The future of singlehanded general practices
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7506.1460 (Published 23 June 2005) Cite this as: BMJ 2005;330:1460
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Dear Editor,
Professor Azeem Majeed’s article on 25th June 2005 merits praise for
raising the profile of single handed General Practice. As he states,
patient surveys value single handed practitioners for their accessibility
and satisfaction.
Single handed practitioners value their independence, control &
satisfying personal care.
Many single handers like myself who have worked in a group and larger
practices can make a comparison and find the benefits of being single
handed both to the practitioner and patients far outweigh some of the
disadvantages. Rural single handers enjoy many facets of primary care
which our urban colleagues have long since given up: viz, treatment of
trauma, maternity involvement and a holistic approach that stems from
being a valued member of the community.
The positive aspects of single handed care should be encouraging NHS
planners to look at this model as a main choice in the spectrum of future
primary care. To stand one of professor Majeed’s ideas on it’s head: If
group practices can show that they come up to the single handed standard
they too will be allowed to survive.
Dr Ray Wood – Single handed G.P. Coniston, Cumbria.
Competing interests:
None declared
Competing interests: No competing interests
Professor Majeed repeats a widespread and damaging error (famously
initiated by Tony Blair in the House of Commons) when he says "The case of
the serial killer Harold Shipman, who was a singlehanded general
practitioner, may also have contributed to this desire to reshape general
practice."
The facts are these: Dame Janet Smith's report of July 2002
found that Harold Shipman had killed 215 patients. In a further 45 cases
there was not enough evidence to make a decision, but it was possible he
caused those deaths as well.
Of the 215, one was killed during Shipman's time as a junior partner
in a practice in Todmorden, Yorkshire, in 1975. A further 71 were killed
while Shipman worked at the seven-doctor Donneybrook practice in Hyde,
Greater Manchester, between 1977 and 1991. During his last six years of
practice, as a single-hander in the town's Market Street surgery, he was
found to have killed 143 patients.
The evidence therefore shows that if Shipman had been apprehended
when he ought to have been it would have been large group practices, if
any, that came under particular scrutiny. It is disgraceful that the BMJ
did not merely fail to redress this damaging and oft-repeated slander on
single-handers but actually used Majeed's editorial to compound it.
Competing interests:
Worked throughout career in a two doctor practice in a large health centre
Competing interests: No competing interests
Single-handed General Practice and the work of single-handers in
General Practice have been in the news in the recent years following the
events relating to the late Harold Shipman and the various inquiries that
have resulted thereform. That Shipman was a killer is now
incontrovertible; that he was a single-handed General Practitioner is
unfortunate and continues to cast a long shadow on the profession of
Primary Care and on single- handed General Practitioners in particular. It
is also recognised that there were failures at various stages in his
career which should have alerted the authorities much earlier than they
eventually did.
The issues raised by Majeed in his paper are valid, but the same
needs to be said of all doctors. Isolation could happen and indeed does
happen in multi-doctor practices where hierarchical practice structure and
specialisation by some doctors in General Practice facilitate isolation.
Working in a larger organisation does not ensure freedom from isolation
unless there is a culture of openness, audit and reflection allied to a
program of work and education to ensure that doctors do not become
deskilled in large practices.
I believe that it is important for all doctors to show that they work
to acceptable standards irrespective of the place of work. This can only
occur from a commitment to quality demonstrated by publication of results
in accordance with criteria set out in the GMC’s document, Good Medical
Practice
Competing interests:
None declared
Competing interests: No competing interests
Professor Majeed's review makes an important plea for the
continuation of the "single-handed" practitioner in UK Primary Care.
Having experienced the growth of a practice from a small to a large
partnership, then the trauma of divorcing myself from partnership and
recreating a single-handed practice which, through necessity, had to grow
to accommodate the requirements and, sometimes, inappropriate demands of
the NHS, I have much practical experience of the benefits and problems
associated with practice dynamics. A proposal was made to our local GPs
by myself some 15 years ago that we should continue working in our own
local practices but be linked to a central hub for administrative and
"shared" resources. Such shared resources could be such services as
currently provided under enhanced services - minor operations; family
planning; childhood immunisations to name but a few. Maintaining
independent but linked practices allows individual doctors/ practices to
develop good practice which can then be shared between all practices in
the locality through the shared central facility... moons and satellites
rather than solar systems.
