‘We were highly profitable, it was a very good functioning partnership. We had 18,500 patients in a seaside area with an elderly population,’ says Dr Eamonn Jessup, a former partner in Prestatyn, North Wales.
‘The problem was, four out of nine partners hit retirement age at the same time. One went ill, so he had to retire. And then I thought “I’m going to be 62, do I really want to have responsibility for 4,500 patients on my head?” So we all decided to give our notice.’
A mere six years ago, experiences like Dr Jessop’s of a practice closing were considered aberrations. But since 2013, the landscape of general practice has changed immensely, with practices now closing in their hundreds.
Last year, the numbers of closures appeared to be slowing. It seemed we had reached rock bottom – the vulnerable practices had closed, with a hope that those remaining would be more secure as a result.
The system is creaking. The smaller practices are being lost
Dr Jackie Applebee
However, a Pulse investigation has shown that assumption was premature. In 2018, almost 140 surgeries closed their doors, estimated to affect a record half a million patients – more closures than in any previous year and almost eight times the number seen in 2013. In the first month of 2019, there had already been 12 more closures, compared with eight at the same time the year before.
And this came despite official attempts to address the problem. In 2015, NHS England set up funding for vulnerable practices, which later became its ‘resilience fund’. Equally, the other UK nations brought in their own versions of emergency funding to stem the closures.
Yet Pulse’s figures reveal those measures have not worked. Tower Hamlets LMC chair Dr Jackie Applebee says: ‘The system is creaking. The smaller practices – which patients prefer and which have good outcomes – are being lost because of the under-resourcing.’
The move to larger groupings of practices, favoured by health secretary Matt Hancock and mandated by the new five-year GP contract, may be the last throw of the dice. By last month, practices in England had to sign up to primary care networks, serving between 30,000 and 50,000 patients – groupings NHS England expects to promote ‘resilience’.
NHS England guidance on networks states: ‘They should be small enough to maintain the traditional strengths of general practice but large enough to provide resilience and support the development of integrated care.’
The profession cannot afford for this to fail. Practice closures are often a last resort to deal with mounting pressures of workload and demand. They have been on the rise – and it is getting worse.
In the five-year period from 2013 to 2017, there were 445 surgery closures across the UK, including full practice closures, branch closures and surgery mergers, affecting some 1.4 million patients.
The latest figures obtained by Pulse through freedom of information requests show 138 UK practices shut in 2018. This led to 519,500 UK patients being relocated last year – many of whom needed to be picked up by other hard-pressed practices.
Many of the problems stem from the recruitment crisis. While demand continues to increase, there are declining numbers of GPs available to meet it, with the most recent NHS Digital figures showing there are 1,180 fewer full-time-equivalent GPs than three years ago.
There are many reasons for this. Older GPs are more likely to retire early, with the threat of the pensions contribution tax charge adding to this trend, while younger GPs are more likely to work less than full time or choose to work abroad.
Whatever the reasons, staffing problems lead to unmanageable workload for GPs who work a full-time shift, as recently exposed by Pulse’s snapshot workload survey, which revealed an average 11-hour day, and GPs dealing with an unsafe number of patients.
GP leaders warn the problems are causing a cycle of disadvantage, trapping some practices in a position where they are unappealing to potential recruits.
Liverpool LMC secretary Dr Rob Barnett says: ‘There is a self-fulfilling prophecy: if practices are struggling and people are stressed and overworked, who wants to go and work there?’
For partners in this situation, who can see no solution to unsustainable workload, closure can be their only recourse.
Dr Rob Mockett, who was a GP partner in Brighton, says: ‘My surgery closed in March 2015, because of the workload – we were doing 10 sessions a week and out-of-hours work. The money wasn’t enough and it wasn’t a financially viable practice. We had taken on staff to do all the QOF work and then they cut the money to the practice.
‘It was a Regency house practice and we owned it. It needed £120,000 worth of work to the waiting room floor, and there was no help with that. My partner and I were both pretty much burned out so I decided to retire early at 55 and my partner decided to do the same.’
Such closures have an effect on the practices around them. Dr James Boorer, a GP in Plymouth – where there has been a spate of closures – says: ‘We are a multisite practice covering 32,000 patients and serving some of the most deprived sections of Plymouth.
‘We’ve seen many adjoining practices hand back their contracts – 58,000 patients have been affected, 15,000 of whom have been dispersed, while 34,000 have been taken on by an interim provider. The future of the remaining 9,000 is still to be confirmed. The pattern of these handbacks is intimately linked with deprivation.
The pattern of these handbacks is intimately linked with deprivation
Dr James Boorer
‘Fortunately, we have an excellent and supportive team, dedicated to delivering excellent care to our patients despite the funding constraints. But there is no denying it can be hard at times.’
It does seem smaller practices are bearing the brunt of the pressures.
Pulse’s analysis shows almost nine out of 10 practices (86%) that closed last year – and had their practice lists dispersed – served fewer than 5,000 patients.
The decline in the number of smaller practices could partly be the result of a bias towards larger practices from policymakers, certainly in England.
In an interview last year, Pulse revealed NHS England’s then director of primary care Dr Arvind Madan had suggested GPs should be ‘pleased’ when small practices close as there are ‘too many small practices struggling to do everything patients want for their families in a modern era of general practice’.
