Do singlehanded general practices have a future in the NHS

Do singlehanded general practices have a future in the United Kingdom's NHS, asks a senior doctor in this week's BMJ?

Between 1994 and 2004, the number of singlehanded general practitioners in England fell from 2,959 to 1,918 (from 11% to 6% of all general practitioners). This contrasts sharply with the United States, where 46% of family practitioners and 34% of general internists were practising alone in 1998.

Ever since the foundation of the NHS, singlehanded general practitioners have made an important contribution in the UK, particularly in inner city and rural areas. Why then is the future of singlehanded general practitioners now in doubt?

Some of the decline represents a desire for doctors to work in larger practices because they reduce the likelihood of clinical isolation, allow scope for specialisation, and offer a wider range of services than small practices, writes the author.

However, a more important reason could be that small practices do not feature in the UK government's long term vision for primary care. Small practices are seen as less efficient and more difficult to manage by many policy makers and managers. The case of serial killer Harold Shipman, who was a singlehanded general practitioner, may also have contributed to this desire to reshape general practice.

But will the government's new vision of large group practices and walk-in centres lead to a more efficient and higher quality service? Studies have found little relation between practice size and quality of care. Smaller practices are also considered by patients to be more accessible and achieve higher levels of satisfaction than larger practices.

Creating a primary care service based on larger practices also reduces patients' choice. This is anomalous at a time when the government is proposing to increase patients' choice in the NHS.

A better approach might be to use the quality data from the new general practice contract to compare the performance of singlehanded practices with that of larger practices, he suggests. This could be combined with making more information about practices available to the public so that patients could make informed choices.

"If doctors continued to want to work in them, if they provided health services of comparable quality and cost effectiveness to larger practices, and if sufficient patients wished to register with them, then they would continue to exist, and possibly even flourish in the NHS," says the author.

"If, however, they failed on these criteria, they could then die a natural death in which their fate would have been decided by market forces and patients' choice, rather than through a policy based on making general practice an entirely collective endeavour."