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by Andrew McHugh
7 January 2016

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Blog: My surgery applied three times last year to close its list

In 2015 my surgery applied three times to close its list. We were a very successful surgery with very high levels of patient satisfaction particularly for access but that became our greatest problem. Our list was growing inexorably. A very large part of our growth was from patients transferring in from other local practices. The patients that were transferring seemed to be complex patients who needed a great deal of working up.

We estimated that 200 of these complex patients transferring-in could represent one whole time equivalent GP in work. For these 200 complex patients in very rough terms we received about 25% of the cost of doctoring them. We were, in effect, buying work. We were working harder and harder for less and less money. An indication of just how stressful things had become is when one of our doctors had 83 patient contacts in a single day. With the best will in the world patient 1 at 08:30  received a very different standard of care to the patient 83 seen at 20:30 and that is before she started work on her referrals, prescriptions, test results et al.

NHS England rejected our application twice. I was faced with GPs in tears on numerous occasions. It became the exception when I didn’t have at least one GP  per week in my office in tears of desperation. My partners started to openly talk about escape routes – early retirement in the late 50s or just plain leaving medicine for those in their late 30s. In November 2015  we submitted a third application to NHS England to close our list. The situation within the surgery had changed significantly for the worse since our second application. Shortly after submitting our third application we were visited by our accountants who recommended a further 10% reduction in partner drawings. At this stage the future of the practice rested on a knife edge.

On 23rd December we received notification from NHS England that we could close our list for six months. This was the best Christmas present the practice could have received. There was a palpable reduction in stress levels. We now have the opportunity to step off the treadmill and modify our access to reduce the demand for GP appointments by implementing clinical triage. This will be another major change we have made to cope with the crisis of recruitment, retention and morale. In the past we have employed pharmacy technicians and Paramedics to reduce the workload of GPs. These have worked extraordinarily well but patient demand always outstrips our ability to innovate.

Much of the talk of leaving the NHS has now ceased. I realise that this is only a six month respite but, if during that time we manage to re-engineer out internal processes then I am moderately optimistic about our short term future. There is, however, a vast amount of work that needs to be done to restore the morale of the profession and prepare it for the medium to long term. I am slowly seeing desperation turn to anger and not just in my practice.

Over the last five years we have seen total GP consultations increase by at least 50%. We have seen GP consultations with the over 80s increase by over 150%. In the same period we have seen funding of general practice fall by around 20%.

There are initiatives such as the NHS Primary Care Transformation Fund that could do much to improve the state of general practice and help create the structures envisaged within Simon Stevens Five Year Forward View. It would be great if general practice could see these opportunities, grasp them and run with them but with current state of morale within the profeesion there are very few GPs or GP Federations willing to put their name to a 25-year lease to invest in the future of primary care

List closure is, at best, a sticking plaster for general practice when what is really needed is an MRI and radical surgery.