The 2004 GP Contract requires GPs to register all patients in their practice area who wish to register with them. Obviously, it is important that patients be able to register with a GP easily, and preferably with the GP of their choice, and that they be able to change GPs easily if they are unhappy with the service their GP offers.
The problem for a practice providing this service is this: as patients choose to register with you, your list size will grow. At some point you will reach capacity: the practice has finite resources and as the demand on these resources increases, at some point the quality of the service will be adversely affected. The practice can grow: it can take on additional staff, and thereby increase the capacity. But again, at some stage, if growth continues, capacity will inevitably be reached again. Capacity cannot grow indefinitely. The building is only so large, there are only so many hours in a week. In addition to this problem, you must remember that a GP practice is a system. A practice that functions well with one patient list size, will function differently, and quite probably less well, as a system if it grows beyond a certain amount.
We are a small practice: we started in the practice in 1991 when the list size was about 2,500 patients. We have grown over the years to 3,520. We are in an area with a growing population; we have a good reputation and people want to register with us. But we have reached our capacity, in fact I would say we have exceeded our capacity. And this adversely affects the quality of the overall service we provide.
Another thing to keep in mind: many of our patients value that fact that we are relatively small, they would not want to lose this.
Our only option, within the framework of the GP contract 2004, is to apply to a panel for permission to close our list. If permission is granted, our list is then closed and we register no patients for a period of time. The inference is that if you have to close your list then you are not coping, you are a failed practice; and therefore you may be denied the option of offering certain ‘enhanced services’ to your patients (which form a significant part of practice income). As your list size declines (as people move away, or leave your list for other reasons), so your income declines.
In May 2009 I woke up and thought this could not go on; I also became more clear that this was a truly bonkers design. We decided as a practice that we could not survive if we continued to obey the directives from above. So we took the decision to cap the list size at 3,520, and we told the PCT we were doing this and why. The only way we could stay ‘legal’ was to shrink our practice area and the PCT had discussions with us about this. But this was never followed through and we are currently in breach of contract.
We have in fact now shrunk our practice area. We have an inner area which is smaller than our previous area, and an outer area which is our previous practice area. To register you have to live in the inner area; if you move to an address in the outer area, you can remain registered. If you move outside that area, you need to get a local GP.
Unfortunately, our list size is creeping up, to 3,600 (the new cap we have decided). We will have to shrink the practice area further. If they let us….
Today we have a list size of 4,148. The only thing that saves us is that the demographic has changed for our area so many of the people moving to our area are professional people 25-40. But we are struggling and it is not sustainable. Most weekdays I work a 14 hour day, in at 7am, often leaving after 9pm (and I almost always have more work to do but simply must go home).
I am about to be 62. I consider myself in my professional prime, but I cannot go on with this model, and when I retire nobody will take my place because it is an impossible job.
More posts related to this issue:
A Chronology of this problem in our practice
The paper I submitted to the PCT in May 2009