The Demise of the Small Practice in the Face of GP Conglomeration – simple economics or an NHS tragedy?

Kalyan Mitra

With the start of my first GP placement of 5th year came about a completely new daily routine. Instead of sleeping in and attending my 9am Zoom lectures in my dressing gown, I was up at half 6, and groggily (read: inaccurately) swabbing my tonsils at 7 for the weekly asymptomatic screening, leaving the house just late enough for my gloating housemate to wish me a safe journey as he rubbed the sleep from his eyes (he was placed at a surgery not 5 minutes walk away). After a brief stop at college to deliver said swab, I soon found myself cycling on the B1049 as it meanders northeast of Cambridge, passing first Aldi and Iceland before the more scenic views of the sun rising over the empty fields opened up. 8 miles later and I arrived breathless and sweaty in Cottenham, and by following the high street up a gentle incline I reached the Cottenham Surgery itself. The practice has just one GP partner, and a list size of just under 4,000 patients, making it quite the rarity in an NHS that encourages ever-larger practices in its endless quest for efficiency. From 2013 to 2018, 900 practices closed, and list sizes have risen by almost 20% to 8,279 patients. But are smaller practices actually less efficient, and what is lost when yet another local surgery joins a supergroup?

The demise of the small practice is not a new issue, but instead the product of reforms going all the way back to the founding of the NHS in 1948. At that time GP partners remained self-employed, getting paid by the NHS per patient, which remains the case today. Nearly all GPs worked in single-handed practices or with one partner, but working conditions were poor, as were standards of care. Over time, with better contracts and increased professionalisation, practices improved, and with the advent of the ‘red book’ deal, where the NHS pays for 100% of facilities costs and 70% of staff costs, the size and scope of services offered by practices has never been greater.

However, it was market-based reforms that introduced more competition into the NHS, combined with increased scrutiny of practice services and quality that really put the squeeze onto smaller practices. With more paperwork to do to maintain standards, and financial certainty increasingly hard to come by, it seems running a small practice has become more and more stressful. The complexity of balancing multiple income streams with staff costs, administration and (perhaps) having a family life is forcing many small practices to merge (for an excellent explanation of GP funding see this from the King’s Fund). Combine this with increased regulation and oversight by various bodies such as the Care Quality Commission (CQC) and the amount of paperwork to do skyrockets. See Dr Mayor’s post after he joined the super-partnership Modality, in Birmingham “There have been many plusses. No more need to worry about paying business bills, cash-flow, payroll and book-keeping – all of that is done centrally by Modality’s 'back office'”. But even if the practicalities of daily life are forcing small practices to merge with larger ones, we still need to look at whether standards really are better, and what patients think. Is the quest for bigger practices mere free-market ideology, or is it rooted in facts?

Dr Sassall from John Berger’s “A Fortunate Man” - perhaps the archetypal single-handed practitioner

A quick review of some literature reveals mixed results. On the one hand, in 2016 the CQC found a direct correlation between ratings and practice list size, with the average ‘inadequate’ practice having a list size of 4,755, ‘requires improvement’ 6,311, ‘good’ 7,682 and ‘outstanding’ 9,598. But are the CQCs outcomes biased towards larger practices anyway, requiring a huge amount of administration to meet their targets and therefore favouring practices with less capacity for such paperwork? Independent research has shown minimal effect of practice size on quality, including this systematic review from 2013, and some other papers have even shown benefits to smaller practices, such as lower rates of preventable hospital admissions. In 2016, the Nuffield Trust published this 111 page report, investigating whether bigger really is better. They found that whilst larger practices improved financial sustainability, there was no significant evidence that they outperformed their smaller counterparts. Equally important were concerns raised by patients, who faced a trade-off between better access to healthcare and losing their relationship with their trusted GP.

It seems only one thing is certain in this exciting area of public health, and that is that sooner or later the end of the small practice will come. Like the rest of the high street - the greengrocer, the butcher, even the local pub, few independent traders can hold out against the conglomerates for long. One American study observed that physicians in smaller practices were more likely to have been working for more than 30 years, and worked in rural areas, perhaps indicating which practitioners are battling the inevitable.  Larger practices will save money in the long-term, and will be able to offer more services for their patients. I’m sure that as we get more experience in operating these bigger institutions, quality of care will increase as well, but something else will be lost, a certain romance epitomised by John Berger in his “Fortunate Man”, of the single GP battling the ills of their community alone. Perhaps it’s not important, but in this increasingly divided, harsh and cruel Britain , the comfort  of seeing a local GP is one that will sorely be missed by many.