GPonline reported earlier this week that the proportion of GP practices in England with fewer than 3,000 patients dropped from around one in five in 2007 to just one in 10 by 2017.
Over the same period, practices with over 15,000 patients more than doubled as a proportion of the total and now account for nearly 8% of practices in England.
Data from the latest GP patient survey reveal that this rapid change in the face of general practice risks driving down patient satisfaction, because patients at the smallest practices are more likely to be highly satisfied with the service they provide.
Across general practice in England, of the more than 700,000 patients who responded to the 2018 GP patient survey, 84% said their practice was good overall. This figure combines responses from patients who said their practice was either 'very good' or 'fairly good'.
At practices with fewer than 3,000 patients, 85% say their practice is good overall, while at practices with 15,000 patients or more the figure drops to 82%.
However, breaking the overall figure down to look at the proportion of these respondents who rated their practice 'very good' reveals a greater gap in patient satisfaction between large and small practices.
At practices with fewer than 3,000 patients, 54% rate their GP service as 'very good' - while at practices with more than 15,000 patients this falls to 43%.
Family Doctor Association chair Dr Peter Swinyard said: 'People who have their own GP and know them, rate it highly. Patients at large practices are less highly satisfied - they are often still satisfied, but the GP-patient relationship is weakened.'
Continuity of care
He pointed to recent studies that had shown a range of benefits from continuity of care - from reduced mortality, to fewer emergency admissions.
The Wiltshire GP added that with larger practices and a workforce increasingly working part time, 'the chances of continuity become less'.
But he said: 'We're caught between the devil and the deep blue sea. Continuity is good, but doctor-intensive - and we don't have the doctors to do it.'
Dr Swinyard called for the reintroduction of a 'basic practice allowance' - a concept eroded in the 1990 GP contract and abolished in 2004, which allowed a fixed sum of funding per GP at a practice.
He said the rapid disappearance of smaller practices was a 'failure of the funding structure, if you believe in the values of a personal service'.
He added: 'There is no doubt that at a CCG level, the money is going into hubs and groupings of 50,000 patients.'
The 4,500-patient practice Dr Swinyard had worked at for many years was 'no longer financially viable', he said - and was now supported by other practices in a group. 'I couldn't run it as a stand-alone practice - I would have gone bust,' he said.
Dr Arvind Madan, who quit as NHS England director of primary care earlier this month, said after comments that appeared to welcome the demise of small practices that this did not reflect NHS England policy. In his resignation statement, he added: 'GPs in smaller practices serve a particularly vital role as a point of constancy in the lives of often very vulnerable patients.
'They know their patients intimately, see families through times of great difficulty, and often hold their communities together. They are also essential to ensuring general practice services reach every inner-city neighbourhood and rural community in England.'