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A view from Dr Gerard Bulger  Comments to here please

Shipman Enquiry and Small Practices

Dr Shipman was a mass murderer who was a doctor. He came across to many of his patients as a good doctor. Many of us in the profession believe that he would have sailed though the new appraisal, accreditation and revalidation procedures that are being been enacted since his crimes were discovered.  Dame Janet Smith's lengthy enquiry had a wide brief, and made many recommendations.  A complete rethink of the role of the General Medical Council is also being undertaken in Sir Ian Donaldson's Report  

The Primary Care trust were expecting her report to suggest closing small practices.  She did no such thing and may have annoyed some NHS bureaucrats by not licensing them to continue their campaign against small practices.  Dr Shipman murdered when in partnership and as a hospital doctor. He had the cremation forms signed by doctors of the group practice.

Dame Janet Smith says some quite nice things in the Fifth Report about small and single-handed practices.  She found that there was an unwritten policy to be rid of single-handed practices, but she now recommends support for them.   We have to thank Dr Micheal Taylor's work and evidence from the Small Practices Association.  It is clear that Dame Janet Smith looked at other clinical evidence, as against rumour.  For example she dismissed the assumption, stated at the enquiry, that small practices had more complaints against them.  She found no evidence for that assertion, if anything the converse may be true.

Who is a single-hander?   Single-handers probably do not exist in their original form in England. The ultimate single-handed practice is likely to be limited to Scotland and the Islands such as Sark.  Very few practices in 2004, which have just one named doctor as the main contractor, has just one doctor working completely alone.  So called Single-handers have assistants and locums, the latter are now called portfolio doctors, as they are also performers on the PCT list.  Many small practices are working in association with other practices, sharing resources.

Since her report Government Policy has now been made more explicit. There are now overt plans wipe out small and single-handed practices.  Jo Whitehead of the Department of Health outlined the policy at Practice Based Commissioning Conference Hammersmith on 10th March  The G.P. "list" would go, there would be walk in centers and G.P.s would be in large practices of at least 10 doctors.  This is occuring now. In 2004 the number of single-handed practices collapsed by more that it fell in the previous decade, from 2,578 to 1,918. The overall number of practices fell by 291, the largest fall since 1994.

Below is Dame Janet Smith's Conclusions as regards single-handed practice which seems to have been ignored by the Government.

See her full 5th report here (1178 pages without appendixes) 

Shipman Report Chapter on Single-Handed Practices:

13.68 It seems to me (Dame Janet Smith) that single-handed practices vary in much the same way as do group practices. Some of each are good, bad or indifferent. Certainly, group practices do not
have a monopoly on high quality patient care. Small and single-handed practices have
their devotees, particularly among those who seek a personal relationship with their GP
and who value the continuity of care which this provides. The number of small practices
may be diminishing for a variety of reasons. However, there are still a significant number
of them and this is likely to be the position for the foreseeable future.
13.69 That being so, it seems to me that the policy of the DH and of PCs should be to focus
on the resolution of the problems inherent in single-handed or small practices rather than
to try to reduce the numbers of them in existence. I know that the DH says that it has no
such policy but I have the clear impression that such a policy exists in the regions, if not
in Whitehall. It is typified by the attitude that single-handed practices are a problem and
that the HS would be better off without them. As I have said, the numbers are likely to
decline with time in any event.
13.70 I have already described a number of the problems that are inherent in single-handed and
small practices. I have also described a number of initiatives that are already being
undertaken in an attempt to resolve or mitigate those problems. To my mind, the important
thing now is that, for the sake of the patients registered with them, single-handed
practitioners should be given more support and encouragement. In return, more should
be asked of them in terms of group activity and mutual supervision. It is not for me to
suggest how this should best be achieved. The current initiatives are patchy and
uncoordinated. I do not suggest that there is a ‘one-size-fits-all’ solution to these problems.
The needs of small practices in Cornwall may be very different from those in Central
Manchester. What is needed, in my view, is a pooling of ideas, a willingness to examine
the ways in which things are done in other places, such as the Netherlands, and a
determination to solve the problems.
13.71 I turn to consider what significance, if any, attaches to the fact that Shipman was always
technically a single-handed practitioner and never worked in a group practice with a
shared patient list. Did this make it easier for him to escape detection? Did he feel more
confident that his crimes would go undetected? First, I observe that Shipman killed at least
71 patients when he was at the Donneybrook practice and that his colleagues at the
practice were, through no fault of theirs, unaware of what was going on. This confirms my
belief that a devious and aberrant doctor is not significantly more likely to be deterred or
detected just because s/he is in partnership and/or working under the same roof with other
doctors. I suspect that it was Shipman’s general character rather a feeling of likely
detection if he were to remain that caused him to move from the Donneybrook practice.
Second, I believe that if the Donneybrook practice had been a true group practice with
shared lists, Shipman probably would have felt less confident that he would escape
detection. If his fellow doctors had had some involvement in the treatment of those who
were to become his victims, he would have felt less confident in making up false medical
histories and they might have become suspicious if unusual patterns had developed.
Much depends on what would have been the actual arrangements and the extent to which
there would have been true mutual supervision or monitoring. Of course, that leaves open
the question whether, if that had been the situation, Shipman would ever have applied for
the position or remained there for so long – he might well not have done.
13.72 In my view, the fact that Shipman had his own patient list, and was free from the informal
supervision and monitoring that accompanies the sharing of patient lists, did mean that
he was less likely to be deterred or detected. However, the availability of other more formal
methods of monitoring, through clinical governance, could have had a similar effect. If
resources and ingenuity were to be applied to the problem, clinical governance methods
of monitoring could be applied to single-handed and small practices, as well as to larger
group practices. I do not think that the fact that Shipman was a single-handed practitioner
should be used as a reason for preventing GPs from practising alone.  


BMJ Editorial on Future of Small Practices June 2005



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