A speaker at a practice management conference earlier this year had something interesting to say about the future of general practice. He told the audience that the government wants to cut the number of GP surgeries from its current number of about 10,000 down to about 1,800 "supersurgeries" – a plan first outlined in 2004. These mammoth practices, with between 10 and 30 doctors working to serve patient populations of between 20,000 and 50,000, have been described as "beacons of the community" – but is that the truth?
Proponents of supersurgeries talk enthusiastically about the provision of additional services that are normally only found in hospitals, such as minor surgery, X-rays, and orthopaedics and gynaecology. They also say that GPs would be "incentivised" (a horrible and ungrammatical word) to open longer and that private companies, such as Boots or BUPA, could offer GP services in areas where there is a shortage of doctors. There is also much talk about economies of scale, meaning lower costs.
Profit and loss
Not everyone is enthusiastic. UNISON warns that trusts already have to cope with deficits, which are often caused by private finance initiative (PFI) schemes to build new hospitals. They say that the billions spent on updating hospitals are in danger of being wasted if more of what has been traditionally secondary care is transferred to primary care. They also say that supersurgeries will lead to higher profits for private companies and more debt for the poor old taxpayer.
Values and commodities
On Merseyside, the opening of a private GP surgery was called "one more nail in the coffin" of the frontline NHS. This is the first such surgery in North West England and only the third in the UK as a whole.
A senior lecturer in public health at Liverpool University said that he was "…deeply concerned about the damage this is doing to the NHS through introducing the private sector initially into hospital services and now into primary care […] Firstly, companies are doing this work primarily to make a profit. Secondly, they have no experience of primary care. Not only will it draw doctors and financial resources away from the NHS, it will inevitably be a poorer quality of care that is provided. It's also about changing the whole quality of the NHS from being part of the welfare state, providing services that we all feel part of, to reducing people and their health to commodities."
This last point is very valid. Public opinion surveys show very clearly that patients like the relationship they have with their GP practice, and there is a real feeling of concern that the list-based system will be wrecked by private initiatives. One interesting point has emerged, though: according to a recent report, private companies that have taken over the supply of public services are rated as some of the UK's top employers.
Expect more headlines to the east of London as well; a practice in Barking and Dagenham has been taken over by a private firm, Essex company Care UK. They have signed a deal believed to be worth £5m over five years, to provide primary care to a population of some 7,000.
Private involvement in general practice was also highlighted in a recent high court case. This concerned a charge of failing to consult properly during the tendering process of a GP contract, which identified an American-owned firm, UnitedHealth Europe (UHE), as the preferred bidder. It is, of course, purely coincidental that the president of that firm's UK branch is Simon Stevens, formerly health adviser to Tony Blair. UHE was chosen from a shortlist of six companies that were bidding to run surgeries in Cresswell and Derby. Two GPs had also put in bids and complained that they were not given fair consideration.
Using the Freedom of Information Act, they found out that UHE had scored the highest marks in its record of engagement with the public and patients – but without showing clear evidence of how this had been achieved. It also had the highest score for its proven track record of providing medical services, apparently on the basis of having a part-time GP as one of its management team. It is interesting to note that one of the criteria for selection was experience of managing primary care in the UK – something that UHE has clearly not had.
Local residents were unhappy at the decision and made a case stating that their local primary care trust (PCT) had failed to consult properly before reaching its conclusion, and that this was a breach of section 11 of the Health & Social Care Act 2001, which states that patient and public involvement in NHS decision-making is a priority. In the high court, Mr Justice Collins ruled that the PCT had failed to comply with section 11 because there had been "no proper involvement or consultation with those affected by the decision".
So the PCT was wrong. Yet Mr Justice Collins said: "Essentially I have decided that, despite the failure to comply with section 11, the patients had an alternative remedy, and therefore judicial review is not an appropriate route. In addition, for reasons set out in the judgment, the failure would not have been likely to have made any difference."
A successful appeal against this ruling has since quashed the selection of UHE, and ruled that Mr Justice Collins was wrong to say the PCT's failure to consult would not have made a difference. Even so, the PCT are simply to go through the tendering process again – what are the odds on a similar outcome?
I just can't help wondering what will happen to the dedicated team members who stand to lose their jobs if more practices become less. No one seems to have thought of that, and it could happen.
Keep Our NHS Public campaign
(Association of Medical Secretaries, Practice Managers, Administrators and Receptionists)
Tavistock House North
London WC1H 9LN
T 020 7387 6005
F 020 7388 2648