Larger GP practices no better

Smaller practices offer quality care

Moves to encourage GPs to work in larger practices may have little impact on the quality of patient care, research suggests.

It is widely known that fewer patients die in larger hospitals that do more operations.

But researchers found little evidence that the same principle holds good in general practice.

The great advantages of small practices are continuity of care and personal doctoring

Dr Michael Taylor

They found little difference in the care offered to patients with ishaemic heart disease by small and large GP practices.

Professor Azeem Majeed and his colleagues at University College London focused on 62 general practices in southwest London.

Practice size varied from 1,265 to 13,147 patients. In total, 6,888 people had ischaemic heart disease.

The number of cases in individual practices varied from 12 to 326.

One superior area

Practices with a larger number of patients were found to be better at recording blood cholesterol concentration.

But all other aspects of care were similar regardless of the size of the practice.

And overall the quality of care was similar across the board.

Writing in the British Medical Journal, the researchers say: "This suggests that the trend in the NHS towards larger general practices by itself has little impact on the quality of chronic disease management in primary care.

"Although recent developments in the NHS have cast doubt on the future of smaller practices, both patients and the doctors seem happy with smaller practices.

"Smaller practices are often seen as more accessible and achieve higher levels of patient satisfaction.

"The NHS should reconsider how it can improve the quality of care provided by general practitioners, without relying on the presumed benefits of consolidating them into larger units."

Human element

Dr Michael Taylor, chairman of the Small Practices Association, said he was not surprised by the findings.

"The great advantages of small practices are continuity of care and personal doctoring.

"That means having a real knowledge of the patient, rather than just information about the patient.

"It also means that there is a greater commitment by both parties to the relationship, and a trust that enables the patient to deal more readily with their disease."

This was of particular importance in the treatment of complex diseases, and of mental health problems, he said.

But the new research showed that even in an area of "hard medicine" smaller practices offered a level of care as good as their larger counterparts.

The Small Practices Association is concerned that the government is keen for all GPs to work in larger units.

Last year Tony Blair said there was good evidence for a move away from single-handed practices.

However, Dr Taylor said ministers would be wrong to "write off" the importance of human relationships in primary care.

The BMA's General Practitioners Committee issued a statement supporting the concept of small and single-handed practices.

It said: "There is no reliable evidence that smaller practices deliver lower quality care and there is evidence that patients value the continuity, accessibility and care given by single-handed practitioners."