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Good things come in small packages



The GP news is full of the joys and opportunities of merging, creating bigger, more streamlined and efficient practices. We see the visions of centralising the boring clerical hoop-jumping tasks, utilising nursing and AHP skills to provide a full range of wholistic care facilities and deal with minor ailments so we don’t have to, freeing-up valuable GP time to concentrate on clinical complexities. What a wonderful utopian ideal with access to mental health support, physical and other therapies, community supports; and happy, enthused, relaxed GPs empowered to spend time with their patients, to do what drew them to medicine in the first place. Professional bliss…?

Argh, I feel dizzy, these rose-tinted glasses are giving me a headache…

I didn’t become a GP to be another worker on a conveyor belt, to see one patient after another, to be constrained as one of the cogs in a bureaucratic behemoth. I want to help people, help families, help communities. And for me that means using my knowledge and skills to influence, adapt and create the services that my patients need. OK, there may be advantages to quick access to physiotherapy and mental health counselling for depressingly bad back pain, but how could a large organisation deal with such a broad range of demographics seen in any urban sprawl, from affluent Acacia Avenue through to the boarded up terraces of Inequality Street? And don’t even get me started on how on earth you can provide quality, effective primary care services to remote or rural populations at scale when even now some patients have to travel up to 20 miles to see any GP, let alone the same GP.  

Large organisations are breeding grounds for the very silos and tribes we see bickering throughout the NHS. The bigger they get, the more bureaucratic they have to be to get things done, creating managers and sub managers, each with their own sticks and carrots to dangle over or whip the next tier down the command-and-control hierarchy. They stifle diversity, leadership and creativity. They are slower to respond to concerns and change; more steps, more decision-makers, more managers to pass-the-buck. Mergers and scale working are recurring themes in business, many for positive reasons, many to just save money on staff and property costs. All very well in a private manufacturing industry, but we are dealing with people, individuals, lives and livelihoods. 

Small practices are flexible, reactive to the needs of their communities, easily accessed and cost-effective when you look beneath the immediate top layer of outgoings. The problem is not the small-business organisational model, but the chronic, short-sighted, boa-like strangulation of resources by increasing demand, failure to invest and dwindling GP numbers.

Well, maybe mega-practices could work in Metropolis, who knows. But good things come in small packages.