On top of this, Pulse later found the smallest practices in England – those serving fewer than 3,000 patients – were least likely to receive funding from the NHS General Practice Resilience Programme in 2016/17, despite accounting for the majority of closures.
But Dr Barnett says there is still vulnerability: ‘Smaller practices may lack the resilience of some larger practices in terms of the number of people who work in them and are able to take up some of the slack. I think there’s safety in numbers.’
And safety in numbers reflects the thinking behind the new drive to form primary care networks from NHS England and the BMA.
They point out that in the financial year of 2017/18, there were fewer closures than the year before according to NHS Digital figures – although these do include mergers where no surgery has been shut.
A spokesperson said: ‘We continue to support all general practices to help them thrive. Thousands of practices continue to be helped through the GP resilience programme, where investment has been increased from a planned £8m in 2019/20 to £13m.’
These networks may address some of the pressures behind closures
Dr Richard Vautrey
The BMA says PCNs will stem the number of closures, by ‘reducing the need for formal mergers, and addressing some of the pressures’.
The networks are intended to provide a new pooled workforce of allied health professionals, allow GPs to share back-office functions and offer a streamlined route to coordinate with secondary care services.
BMA GP Committee chair Dr Richard Vautrey says: ‘As with all those that have had a challenging time in recent years, we hope smaller practices will receive greater mutual support from others with the development of the new networks.
‘These networks, built on top of existing contracts, mean practices can support one another with workforce and resources, which may reduce the need for formal mergers, and address some of the pressures behind closures.’
Yet GPs are worried the proposals won’t be enough to reduce the number of closures. There are concerns the extra money available in the contract – which includes £1.50 per patient from CCGs – will not fully materialise.
Dr Applebee says: ‘Primary care networks certainly won’t save general practice. We’ve been told there’s all this extra money coming in but the CCGs have to find the £1.50 per patient from their budgets. They haven’t budgeted for that and didn’t know this was happening until January of this year.’
In addition, the process of setting up networks is time consuming, only adding to the pressure in the short term.
Dr Applebee adds: ‘There’s so much work going into setting up primary care networks, it’s taking people away from the day job, away from seeing patients as we set up yet another structure.
‘I think that at best it will make things stand still but at worst it’s just a whole new layer, a whole new reorganisation, which is taking people’s eye off actually being able to sit and see patients.’
Others agree the networks will cause ‘additional strain’. Dr Barnett says the requirement in the new Network DES for surgeries to offer extended hours in exchange for funding is a problem.
Adding one pharmacist to a population of 50,000 patients is a drop in the ocean
Dr Rob Barnett
He says: ‘If the workforce is already stretched in relation to the in-hours contract, we’re going to stretch it even more and I’m worried that will pose additional strain on the system. It’s almost as if one good initiative is counterbalanced with something that hasn’t been properly thought through.’
Dr Barnett also warns the promised new workforce of 22,000 practice staff for networks will not ease the problems.
He says: ‘Adding one pharmacist or a paramedic to a population of 50,000 patients is a drop in the ocean and that’s not going to prevent practices closing.’
Dr Boorer adds: ‘We are not convinced the new GP contract will deliver on its promises as it discriminates against practices like ours that have already invested in a diversified workforce. I think the contract will only serve to further widen health inequality issues.’
In the past, practices have been able to temporarily shut their lists to new patients if they are unable to take them on.
But it appears an increasing number are unable to do this. An FOI request Pulse sent to NHS England last year showed 106 GP practices temporarily closed lists to new patients in 2017/18, compared with 145 in 2016/17 and 175 in 2015/16.
Many practices have had to turn to mergers to survive. Pulse’s FOI figures show 31 of the 138 surgery closures in 2018 came as a result of mergers, affecting an estimated 161,126 patients.
But GP Survival chair Dr Alan Woodall warns: ‘I think the merger of practices is a sticking-plaster solution. A lot of them are simply covers to close branches.’
For Dr Hazel Drury, following the closure of her own North Wales practice, resilience has been found through joining a larger practice – through necessity, not choice (see case study, below).
She says: ‘I’m in a surgery that is five miles away from my old practice. Because of closures of all the practices around us, it’s like everyone jumped onto the one ship that’s actually still floating.’
‘I did my best but it was too much’
dr hazel drury unp
My practice closed in 2016 because of recruitment issues and lack of funding and I couldn’t afford locums either.
I was ill and the health board sent me a breach of contract notice when I was in hospital because we struggled to get locums. We tried to provide services – I was sending scripts from the hospital bed. I did my best but it was too much.
Then I said, I’ll give it up. It was my decision but it was the final nail in the coffin.
I’m now in another surgery five miles from my old practice. My former patients have had to join a local health board-run practice and I think their services are being cut. They don’t get as much doctor time now and have to see a nurse or physiotherapists instead of GPs.
When I first came to the new surgery, we had recruiting problems as well but after a year we became fully doctored. Because of other closures of all the practices around us, it’s like everyone jumped onto the one ship that’s actually still floating and not sinking.
We recruited another GP from another practice that has closed and then we were ok. Because of smaller practices closing, the large practice I am part of has done a lot better.
I cannot see any changes to general practice in Wales with the Welsh contract. There’s a massive recruiting problem: I was in a deprived area and think there’s not enough people coming to Wales unfortunately.
Dr Hazel Drury, was a GP partner at a 2,000-patient practice in North Wales for 13 years. She is now a partner at a neighbouring surgery.