Helen Salisbury: Small is beautiful


PRIMARY COLOUR

Helen Salisbury: Small is beautiful
Helen Salisbury GP

Oxford

This week I learnt that 138 GP surgeries closed their doors for
the last time in 2018.1 Some of the practices merged, some
doctors were employed or became partners elsewhere, and some
GPs, wearied and defeated, took early retirement.
Most of the practices affected were small, with lists of fewer
than 5000 patients. It’s easy to see why smaller practices are
vulnerable. A single retirement or episode of ill health can be
enough to close a practice if it can’t recruit new staff. The ever
increasing regulatory burden on primary care is harder to bear
if you have only two partners and a part time practice manager.
Larger, merged practices may be more resilient in the face of
change, and there are some economies of scale, especially in
administration. The direction of travel for general practice seems
to be towards ever bigger organisations—through networks,
super-practices, or corporately owned chains.
When considering the benefits of scale, it’s also worth asking
what we risk losing. Patients may lose a place that they know
and where they are known. Where once they walked to the
surgery and greeted the receptionist by name, now they take a
bus and see a new face on each visit. They’re also less likely to
see the same doctor.2 This loss of relational continuity isn’t just
about how patients feel—although familiar places and people
probably make it less stressful to seek help and advice. We know
that seeing the same doctor at most appointments reduces the
likelihood of an avoidable hospital admission, especially among
patients who consult frequently.2 This makes sense: if I know
that my breathless patient also has anxiety but actually his chest
is no worse than two weeks ago, I can reassure him confidently.

It’s not only patients who risk losing something important in
the rush for scale. Many GPs chose their speciality because it
offered a chance to treat people, not just diseases, and to come
to know their patients over time. A particular satisfaction comes
from treating whole families over many years: relationships
deepen, trust grows, secret fears are shared, and you go the extra
mile willingly for your patients. I admit to being an idealistic,
old fashioned GP who wants to know what makes my patient
tick, to recognise when something’s wrong, and to know what’s
most likely to help each one. If I worked shifts in the extended
hours service I’m confident that I could be a safe and efficient
dispenser of medical knowledge, even an empathetic listener,
but I’d be doing only half the job I trained for.
If we lose continuity we lose job satisfaction and, with it, our
main recruiting tool to general practice. We should be careful.

Competing interests: See www.bmj.com/about-bmj/freelance-contributors.

Provenance and peer review: Commissioned; not externally peer reviewed.

1 Perraudin F. GP surgery closures in UK “hit all-time high” in 2018. Guardian 2019 May
31. https://www.theguardian.com/society/2019/may/31/gp-surgery-closures-in-uk-hit-all-
time-high-in-2018.

2 Barker I, Steventon A, Deeny SR. Association between continuity of care in general
practice and hospital admissions for ambulatory care sensitive conditions: cross sectional
study of routinely collected, person level data. BMJ 2017;356:j84.28148478

Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
permissions

helen.salisbury@phc.ox.ac.uk Follow Helen on Twitter: @HelenRSalisbury

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe

BMJ 2019;365:l4117 doi: 10.1136/bmj.l4117 (Published 11 June 2019) Page 1 of 1

Views and Reviews

VIEWS AND REVIEWS

 o
n
 5

 A
p
ril 2

0
2
1
 b

y g
u
e

st. P
ro

te
cte

d
 b

y co
p

yrig
h

t.
h
ttp

://w
w

w
.b

m
j.co

m
/

B
M

J: first p
u

b
lish

e
d

 a
s 1

0
.1

1
3

6
/b

m
j.l4

1
1

7
 o

n
 1

1
 Ju

n
e
 2

0
1
9
. D

o
w

n
lo

a
d
e
d
 fro

m
 

http://group.bmj.com/group/rights-licensing/permissions
http://group.bmj.com/group/rights-licensing/permissions
http://www.bmj.com/permissions
http://www.bmj.com/subscribe
http://crossmark.crossref.org/dialog/?doi=10.1136/bmj.l4117&domain=pdf&date_stamp=2019-06-11
http://www.bmj.com/