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Does size matter?



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There’s been a growing trend in recent years for our GP Leaders to make proclamations which come back to bite them. I’m sure you remember the infamous quote from Professor Steve Field within the Daily Mail, stating he was ashamed of some GPs in relation to CQC inspections. Many, including the GPC, called for his resignation, which I supported.

A few years later and it is the turn of the Director of Primary Care for NHS England, Arvin Madan, who states GPs should be pleased when small practices close.

This disingenuous comparison with the business sector is quite astounding. I quote from his article:

‘Most businesses are pleased to see a rationalisation of providers, as it makes the remainder more viable. In the general practice market, there are too many small practices struggling to do everything patients now want for their families in a modern era of general practice.’

These insensitive remarks do nothing to allay the anxieties of struggling practices and those already forced to hand back contracts

What this statement so obviously fails to appreciate is that general practice is not a small business in the competitive sense of the word, there is a monopoly provider within the NHS, and it is not a level playing field.

And business issues aside, what of quality of care? It’s no good spouting some anecdote about the single hander who sends everyone into hospital; what does the evidence tell us?

This report from 2014 states that although smaller practices perform slightly less well in QOF and have higher emergency admission, they have fewer elective referrals and significantly higher patient satisfaction scores. A more recent review shows that continuity almost halves mortality, which trumps earlier research conducted by Sir Denis Pereira Gray, linking continuity with reduced admissions and referrals.

But enough of evidence, what of the human cost here? These insensitive remarks about smaller practices do nothing to allay the anxieties of those struggling, or even those practices like mine, who have been forced to hand back contracts.

So, let me be blunt Arvind, I am not pleased. I am furious. Furious that so many practices have been allowed to fail by NHS England, furious that I am contemplating alternative career options, and furious that my vulnerable patients will lose the continuity of care they so badly need.

I am certain these vulnerable patients are not ‘pleased to see a rationalisation of providers’.  As per the inverse care law, they have no voice. 

Dr Shaba Nabi is a GP trainer in Bristol