How small GP practices are being pushed towards extinction

GP leaders have pointed to the 'death of the single-hander' in England, as official data revealed that the proportion of practices with fewer than 3,000 patients has halved over the past decade.

Practice closures (Photo: iStock)

One in 10 GP practices in England had a patient list with fewer than 3,000 patients in 2017, compared with one in five a decade earlier, according to data published by NHS Digital.

Over the same period, the proportion of GP practices with more than 15,000 patients more than doubled - from 3% to nearly 8%.

The data come just over a week after NHS England accepted the resignation of its director of primary care Dr Arvind Madan following comments he posted online under a pseudonym, suggesting that GPs should be pleased about the closure of small practices.

A statement published by Dr Madan when he resigned said that negative comments about small GP practices 'are not a reflection of NHS England policy'. The London GP added that he had 'always believed that smaller practices serve a  particularly crucial role'.

However, it remains NHS England's policy to move towards GP practices working across populations of around 50,000 patients - either through mergers or networking arrangements.

And small practices are closing or merging at a rapid rate - while larger practices continue to grow as a proportion of the total general practice system. More than a third of GP practices in England now have more than 9,000 patients, and one in six have more than 12,000 patients, NHS Digital figures show.

Family Doctor Association (FDA) chair Dr Peter Swinyard told GPonline: 'These numbers reflect the death of the single hander. So many are giving up and as they come to retirement their practices are shutting.'

Working at scale

Dr Swinyard said that very few small practices in urban areas in particular had been able to escape 'extraordinary pressure from CCGs to merge or work at scale'.

Although he did not believe that there was a deliberate agenda to 'rid the landscape of small practices', they had come under intolerable pressure from the way funding for general practice had evolved.

'The way funding is allocated is a sort of subtle, unintentional discrimination. We don’t have fixed cost cover, for example,' he said.

'You don’t make much as a single hander unless you are dispensing - and even that is not so good now. Things like the loss of the minimum practice income guarantee (MPIG) have been particularly hard to deal with in small practices.'

Practice closures

Echoing recent warnings from LMC leaders about the rate of GP practice closures becoming a 'national disgrace', Dr Swinyard said: 'The pace of change is ridiculous. There is a cataclysm among small practices at the moment. The basic virtues of small practices have been overlooked by government policy - such as the virtue of continuity of care, people going into their practice and being greeted by name by a receptionist they have known for a long time. We know continuity of care saves lives.'

GPonline reported earlier this year that GP continuity of care was linked with a lower death rate in patients.

In the statement following his resignation, Dr Madan said of small GP practices: 'I know they work tirelessly, alongside all primary care colleagues, to serve their patients and perform a role that goes well beyond being their doctor.

'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.'


"I also know that too many smaller practices are struggling, which is why I believe that working in collaboration with others in an integrated manner should form a key part of how we strengthen them and prevent practice closures.'

However, the FDA chair warned that as things stand small practices were heading for extinction due to a 'cumulation of pressures against them'.

Small practices would be watching with interest the development of Dr Nigel Watson's review of the GP partnership model, in the hope that it would offer potential solutions.

Dr Swinyard called for more support for small practices, adding: 'We are all single-handed in the consulting room.'

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