Why bigger GP practices are not a cure-all for patients – Nick Summerton

Over the years, many smaller practices have been encouraged (or cajoled) to link together. But now the NHS has gone even further by ‘persuading’ (with offers of additional money) every general practice to become a member of a Primary Care Network (PCN). An average PCN covers a population of around 50,000 patients – over 25 times the size of my original practice.

Sir Simon Stevens, the chief executive of NHS England, has stated that primary care networks will ‘allow us to keep all that’s best about British general practice while future-proofing it for the decade ahead’.

But is becoming so much bigger really so much better?

Though the immediate priority is responding to the coronavirus outbreak, the amalgamation and centralisation of some hospital services ha brought about improvements in cancer care and heart disease. On the other hand, individuals with asthma or diabetes – who might now find themselves living much further away from specialist units – don’t do so well.

GPs working in larger confederations will have access to a much wider range of services for their patients than I did as a single-handed practitioner. They are able send individuals off for a whole spectrum of scans and a raft of laboratory tests. Clinical work that GPs would have undertaken in the past can now be passed over to nurses, pharmacists, physiotherapists and others. This will help some people with problems such as bronchitis, epilepsy or heart disease to live longer and healthier lives.

But a tired, stressed and upset individual might just need time to talk to a friendly GP rather than being rapidly dispatched from a surgery with a prescription and a fit note. They might also welcome being handed a tissue rather than a form to enable them to get a few tests.

For NHS managers, getting independently-minded GPs to work in networks is a great coup. They can now exercise more control, set more targets, bring in more IT, tighten up regulation, and, God forbid, even re-design general practice as a whole.

But has Sir Simon Stevens given any thought to the folk who use the NHS on a daily basis?

Patients and patient groups continue to voice concerns about the difficulties they experience getting to see any GP, never mind the GP they are actually registered with.

Therefore, to ensure that size does not take precedence over substance, I have three C’s that I would like Sir Simon to keep in mind – continuity, communication and care.

Continuity: Many older GPs often speak nostalgically about continuity of care. This is about the doctor getting to know his or her patients and the patient getting to know his or her doctor.

Have an ongoing therapeutic relationship with the same doctor is better for both the GP and the patient. Also, although an average encounter with a GP might only amount to 10 or 15 minutes, continuity can extend this to, perhaps, an hour but spread over the course of a year. It is also a much more efficient way to practice medicine with better co-ordination of care and less duplication of activities.

It should be possible to restore some degree of continuity within primary care networks. It is easy to spot individuals who would benefit from seeing the same doctor again and helping them to arrange this – for example a mother requiring ante-natal care after losing her first baby, a person being cared for with cancer or an older individual with several medical problems confused about tablets and multiple outpatient appointments.

Communication: When I started in general practice, I knew my local specialists. I could pick up the phone and ask for advice. Also, although we had to rely on the Royal Mail rather than electronic communications, letters always arrived promptly.

Sadly, nowadays it is not unusual for a patient to attend the surgery to discuss a recent outpatient appointment but to find that no letter has arrived or that the information provided is adequate.

Perhaps the solution is for specialists to be asked to write all their letters to my patients and to copy me in. Making such a change might also help to address other concerns individuals have raised about lack of information, poor involvement in decisions about their care and confusing plans around transfers back from hospital to home.

Care: As health care professionals become more distanced from patients in larger organisations, is there a risk that we also become less caring? Will we still bother to go that extra mile for a patient that we have never met before and are very unlikely to ever see again? Is there a concern that, although our clinical skills might improve, we lose our clinical consciences?

Being bothered about the care we deliver matters not because it generates us more income, and not because it protects us against complaints, but simply because we should know that it is the right thing to do for our patients.

Nick Summerton is a GP and author in East Yorkshire.