Even at time when the pandemic was overwhelming the NHS, we saw close to three-figure practice closures. Awil Mohamoud reports
‘Shocking’ is the way one LMC leader sums up the closure of GP practices in their region during the Covid-19 outbreak.
‘The fact any practice has not been given sufficient support to stave off closure during the biggest health crisis in decades is a worrying indictment of how much commissioners and regulators value the role of the GP and the trusted place of the practice in the community,’ adds Londonwide LMCs deputy chief executive Dr Lisa Harrod-Rothwell.
In the past year since Covid-19 hit, practices have had to keep on top of remote working and to adapt to ensure their premises – and staff – are safe from infection. The pressure has been increased by the return of large numbers of patients who stayed away in the early months of the pandemic. GP leaders had predicted these added challenges would be reflected in practice closure figures for 2020 and called for pre-emptive action.
Pulse’s annual investigation has revealed 96 practices shut across the UK, a similar figure to last year. Any hope has gone that we might have reached saturation point and the high numbers of closures in recent years would mean fewer unstable practices were left.
The figures, obtained through freedom of information (FOI) requests to CCGs and health boards, show an estimated 263,000 patients, almost all in England, were forced to move surgeries.
The closures have been felt even more acutely by patients, and by neighbouring practices, because of the pandemic.
Why are practices still closing?
It seems lessons have not been learned by healthcare authorities. The reasons for closures remain the same as in previous years: mainly recruitment problems, singlehanders being unable to pass their contract down, the CQC removing practices and burnout.
Derby and Derbyshire LMC treasurer Dr Peter Holden says: ‘[There] are problems of succession, premises problems, or situations where a practice might have had too little investment for too long and is no longer viable, lists may be getting small, or people may retire.’
Practice closures might be commonplace now, but it must not be forgotten they are a relatively new occurrence. Dr Holden adds: ‘Handing back contracts is a phenomenon of the last five to seven years, and is usually driven by an inability to recruit and the workload issue.
‘Many practices are only two resignations away from collapse. This is what happens when the system is running at capacity all of the time.’
As the NHS, in England especially, moves towards larger-scale general practice, the pressures on smaller practices could become even greater. Premises issues may be a decisive factor for those that struggle.
In Kent, a singlehanded practice with a list size of almost 3,000 closed last year after struggling to meet CQC quality requirements. Kent LMC medical secretary Dr John Allingham says it had been operating from a converted house, and ‘struggled to fulfil modern standards’ because the site was not purpose built and was limited by its small size.
There are a number of similar practices across Kent and elsewhere, which Dr Allingham believes are unlikely to ‘continue in their current premises for another 10 years, as they’ll either build new premises or merge’.
Pandemic compounds concerns
Covid-19 hit a profession already struggling with these longstanding issues. There were some attempts to alleviate workload: in March 2020, NHS England assured practices that funding for QOF, DES and LES work would be protected for 2020/21 by paying them based on the previous year’s income.
But it did add other pressures, such as hot hubs, the move to remote working, the expanded flu programme and so on.
According to GP leaders, the real effect of the pandemic on practice closures wasn’t seen last year. Dr Holden says closures ‘are a concern at any time. Covid is merely another straw to break the camel’s back’.
But it may accelerate closures in the next year or so: ‘There are some who are approaching retirement saying we can’t go through another winter like this.’
What Covid has meant is that the dispersal of patients when practices have closed put even greater pressure on neighbouring practices when they could least handle it.
Dr Allingham said the closure in his area meant 3,000 patients were dispersed to five neighbouring practices. He says some of the practices near the one that closed ‘are under extreme pressure and facing deprivation and difficulty recruiting’, meaning ‘they were afraid picking up 400 or 500 patients would destabilise them’, which creates ‘the risk of the domino effect’.
Dr Harrod-Rothwell says practices on the edge of closing need more support, especially during the pandemic, such as ‘addressing unresourced transfers of work from elsewhere in the system’. She says improving working conditions in this way ‘would both reduce burnout and release capacity for patient care’.
PCNs yet to solve recruitment woes
NHS England had hoped primary care networks, set up across England in 2019, could tackle pressures that predate Covid.
When Pulse conducted its investigation into practice closures in 2019, NHS England said ‘the expansion of primary care networks’ was ensuring ‘greater availability of appointments’ and ‘support for constituent practices’.
One of the biggest pillars of PCN funding, the additional roles reimbursement scheme, is designed to help PCNs recruit more staff.
Yet Pulse revealed PCNs used less than half of the funding they were entitled to last year to recruit additional clinical staff, leaving CCGs with the surplus. GPs told Pulse they had encountered a shortage of suitable professionals.
Dr Rob Barnett, medical director of Liverpool LMC, says the additional roles initiative has done little for GP workload or recruitment.
‘It’s great saying there should be more first-contact physios, but there aren’t enough physios in the system, and it’s the same with paramedics and mental health practitioners. These people can’t be knitted.’
Mergers can offer hope
However, there is a glimmer of hope. Annual closures, while still high, have fallen from the 2018 peak and mergers can sometimes be better for patients than practices struggling to survive against the odds.
Dr Nigel Watson, chief executive of Wessex LMCs, says: ‘Over the last year or so, the practice closures that I have witnessed have seen a consolidation onto fewer sites. Over the last 30 years, the average size of practices has gradually got bigger, and that helps with resilience and providing a wider service to the population.’
A London GP, who wishes to remain anonymous, says their singlehanded practice closed its site last year after merging with a nearby practice. The practice, which had 2,000 patients, had neither the space nor staffing to provide a full range of services, meaning patients had to go elsewhere for some treatments The building itself had been ‘unsuitable for many years’, they add.
The GP says the merger has been ‘a very positive move’. The patients, who mostly followed, are happy at the new practice ‘where they can be offered extra staff such as pharmacists, musculoskeletal doctors, care navigators on site, and a whole range of practitioners in a multidisciplinary atmosphere – things that I just couldn’t provide’.
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Like when the toilet is shut and you have diarrhoea. That is what is here and coming. With added dysentery.