Behind its Regency façade Brighton has some familiar problems including pockets of deprivation, a transient population and issues with drink and drugs.
Keeping 270,000 residents in good health is challenging enough in normal times but the closure of nine GP surgeries in little over three years has increased the pressure.
Talk locally suggests there could soon be a tenth closure. Brighton and Hove CCG said that it was actively working to sustain existing practices even as it accepts the inevitability of further changes.
In its draft primary care strategy, the CCG said: ‘Many of our practices are struggling with a range of challenges and some can be considered to be particularly vulnerable.’
‘I can see the workload’s gone through the roof. It’s much harder work than it used to be’
Dr Rob Mockett
Each closure brings headaches for surgeries nearby. List sizes locally have risen from an average of 6,900 to 8,700, and there have been cases of patient records going missing when they are transferring between surgeries.
When an entire list is transferred to another practice but some patients opt out of the switch, they often register elsewhere. If they delay, problems may arise.
Dr Manas Sikdar, senior partner at Albion Street Surgery, urged those patients to register somewhere, saying: ‘If you don’t remain registered, then your electronic records disappear.’
Meanwhile, GPs are moving abroad, adding to the many opting to retire. And often those choices are down to a mix of the growing workload coupled with a simple financial calculation.
Dr Rob Mockett was one of those who made that calculation, retiring three years ago at 55. His fellow partner Dr Malcolm Stalker retired at the same time. Their practice, Eaton Place, closed.
Now Dr Mockett does two sessions a week at Lewes Prison and a day a week as a locum.
‘Most locums don’t want to be salaried, let alone partners. They don’t want the hassle – the responsibility – with the lease, the buildings, document management,’ he says.
‘Brighton’s quite a tough area…there are also the estates and lots of people coming in from abroad’
Dr Rob Mockett
‘I can see the workload’s gone through the roof. It’s much harder work than it used to be. Practices rely on locums more and more. They’re struggling to recruit. It’s just very intense.
‘When I qualified I went for my interview in 1989 and there were something like 50 people who went for the job. Now they advertise and no one applies,’ he adds.
‘Brighton’s quite a tough area. Everyone thinks it’s a lovely place by the sea but there’s lots of poverty. There are lovely Regency houses but there are also the estates and lots of people coming in from abroad,’ he says.
Brighton is home to two universities and one of them, Sussex, has a long tradition of attracting overseas students. They are among the transient patients who can tilt lists from viable to not sustainable – and all at a time when rising Medical Defence Union fees add yet more to the financial pressures.
Dr Mockett notes that in a few years, six of the practice closures had been in east Brighton – one of the poorest parts of town. His surgery was in a Regency building. It needed £150,000 spending on it. The new owner has turned it into flats.
Dr Sikdar, a former member of the Brighton and Hove CCG governing body, says: ‘General practice is difficult at the moment. The value of the GMS contract is less than it should be for the work that is expected.
‘People are retiring and moving away…There’s no financial reason to continue working’
Dr Manas Sikdar
‘People are retiring and moving away because they are taking an objective view that the current landscape is not going to fulfil them professionally or will cost them financially when they come to retire. There’s no financial reason to continue working.’
‘There might be a cohort who think, “this is my time to go. The climate … is too dangerous to work safely in. I’m going to go and voluntarily and relieve myself of that responsibility.”
‘When a doctor feels stressed, we used to think, “suck it up, pull your socks up and get on with it.” But actually it’s alarm bells,’ he explains.
Some practices locally are taking deliberate steps to tackle stress factors head on, including the Wellsbourne Health Centre, where former CCG accountable officer Dr Christa Beesley is a GP and director.
‘The stress levels can be incredibly high. We’re seeing more people who might previously have been in hospital,’ she says.
‘We build in time to eyeball each other – to support each other. It’s really difficult but it’s really essential,’ she adds.
Patients are given 15-minute appointments at Dr Beesley’s practice, which serves one of the poorer estates away from the seafront and Regency squares and terraces. The aim is to focus not just on illness but wellness, encouraging healthier lifestyles.
Commenting on the longer appointments and new approach, she says: ‘It’s hard to keep faith with it at the moment because we’re under so much pressure. It’s slightly counterintuitive, so watch this space.’
Her practice, run by Wellsbourne Healthcare CIC (community interest company), was recently awarded a five-year APMS contract. It serves an area where the Practice Group closed a surgery when the cost of its PMS contract came under review.
‘The stress levels can be incredibly high. We’re seeing more people who might previously have been in hospital’
Dr Christa Beesley
But Dr Sikdar questioned the stability of APMS contracts and whether they were the solution to the problems facing general practice in Brighton and Hove.
‘You have to bid for your contract every five years. It’s difficult to have continuity. It’s difficult for an individual doctor to want to invest their own time and money and then in five years’ time know they might not get it,’ he says.
Dr Sikdar says he is not criticising Brighton’s surgeries run by CICs – particularly in light of the five local surgeries closed by the Practice Group – but adds: ‘A commercial provider comes in when they’re offered a very good deal. But when the ground’s more equal some of them just pull out. It’s a business decision. They don’t feel as committed as other practices.’
With the closures and likelihood of further GP retirements it’s probably not surprising that more consolidation is expected – as has been indicated in the CCG’s primary care strategy, which features six clusters and three localities in Brighton and Hove as a potential framework.
But the trend towards consolidation and scale is not necessarily a panacea, warns Dr Sikdar: ‘Big is not always resilient. Big can fall apart. Big can be decommissioned on a whim.’
Brighton and Hove is showing symptoms seen elsewhere but how to diagnose and treat the underlying condition remains open to debate.