitions probably lie elsewhere whose comments we are supposedly to take on board. This time they are not two steps ahead of us and have been caught out for the creepy spin doctors that they are. Dishonest and even potentially corrupt in my opinion.

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