A major Pulse investigation reveals the reasons why some practices are forced to close and will never be replaced. Rachel Carter and Jaimie Kaffash report
Nine years ago, GP practices shutting for good was almost unheard of. A Pulse front cover warning about 60 potential closures was seen by many as an exaggeration. But today, closures are disturbingly common, with more than 800 since 2013.
This might not be news to many readers, as Pulse reports on the situation annually. While each practice closure may be a tragedy – for GPs and for patients – there are different types of closure. In some cases, a closure is really a transition to new ownership, or a takeover by a neighbouring practice.
However, the most devastating instances are where a surgery closes permanently, with no practice taking its place. For the first time, Pulse has done a major investigation into these ‘lost practices’. We found that at least 474 surgeries across the UK have folded with no replacement, with the impact felt by 1.5 million patients.
In some cases, these permanent closures have left patients traumatised as they say goodbye to a surgery that has served their community for decades. For others, access to GP services will have become significantly more challenging. And in all cases, neighbouring practices will have had to absorb the extra numbers.
Pulse has used dozens of datasets to dig deep into the reasons behind these closures. We have looked at the individual cases, finding out what the triggers were. But we have also looked at the wider picture, analysing what factors link these closures, and the role of funding, recruitment, deprivation and size.
The results are fascinating, and we will not allow them go to waste: we will highlight our findings with politicians, the NHS, the BMA and the RCGP and will report on the responses in coming months.
The triggers for closure
To define ‘permanent closures’, we looked into cases where there is no longer an active surgery in the same postcode. Of the 474 practices with no replacement surgery, we found 264 that had closed completely and 119 that had closed after a merger, while 91 were branch surgeries closed by a parent practice.
We identified the triggers in 162 instances of full practice closure, with staffing the most common by a distance (some 42% of all closures). In a fifth of all cases it was a retirement, in 8% resignation of a partner and in just over one in 10 an inability to recruit. We identified 30 cases of permanent closure as a result of an ‘inadequate’ rating and enforcement action from the CQC, while 37 were due to non-renewal of an APMS contract.
Dr Kaye Ward is a partner at Central Lakes Medical Group in Cumbria, which was forced to hand back its contract last month. The trigger was the decision by commissioners to remove annual atypical funding worth £70,000. ‘This funding helped keep us afloat,’ she says. ‘Its removal also made us more vulnerable if a GP left.’
And Central Lakes is not the only vulnerable practice in the area. ‘Around us, GPs tend to be over 50. Locally, age, retirements, illness have all been triggers for closures.’
Closure affects everyone, she says. ‘Patient feedback has been lovely. They’re anxious about what’ll replace us.’
Northumberland LMC medical secretary Dr Jane Lothian says: ‘I’ve seen practices tip over the edge for many reasons. Personal issues, political things that go back many, many years.’
These are just the final straws, however. In most cases, there were structural problems that often had little to do with the GPs running the practices. And Pulse’s analysis produced some interesting findings in this respect.
By far the biggest factor in permanent closures is size. Small businesses are often at greater risk than larger ones, though mergers have helped mitigate some closures. 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 some GPs say smaller practices can and should be viable – not least because they so often provide continuity of care and greater patient satisfaction.
Yet the failure to replace smaller 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. And some local commissioners seem to be explicitly stating that small practices aren’t viable (see examples below).
This move to larger healthcare premises 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.
Last month, five retired GP partners wrote to the clinical lead of the hub programme, Dr Charlotte Hart, with concerns about 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.’
Dr Evans points out that larger practices are not immune, however: ‘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 five years.’
• A CCG statement on the closure in 2019 of Leicester Road surgery in Coventry, which had 2,635 patients, said: ‘Leicester Road is one of our smallest contracts and we believe that the best use of our funding would be to support patients to find a different practice nearby.’
• Following the 2018 closure of 4,000-patient Woodrow Medical Centre in Redditch, the CCG reportedly said that ‘to be viable, a GP practice needs at least 6,000’. The CCG was unable to find a new provider so patients were directed to other practices, the closest 1.7 miles away.