Needless to say, 15 years ago my ideas were laughed out of town. I
believe that now is the time to reintroduce the concept of local
"polyclinics" with satellite practices which would provide the
administrative and technological backup for those practitioners who
preferred to remain "solo" while still providing the opportunity for large
practices to develop. Cost increases would be minimised as the current
trend to "supersurgeries" raises NHS overheads by as much as 1000% while
removing much of the personal approach that smaller practices offer.
Within the NHS there is room for variety. Patients soon learn to
choose the type and style of practice that suits them. In general small
practices are able to provide better access and more personal long term
care while larger practices tend to be more proactive in defining the
development of medicine. Technology - if used appropriately and sensibly
allows the "virtual" supersurgery in any village, town or city without the
need to lose identity and enjoyment of primary care.
Competing interests:
None declared
Competing interests: No competing interests
When I first was in singlehanded Practice in Tolworth (this was
during the enthusiastic renaissance of the "new new General Practice",at
the time of the Abies group-Tim Benson,the development of the Read code,
and the initial studies concerning the introduction of computers into
general Practice-Trevor Silva),I set up the single handed Practitioners
association in England.
I invited Jon Hamil (Hampton ) and Nick Robinson(Hounslow) to join me ,and
later Michael Jameson.The name "Single Handed Practitioners Association"
was later changed to "Spa" the "Small Practices Association",to allow
inclusion of Practices with more than one Doctor .
I well remember the comments and criticisms I received by post about the
organisation,and the hard work in it's infancy,but also the tremendous
fun we had ,the widespread support from single handed Family Doctors
throughout the United Kingdom,and the ebullience and confidence we all
felt after the first meeting was held at the Royal College.
Discussions and views about the future of "Single handed Practice" set out
in the article are "cold coffee".Single handed Practice is here to
stay.Why? Because both patients and Doctors want it.
Competing interests:
None declared
Competing interests: No competing interests
Encouraging fewer, or less isolated doctors?
Quotes from the editorial:-
"Over the past 50 years in the UK, general practices have gradually expanded, with both the mean number of doctors and the mean number of patients per practice increasing.3 Some of the decline therefore represents a desire for doctors to work in larger practices"
That does not follow from the change reported here.
Surely that effect causes singlehanded practices to become two handed practices, and in time three handed practices, provided nothing intervenes to prevent this, such as a preferential funding of practices already larger, or of new Principal posts and basic practice allowances in larger practices, back when we had both of those things.
"Among the recommendations arising from the Shipman inquiry was that the NHS should take steps to reduce the clinical isolation of singlehanded practitioners. Encouraging general practitioners to work in larger practices is one way in which the NHS can achieve this objective"
Now that is plain wrong thinking.
Consider Doctor A, a singlehanded practitioner, and Doctor B, another one. (Neither of them being a murdering member of a larger Practice, such as was the doctor enquired about, while murdering many people.)
Assuming for the moment that both are clinically isolated, if you "encourage" Doctor B to close his practice and move into another Practice, then, unless it is actually Doctor A's Practice, you have done absolutely nothing at all to reduce Doctor A's clinical isolation, indeed, given that you have managed to reduce the number of similar doctors around him, you would appear likely to have increased it.
If, as seems likely, the "encouragement" you apply is denying funding, imposing demands for the documentation appropriate to a large practice (minutes of the partners meeting, agreement on policy for this, that and a third thing and the whole nine yards of bumph) then you have done nothing but harm, except that the headcount has gone down.
If instead you looked for clinical isolation, and then tried to make each isolated doctor a little less isolated, at the end of five years you might well have less isolated doctors, whether their number is the same or smaller.
Regrettably, there are many people who confuse fewer of something with less isolated somethings, and not all of them are not in NHS management.
After a man drowned in a stream with an average depth of 6 inches, the local council arranged to make it safer, by making the shallow parts shallower.
Filling in the 8 foot deep hole he fell into would have been much harder.
Competing interests:
I'm the only Principal in my Practice
Competing interests: No competing interests