Practice closures seem to have levelled off after a steep six-year climb, but PCN workloads and uncertainty caused by the pandemic might halt the improvement, finds James Hacker
It is indicative of the state of general practice that figures revealing almost 100 practices closed in a year can be seen in a relatively positive light.
A Pulse FOI request to CCGs and health boards across the UK show there were 99 closures throughout 2019, with many thousands of patients uprooted.
But this is an improvement on 2018, which saw an all-time high of 138 closures. To put both figures into context, there were only 18 closures in 2013, when they were pretty much unheard of.
The 2019 practice closures – which affected whole practices, branch surgeries and those that shut following a merger – meant an estimated 350,000 patients had to move to another surgery.
Some GPs say 2018 represented a low point for the profession, with many left unable to tackle the growing workforce and financial challenges they faced.
‘I think we reached a point in 2018 when the future looked bleak, so some GPs felt their only option was to hand their contract back,’ says Wessex LMCs chief executive Dr Nigel Watson, who led the Government review of the partnership model, which reported last year.
‘We worked hard locally to support them, but not a week that went by without a practice contacting us to say they were thinking of handing their contract back, and asking what it meant for them.’
Dr Watson warns last year’s slowdown in closures should not be taken to mean there are no longer any vulnerable practices.
‘I think it’s quite possible we will see more [closures] unless we continue to support general practice,’ he says.
An increase in funding and the formation of primary care networks as part of the 2019/20 GP contract has helped stabilise some practices, Dr Watson says.
‘The additional roles funding has been a catalyst to get practices to work together, and in some cases PCN practices realise that if one falls over it will have a negative impact on all the others – so some mutual support has happened.’
NHS England agrees PCNs have helped. A spokesperson says: ‘The expansion of primary care networks is ensuring greater availability of the right kind of appointment for patients – whether face to face or remote – and support for constituent practices.’
Health departments in Scotland, Wales and Northern Ireland highlighted efforts to increase GP numbers and trainees.
Vice-chair of City and Hackney LMC and a GP in east London Dr Ben Molyneux says other contract changes in 2019/20, such as the NHS taking on the cost of indemnity, may have helped ease some financial concerns.
‘A lot of people recognised indemnity was becoming a dangerous prospect, with GPs paying huge, above-inflation fee increases. So I think that’s given some peace of mind. While partners won’t have felt that as much as salaried GPs, if those salaried GPs are now covered that is a positive for you as a business.’
Dr Molyneux says PCN funding, which improves as the years go on, may also have offered hope. ‘The positives of PCNs in their first year were not so much about the absolute amount of cash but the hope attached for managing future workload.’
Even this guarded optimism cannot mask the fact that almost 100 practices were still forced to close last year. The major reason remains severe recruitment difficulties. Latest NHS Digital figures show full-time-equivalent GP numbers continuing to fall; between June 2019 and June 2020, the number dropped by 651, from 28,256 to 27,605.
Londonwide LMCs reports that it has seen high levels of GPs nearing retirement and high numbers of vacancies in the capital over the past four years. Pulse’s figures show the capital suffered 18 surgery closures in 2019, affecting around 61,000 patients.
Londonwide LMCs chief executive Dr Michelle Drage says: ‘Throughout this time we have consistently found that a third of practices are carrying GP vacancies and two-fifths have impending retirements – the workforce crisis that threatens the stability of so many London practices is not going away.’
Sadly, the pandemic may well affect the long-term stability of practices. Dr Drage says: ‘The coronavirus response poses new threats to viability, with infection-control measures and increased demand further stretching resources, and lack of full reimbursement of pandemic-related expenses squeezing finances.’
BMA GP Committee workforce lead Dr Krishna Kasaraneni shares this concern: ‘There are added challenges of the Covid-19 pandemic, which we could expect to be reflected in the practice closures figures for 2020. Through this, practices have worked tirelessly to maintain services for their communities.
‘With a possible second Covid spike and the onset of a major flu vaccination programme imminent, practices are looking for guarantees that additional resources from NHS England will be forthcoming.’
Last year may not have been quite as disastrous as the previous three years in terms of numbers of closures, but this will be of little comfort to practices that continue to struggle.
Dr Molyneux adds: ‘I don’t think the trend of closures reducing will continue. Even if everything else had been perfect, Covid is putting so much pressure on practices – emotionally, bureaucratically, financially – that I think some are limping on purely through a sense of obligation.
‘As soon as we’ve got a vaccine and jabbed everyone I think there’ll be a run for the door from the people who really didn’t want to be here anymore.’
‘I resigned as a partner and my practice tried to close’
My situation was typical of practices in the area. We are unable to recruit enough GPs so every practice is under stress the whole time, and that’s when a partnership gets pushed to its limits.
We couldn’t recruit partners or salaried GPs. There were originally five partners but with people retiring it wasn’t possible to replace the outgoing partners – and then those who remained were wanting to reduce their sessions because of the stress. Even locum GPs have been difficult to get hold of – or you end up in a position where you are paying the locums more than you pay yourself.
Various practices in the area had closed so we had to take on hundreds of extra patients, and we already had an increasing population due to a thousand more houses having been built in the area. It was a perfect storm.
I tendered my resignation in July 2019, which led to the other partners trying to close the practice by handing our contract back. They found they couldn’t do that because we own the building and the health board wouldn’t buy it, so the practice wouldn’t have been able to maintain the loan had it closed.
One thing that did help was the Scottish Government’s proposal to eventually buy GP buildings by offering increasingly larger loans, which was due to come in over the next few years – but with Covid-19, who knows when that will happen.
The practice is now limping along but I am no longer a partner at all because it was going to break me if I kept working in that environment. I left in June and I’m now working two days a week as a salaried GP.
Dr Joanna Coy, former GP partner at St Brycedale Surgery, Fife