• A CCG representative commenting on the 2020 closure of Brandon Estate practice in Southwark, south London, said its small list of around 3,000 made it ‘less financially viable and unlikely to interest a provider’.
• Dr Prabhakar Kusre – a singlehanded GP for 28 years in Milton Keynes – told the Milton Keynes Citizen local paper on his retirement in 2019: ‘I wanted to retire, but I didn’t want to see [the practice] close down. Unfortunately, things are different now, they don’t want small practices.’
Pulse’s analysis mapped the postcodes of 474 permanently closed practices against the deprivation index, and found a link between deprivation and closure, with the median deprivation score of permanently closed practices well below the median deprivation score of all UK practices. There is a longstanding issue in England that the funding formula for GP practices doesn’t give much weight to deprivation.
Fleetwood GP and former clinical chair of NHS Fylde and Wyre CCG in Lancashire Dr Adam Janjua says deprived areas are losing staff at ‘an alarming rate’. ‘I can only speak for Fleetwood, although it’s a nationwide problem, but in deprived areas you can’t attract them as well.’ He adds that it is more ‘labour intensive’ to manage patients who live in a deprived area, as they are likely to have a greater disease burden and require more frequent supervision and monitoring. This increases the number of appointments GPs and nurses need to offer.
Dr Janjua adds that a permanent closure in a deprived area that obliges patients to travel further to access a GP can worsen health inequalities. ‘The patients may not make the trip as often and so may not attend all their check-ups, which adds to funding pressure on a practice.’
• Gorton Street Practice in Blackpool closed when its only GP left in 2017. It was in the 16th most deprived postcode of 33,000 in England. The town was badly affected by recruitment problems, with poverty cited as a key issue.
• Two surgeries in Lowestoft, Suffolk, Oulton Medical Centre and its satellite branch of Marine Parade Surgery – which is in the 25th most deprived postcode in England – were closed in 2015 due to CQC concerns. Peter Byatt, a local councillor at the time, said ‘not enough’ was done to save them, adding: ‘These practices are in areas of Lowestoft that are very deprived, with many disabled, elderly and vulnerable people making use of these services. These people are now left in the lurch.’
Workload and staffing
GP workforce and workload problems are well known. The profession has lost 1,806 fully qualified FTE GPs since September 2015 and the latest major Pulse workload survey revealed GPs are still working an average 11-hour day, including eight hours of clinical care.
However, somewhat surprisingly, our new data show that in practices that permanently closed, the number of patients per GP was only slightly higher than the national average. There is a possibility that too many patients per GP would represent too much workload; whereas the opposite could mean very low income, both of which could lead to closure. More important was the number of GPs in those practices – the median was 1.5 FTE GPs, which is in keeping with smaller practices being at greater risk.
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 an alternative which is often to merge with another practice or disperse a list altogether.’
• A statement on the 2020 closure of Eagle Way surgery in Southend, Essex, reads: ‘The last five years have seen a huge increase in regulation and bureaucracy and huge increases in the workload involved in running two surgeries.’
• A singlehanded GP in Kent had decided to retire because they ‘could no longer cope with the demand of 12-hour shifts’. The GP said they had spent three years trying to make arrangements for the future of the surgery.
• In 2019, Eveswell Surgery in Newport, Wales – which had served its community for 70 years – closed after struggles recruiting. A local news article said the remaining two partners had been sharing the workload since 2017.
Pulse’s analysis found that more than two-thirds (69%) of 265 practices in England that we have full data for were receiving below the average funding per patient in the year before they closed.
Dr Janjua explains that in 2014, his practice merged with another after both experienced a loss in historical funding agreed under the primary care trust, which the CCG was unable to carry forward.
Dr Vautrey adds that finances ‘do play an important part’ and if practices haven’t had the necessary resources for a number of years this compounds their problems.
But he says that even with adequate finances, practices can still be struggling, especially with recruitment.
