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Life & Times

And then there was one

Saul Miller
British Journal of General Practice 2021; 71 (702): 36. DOI: https://doi.org/10.3399/bjgp21X714569
Saul Miller
Wooler, Northumberland.
Roles: GP
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Figure1

Retirement is a question that dangles lower in the mind. The closer it gets, the more not grasping it requires reasons to continue. Sadly, COVID-19 finally caused enough difficulty for my partner that those reasons proved insufficient. After years of partnered bliss, I found myself facing becoming single-handed as the second lockdown loomed.

What followed could hardly be described as supportive. A practice rated as good by CQC in March, with a 100% positive rating from patients in the government’s own survey published in July, had approval withheld for the change of contract. The CCG committee involved does not publish minutes, but I am led to understand there was a risk concern based purely on the reduction to a headcount of one principal. When challenged, the purported risk assessment really appeared that basic. Other practices, such as those run by married partnerships, large practices with only two partners, practices with questionable performance data, all seemingly avoid such questions about risk.

There is history here. In 2000, hot on the heels of the conviction of Harold Shipman in January, the government published a paper in which it promised ‘a big extension of quality-based contracts for GPs in general, and for single-handed practices in particular.’ 1 A 2006 BJGP paper noted the 2004 Fifth Report of the Shipman Inquiry had acknowledged that a review of the literature over the previous 10 years found no definitive evidence that the clinical performance of single-handed GPs was inferior to that of their colleagues in group practice.2 The same paper highlighted that there was no association between practice size and quality of care. The lack of evidence did not matter: a 2013 survey found that the number of single-handed GP partners nearly halved in the decade from 2002 (9.1% to 5.5%), the number of single-handed practices collapsing from 25.8% to 11.4%.3 In 2016, the head of the CQC asserted that the days of single-handed GPs ‘are over’ 4 on the basis that larger practices and federations achieve its highest ratings.5 It appears overlooked by him that this simply undermines CQC’s claims to objectivity. In 2018, in a powerful piece of personal testimony, an author accused the NHS not only of a lack of objectivity but of widespread racism.6 The account is such that it is hard not to conclude racism was so endemic it was institutional. He describes that his generation of immigrant doctors were often pushed towards ‘single handed practices in deprived areas’. Perhaps Shipman was not the only reason single-handed practice itself became a target? As context, last year the number of whole-time equivalent GPs fell further, particularly in England and Wales.7

A mixture of factors underlies this: more leaving than arriving, a rising population, and a continued fall in the average number of hours worked per GP. Managing the consequences is not easy. Practice mergers present organisational risks that those in the NHS whose income is independent of the consequences of their decisions may not fully grasp. For my surgery, at present, its safest future is this way: nurturing a salaried ex-trainee towards partnership when she is ready.

The government’s recently launched consultation on integrating care in the era after the abandonment of the internal market in the NHS puts the emphasis on Primary Care Networks as the functional units of primary and community care.8 There is scope here finally to end the period of hostilities towards single-handed practices. Place-based care is what smaller practices are most expert in and why we are so often rated so highly by our patients. The super-practice industrial model may have its place but has proven no panacea. In the end, the biggest risk to primary care everywhere is any reason that causes retirement to dangle lower in the mind of all those for whom it is a choice. As 2021 dawns, there are already enough of those.

  • © British Journal of General Practice 2021

REFERENCES

  1. 1.↵
    1. Department of Health
    (2000) The NHS plan A plan for investment A plan for reform, https://webarchive.nationalarchives.gov.uk/20130124064356/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118522.pdf (accessed 10 Dec 2020).
  2. 2.↵
    1. Atenstaedt R
    (2006) Single-handed or group practice, quality of care and patient satisfaction. Br J Gen Pract 56, 525, 301.
    OpenUrlFREE Full Text
  3. 3.↵
    1. Helen J
    (2013) Number of singlehanded GPs in England has nearly halved since 2002. BMJ 346, f2473.
    OpenUrlFREE Full Text
  4. 4.↵
    1. Millett D
    (Oct 25, 2016) Days of single-handed GPs are over, says CQC chief inspector. GP Online, https://www.gponline.com/days-single-handed-gps-over-says-cqc-chief-inspector/article/1413227 (accessed 10 Dec 2020).
  5. 5.↵
    1. Millett D
    (Oct 13, 2016) Larger practices and those in federations score highest CQC ratings. GP Online, https://www.gponline.com/larger-practices-federations-score-highest-cqc-ratings/article/1412067 (accessed 10 Dec 2020).
  6. 6.↵
    1. Menon R
    (2018) The NHS owes doctors who trained abroad an apology for racism. BMJ 361, k2360.
    OpenUrlFREE Full Text
  7. 7.↵
    1. Palmer W
    (May 8, 2019) Is the number of GPs falling across the UK? Nuffield Trust Blog post, https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk (accessed 10 Dec 2020).
  8. 8.↵
    1. NHS England
    (2020) Integrating care Next steps to building strong and effective integrated care systems across England.
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British Journal of General Practice: 71 (702)
British Journal of General Practice
Vol. 71, Issue 702
January 2021
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British Journal of General Practice 2021; 71 (702): 36. DOI: 10.3399/bjgp21X714569

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  • Ambivalent sexism within medicine: reflections from four medical students
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