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Small practices must not be the collateral damage of reform

We are at a crucial point for the future of the profession. NHS England has said the GP contract is set for its biggest reform since 2004.

Much of this will be determined by the review of the partnership model, which is set to make its recommendations later this year.

We held a round table on the review with a group of leading GPs, and one of the points that struck me was how almost everyone was in favour of practices networking, federating, merging and all the other ways they can work together.

The ‘upscaling’ of general practice had much support from the newly qualified GPs present, who said opportunities to work flexibly and to pursue special interests were far more likely to arise in bigger practices.

In the drive to upscale we need to ensure no practice is left behind

This will be music to NHS England’s ears. It has made no secret of its plans to promote upscaling, incentivising practices to work together with promises of funding and staff

There are definite merits to this approach. Increased resources have to be the priority (although the pitiful GP funding award suggests the new health secretary hasn’t yet grasped this).

But, as I argued last month, even proper increases to pay are not enough in themselves to attract the next generation of GPs. We need to make sure the model is one that appeals to them, and I am starting to believe that working in larger practices is attractive to many young GPs.

However, I still have major reservations, and these came to the fore in our explosive interview with NHS England’s director of primary care, Dr Arvind Madan. It seems he is happy for small practices to be collateral damage in the march towards big general practice. He believes there are ‘too many small practices’ struggling to meet patients’ needs, and that GPs should be ‘pleased’ that the ‘rationalisation’ of the market makes ‘the remainder more viable’.

Plenty of GPs have attacked Dr Madan’s reported comments for applying the principles of the free market to general practice, and with good reason.

But there is also a practical consideration. Because it seems obvious to me that general practice relies on small practices. Unless there are potential patient safety issues, we simply can’t afford any more practices closing right now. We only have to look at the impact of closures in towns like Brighton and Plymouth to see how disastrous they are – regardless of the size of the practice.

We’re nowhere near the point where these ‘upscaled’ practices can absorb the shock of closures for the local health economy. I can’t imagine anyone close to these practices being ‘pleased’ when they shut.

Ah, the argument goes, practices should be willing to transform to prevent closure. But many smaller practices don’t have this option due to local factors. Practices in Bridlington – another town in crisis – had funding for a promised new health centre pulled, plunging them deeper into trouble. And, of course, many are too stretched to have the headspace to attend discussions about upscaling.

There are real benefits to working together, but for any model to work we need to ensure no practice is left behind. And that means valuing small practices as a vital part of the fabric of the profession.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at