MPIG and contract types
The impact of other funding changes – specifically the withdrawal of ‘minimum practice income guarantee’ (MPIG) – is less clear. The MPIG was introduced in the 2004 contract to protect practices disadvantaged by the new funding formula. In 2014, the Government began phasing it out, claiming it would lead to fairer funding.
But Pulse found the MPIG wasn’t a major factor in permanent closures. We reviewed practices receiving MPIG in 2014/15, when phasing out began – 37% of practices received it that year. When we looked at the number of practices that permanently closed since 2014, 37% had received MPIG funding in 2014/15. This only slightly changed for more recent closures, when the effect of the funding withdrawal is more likely to be felt.
Medical accountant Andy Pow says: ‘A lot of the effect of MPIG withdrawal depended on solutions implemented locally.’ However, he adds: ‘The risk is how integrated care systems look at local funding… [if] they want to move it to PCN level, that will destabilise practice level funding.’
The proportion of closed practices in England that were GMS, APMS and PMS also broadly mirrored the national picture, although Pulse’s analysis did identify 37 examples where an expiring APMS contract had been the trigger.
• Central Lakes Medical Practice in Cumbria handed back its contract in August 2022 after commissioners withdrew £73,000 of atypical annual funding.
The geographical hotspots
We looked at areas where a permanent surgery closure meant patients had to travel much further to the nearest GP. Click here for the full UK map.
Milverton Surgery, Somerset
Milverton Surgery, a branch of the Lister House practice, closed in 2018. Local news reports at the time said the Somerset Partnership NHS Foundation Trust, which managed the practice, had applied to close the branch surgery because of difficulties recruiting GPs. The closure meant patients would have to make a six-mile round trip to see a GP. There had been a surgery in Milverton for 90 years.
Birch Surgery, Colchester, Essex
Birch Surgery, a branch of Winstree Medical Practice, closed in 2016. According to local reports, the closure was triggered by the lease expiring and the practice not having ‘the ownership structure to commit to the new lease on offer’. The closest alternative surgeries for patients were more than two miles away. The Daily Gazette later reported that plans to continue GP provision by holding sessions two days a week in the village school fell through after parents complained.
Gardenstown Surgery, Scotland
Gardenstown Surgery in Aberdeenshire was originally closed on a temporary basis in 2015 after two doctors left – one to take up a new role and the other to recover from an accident, according to the Scotsman. It was later closed permanently in 2016 as a result of a merger with Macduff Medical Practice, which is a 20-mile round trip from Gardenstown.
Beech Grove surgery, Brading, Isle of Wight
Beech Grove surgery closed after the wife-and-husband team said they could ‘no longer cope with rising demand and decreasing resources’, according to local reports. The list of around 4,500 patients was dispersed to other practices after the CCG was unable to find anyone to take on the surgery. The nearest primary care services are in Ryde (a 12-mile round trip), St Helens (a six-mile round trip), or Sandown (a three-mile round trip).
What does this mean?
Pulse’s investigation has made clear that practice size – and the number of GPs – is the most important factor in determining permanent closure, while per- patient funding and deprivation scores are also relevant.
But other factors – including patients per GP and whether the practice received MPIG funding – had far less influence than would have been expected.
Sadly, the likelihood is that there are a number of practices on the edge and in many cases, it only takes one trigger to tip them over. Often the retirement or resignation of a partner, burnout, poor decisions by commissioners or a perfect storm of factors is enough to create a community without a GP surgery.
In many areas, it is simply impossible to bring in new contract holders, however much effort commissioners and the outgoing GPs themselves put in.
And things aren’t improving. In August, Pulse reported that 22 practices in Northern Ireland on the brink of handing back their contracts were being looked after by a ‘crisis team’.
We hope our research will spur decision-makers to tackle the causes of practice closure, and their effects on GPs, patients and the wider community. Otherwise, many more people – especially those in deprived areas – are going to find it even harder to access general practice.
Additional reporting: Madeline Sherratt, Rhiannon Jenkins and David Burns