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Are CCGs turning their back on smaller practices?

Practice closures are a known problem policymakers say they are trying to avoid. But there are fears commissioners are reluctant to help smaller surgeries survive.

CCGs in three regions of England have recently been accused of failing to assist practices serving around 3,000 patients or fewer.

Last year, NHS England’s former primary care director Dr Arvind Madan suggested GPs should be ‘pleased’ to see small practices closing – and new primary care networks serving 30,000-50,000 patients have been prioritised in the GP contract.

Pulse’s investigation of practice closures in 2018 revealed that in 54 of the 98 cases for which we had patient data, the practices had 3,000 patients or fewer. In Lancashire and in two areas of London, smaller practices have recently had to close, with the finger pointed at CCGs for allowing this to happen (see box below).

‘I don’t think CCGs are willing to pay the extra needed to keep small practices open’

Peter Higgins

GPs believe the lack of support these practices receive from CCGs is due to a perception that their longer-term prospects do not justify the extra expenditure required.

Lancashire and Cumbria LMCs chief executive Peter Higgins says: ‘I don’t think CCGs have truly addressed the atypical nature of these small practices. They begrudge paying more money to them than your average practice costs.

‘I think CCGs just see the bottom line and see this practice is costing £X per patient when the average is lower.’

Mr Higgins says more money is required for smaller practices due to their often being singlehanded: ‘If that GP goes sick or goes on holiday, it’s a fragile situation. I don’t think CCGs are willing to pay the extra needed to keep these small practices open.’ 

Dr Nicholas Grundy, chair of grassroots campaign group GP Survival, notes that the recruitment crisis is making smaller practices even more vulnerable: ‘A small practice with two partners where one of them goes and can’t be replaced is more likely to close as the remaining GP is going to carry more of the weight.’

PCNs are now being touted as the way to make smaller practices sustainable.

BMA GP Committee executive team member Dr Krishna Kasaraneni says small practices ‘often provide higher levels of care and have strong bonds with patients’. He adds: ‘PCNs should offer them the opportunity to work with others around them collaboratively without being forced to join larger organisations.’

But the introduction of networks is no excuse for CCGs to wash their hands of the matter, he says: ‘With surgery closures reaching a record high last year, it is also important for commissioners to work with LMCs to support struggling practices and help them stay open.’

CCGs failing to help small practices

NHS Haringey CCG

Practice Myddleton Road Surgery Patient list size 3,100

Has the CCG failed to prevent closure? The north London practice is set to close after its singlehanded GP died and NHS Haringey CCG failed to have the new contract ready for the GP who was set to take over. It meant the contract had to be terminated in line with national regulations.

What the CCG said ‘In the months leading up to Dr Prasad’s death, NHS Haringey CCG had been discussing and supporting the practice’s plans to merge with two other practices and to relocate to a new building.

‘Following the committee’s decision on 20 June [to approve a replacement GP], the next stage is to amend the contract and get it signed by the contract holder (Dr Prasad). Very sadly, he passed away on 28 June before this could be completed.’


NHS City and Hackney CCG

Practice Abney House Medical Centre Patient list size 2,700

Has the CCG failed to prevent closure? The GP principal at this east London practice handed in his resignation over the summer because, he said, NHS City and Hackney CCG was unable to provide staff cover while sending him to attend ‘silly’ meetings that had no benefits for his patients.

What the CCG said ‘Although the CCG and the local GP confederation has provided assistance and support to Dr Salih, he has been unable to resolve a number of staffing and premises issues which has resulted in the centre permanently closing on 20th October.

‘Following a review, we concluded that the current patient list was too small to advertise for a new provider and due to the premises lease expiring, this was unfortunately not an option anyway.’


NHS East Lancashire CCG

Practice Slaidburn Country Practice Patient list size 1,100

Has the CCG failed to prevent closure? The CCG has been accused by the LMC of being ‘unwilling’ to fully pay for the costs of keeping this rural practice open. The LMC said a GP-led out-of-hours service running the practice had been forced to hand back the contract after subsidising the service out of its own pocket for some years. The local GPs said bidding for the new APMS contract is at a ‘much lower contract value’ than what is currently paid and has an ‘impossibly short deadline’.

What the CCG said ‘No one wishes to see the loss of a much-valued GP service, and we are working hard to ensure this doesn’t happen. We do see this as an opportunity to be innovative and provide a service that not only ensures continuity but meets the health needs of local people.’