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Views And Reviews Primary Colour

Helen Salisbury: Patients lose out when practices compete

BMJ 2019; 364 doi: (Published 18 January 2019) Cite this as: BMJ 2019;364:l119
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

With too few doctors,1 nurses,2 and experienced admin staff to go around, general practices are endlessly poaching from each other, and the pool of available talent is shrinking.

When I first became a partner, GPs were encouraged to compete for patients. The idea was that innovative practices that responded to patients’ needs would thrive and grow, driving up quality as a result. Most GPs ignored this, and patients are remarkably reluctant to change doctors anyway, even those getting a terrible service.

In terms of patient care the pendulum has swung away from competition: the new rhetoric is all around collaboration and integration. Yet practices really are competing now—for staff. It’s a struggle for survival because, once you start losing staff, the death spiral is difficult to escape.

A doctor leaves unexpectedly, and your already tough workload increases. This sparks an early retirement, and any potential recruit looks at how hard the remaining staff are working and decides to go elsewhere. Soon you’re handing back your contract or holding your nose as you go into partnership with a corporate medical chain.

In some areas the solution has been to merge into “superpractices”: these gain stability, but doctors risk losing autonomy and personal connections. Federations of smaller, traditional practices have banded together to bid jointly for contracts and support each other, but in many places this hasn’t stopped practices from going under—either merging reluctantly or closing their doors completely.

In many cases each practice that closes destabilises the one next door, pushing it closer to collapse

There are tiny glimpses of silver linings. Quality of life among NHS workers may improve as practices compete for staff. If you can’t afford to compete on price the only chance of retaining your staff is to make your practice a friendly place to work, with coffee and cake, support and education, and almost infinite flexibility around sessions and timing.

But competitions inevitably have losers. Too often, alongside the exhausted and defeated partners of a collapsed practice, those who lose out are the patients they served. These patients must now travel further, to an unfamiliar surgery with unknown doctors and nurses.

The struggle doesn’t end there. When practices close, patients are often given a list of available surgeries and advised to re-register. Some do so immediately, especially those who are ill or need medicines. But young and fit patients may not get around to it until they’re unwell.

This is a problem, because the current funding model is based on providing a weighted payment for each patient registered. Calculation of this weighting is far from perfect and, in usual circumstances, income attached to healthy patients helps to pay for the sicker patients’ care. This can’t work if only sick patients re-register with nearby practices. Instead, these practices see their workloads rise without getting the necessary resources. At this point, in many cases, the domino effect begins: each practice that closes destabilises the one next door, pushing it closer to collapse.

The recognition that competition doesn’t help patients in an underfunded and understaffed system is welcome. It’s not clear whether the latest NHS long term plan,3 which links a desperately needed increase in primary care funding to collaboration in new networks of practices, will be a solution to our problems. For many surgeries it may be too little, too late.


  • Competing interests: I am a GP partner, I teach medical students at Oxford University and St Anne’s College, Oxford, and I answer readers’ medical problems for Take A Break magazine. I am also a member of the National Health Action Party and serve on its national executive committee.

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


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