How list size and staffing impact practice closures

The biggest factor in determining the permanent closure of a GP practice is size, a major investigation by Pulse into practice closures has revealed.

Our Lost Practices investigation, which looked at the reasons behind the closure of around 470 practice and branch surgeries in the past nine years, found the median list size of those that closed was 2,738. This compared to a median list size of 6,279 for all open practices in 2014-15.

The straightforward explanation for this is that smaller businesses are often at greater risk than larger ones, which is the case in most sectors, and it is true practice mergers have helped some practices to stay open. But some GPs say that smaller practices can and should be viable in their own right – not least because they so often provide continuity of care and greater patient satisfaction.  

Yet the failure to replace small practices may be a de facto national policy. When Dr Arvind Madan resigned from his position as NHS England’s director of primary care in 2018 over his comments that there were ‘too many small practices’ struggling to meet patient demand, NHS England was insistent that his comments were not a reflection of wider policy.

But federations, super practices and primary care networks all focus on GPs working at greater scale, with smaller organisations subsumed into larger ones.  

This move to larger healthcare providers is happening in Shrewsbury. There are controversial plans to move six small practices with a combined 40,000 patients into a single location – while retaining their individual identities. The proposal has sparked two protests so far – with patients concerned about having to travel further, maintaining contact with their regular GP, and the loss of what they consider to be their local practice, according to reports in the Shropshire Star.  

Last month, five retired GP partners also wrote to the clinical lead of the hub programme, Dr Charlotte Hart, with concerns around the new centre. They said: ‘As regards the Hub, it is self-evident it is going to be huge to cope with 40,000+ patients. The waiting room alone will be airport lounge size, never mind the car park with on some days up to 2,000 visits… not everyone has access to a motor vehicle during the working day. Lack of transport links are obvious.’

Dr Hart replied: ‘You seem to imply a large building is a bad thing but I’m not sure why. The architects propose a building that is light and spacious and easy to navigate.’

Gateshead and South Tyneside LMC chair Dr Paul Evans says: ‘In a singlehanded practice, when one goes, that is it, the contract has to be handed back.’ But he points out that smaller practices are not alone in struggling: ‘In our patch, there’s a practice of about 12.5k that is struggling to recruit and the partners are working extremely long hours, and one of about 7.5k that’s gone from four partners to one in the space of five years.’

He adds: ‘I think if small practices have a future, then they do need – in urban areas at least – to collaborate with neighbours on projects of mutual interest. But I don’t think that should mean they can’t be independent – I think there should be viability to smaller practices.

‘There is evidence that small practices tend to offer better continuity and we know that continuity is associated with fewer admissions, better results on morbidity and mortality, and importantly patient satisfaction. A big theme of super practices is you never get to see the same doctor twice – if it’s a single-hander then by definition a patient will see the same doctor every time…’

Workload and staffing

It will come as no surprise that workforce and workload problems play a part in closures. The profession has lost 1,806 fully qualified FTE GPs since September 2015. There are less staff to do the job – and for those that remain, the pressures are increasing all the time, with closures themselves adding more workload where neighbouring practices must absorb the extra patients.

This was highlighted in the closure of Victoria Medical Centre in Bridgewater, Somerset, last year, which was forced to shut due to ongoing clinical staffing shortages. Commissioners had spent 12 months trying to find a solution. Commenting on the closure local MP Ian Liddell-Grainger said transferring patients to other health centres would only ‘add intolerably to the pressures their staff are currently working under’ and that this could only be a ‘stop-gap solution’.

Somewhat surprisingly our investigation found that in practices that permanently closed the number of patients per GP was only slightly higher than the national average. But more important were the GP numbers – the median was 1.5 FTE GPs, which is also in keeping with smaller practices being at risk.

GPs leaders said all practices have intense workloads but those with fewer GPs are less likely to withstand the loss of a GP through burnout or any other reason.

Dr Richard Vautrey, former chair of the BMA GP Committee, says: ‘Practices get to the point where they are not able to recruit, fewer GPs are left seeing more patients and that places them in an impossible situation, leaving them to look for alternatives which is often to merge with another practice or disperse a list altogether.

Dr Evans adds: ‘There’s a point when everyone has to ask the question can I keep doing what I’m doing…do I need to cut down my sessions if there is a concern that the job may actually literally kill me? We know that the hours and the stress are not necessarily conducive to good health.

‘I know plenty of GP partners whose typical working day is 12-14 hours and many of these are people of my age or a little bit older or younger who can’t retire now. But we would all be daft to not at least be taking a look at the alternatives for that day when we can’t keep going.’