Stephen J Humphreys
BA(Econ) CDipAF DipTQM LLDip DPMSA DipMHSC MBA MA MSc LLM MAMS MIHM
Dr Hanak & Partners
Welwyn Garden City
Stephen, when he isn't "QOFing" at work, is a member of the Advisory Committee on Clinical Excellence Awards (ACCEA) and of both an independent and an NHS research ethics committee. His membership of CAMRA (the Campaign for Real Ale) ensures that any other quaffing he may engage in is not constrained by working hours. Stephen has written this article in a purely personal capacity
Dr Sweeney ("Politics, practice and people: changes at the heart of primary care"; MiP 2007;No 11;36-38) is right to draw attention to changes that will affect general practice in this country in the coming decade – but to this writer's mind he fails to see the wider longer-term objectives, and his belief that Choose and Book is premised on some "committed thinking on behalf of the disadvantaged" is, merely, to present the naive version.
Similarly, when he enthuses that "policymakers want to make sure that less able groups get what their more able and better off countrymen have had for years: choice", he chooses to see only the topiarist's tree, which has been pruned and shaped by the government so as to catch the eye and obscure the less attractive wood behind it.
Does he really believe that in the near future, the "patient and the doctor will jointly come to a decision about the wishes of having a cholecystectomy, and then the patient will choose which hospital to go to"?
I would suggest that few patients would be able, with any real confidence, to enter into meaningful discussions about the merits of various surgical and alternative treatment options for such conditions; they will, as now, by and large continue to rely on their GP's advice.
The GP is a person they have come to know over the years and who knows them, their family and their concerns. The good GP is a friend to his or her patients, and as such will still be expected, in most cases, to recommend the appropriate treatment for the patient.
Discussion will remain at the core of the consultation, but I feel Sweeney exaggerates the codecisional aspect of the near future. The typical patient may expect more say in the selection of the hospital, but this will typically be on the basis of its nearness, coupled with some knowledge of its marketing.
As public relations are much more honed by the private sector, patient choice will probably tend towards the nearest private ("independent") provider – on the proviso that where the patient is not already a subscriber to private insurance, the NHS will pick up the tab.
The future is undoubtedly greater involvement by the private sector. This has the advantage that if the patient is unhappy about his or her treatment, the government can step back and point out that any failure is with the provider, not the purchaser (the NHS), and so sidestep accountability.
Another view might be that with choice must come responsibility, and we might see this developing too. "Choice" is a sugarcoated tablet that obscures the bitter-tasting introduction of fullscale privatisation to our health system.
Sweeney sees GP commissioning as a "must do" policy, but chooses not to explain why it has not succeeded in the four years since it was first launched as a policy objective.(1)
There is still no part of the country that is anywhere near to getting a comprehensive provision of services commissioned via practice-based commissioning (PBC) – it seems the best achievements amount to up to a handful of services, which usually have either been championed by individuals or are pre-existing schemes "rebadged" as practice-base commissioned.
In fact, regular readers of Management in Practice will be well aware that, despite four years of PBC, nothing has really changed. Most primary care trusts (PCTs) are still at the talking stage, going around in circles, pretending that things are about to happen and that they are doing things.
Some are even putting serious effort into getting things moving, and just cannot understand why nothing is really changing. And the truth is not "cock-up" but conspiracy – the policy as presented has always been meant to fail. The emperor really has no clothes.
When it is time to acknowledge this failure – no doubt reluctantly – the government will be able to say they have given every GP/PCT every opportunity to make PBC work. Its demonstrable failure will be announced as soon as the 14 private sector groups approved last autumn (who are currently waiting in the wings, shadowing developments) have their plans in place and it is politically timely.(2) No one could seriously have expected world-class commissioning to be done by amateurs.
The Quality and Outcomes Framework (QOF) is the third policy tool Sweeney refers to as changing the face of primary care. He is right of course – but again, does not tell the whole truth about matters.
The QOF acts as a quality proxy that can be, and has been, coupled with such patient concerns as access and "patient experience". Despite the fact that – as is well known – more than 80% of patients who responded to the government's own independent survey expressed satisfaction with the current arrangements, the government chose to concentrate on the 16% or so who might not have been wholly satisfied, despite having better opening times than their bank offers.
The government is now insisting that providers are not offering a reasonable service in terms of access. Hours must be extended – to shift further in line with hours offered by supermarkets to their customers. Competition is very much the name of the game. Similarly, every PCT is to have a "Darzi" centre whether it needs one or not.
National service frameworks and National Institute for Health and Clinical Excellence (NICE) and Healthcare Commission standards are other tools in creating a surface upon which to reflect a notion of quality – and so develop competition. The healthcare sector is being prepared with increasing rapidity for the arrival of the private sector in ways previously undreamt of in this country since the inception of the NHS.(3)
The private sector cannot get into the marketplace efficiently, however, until they can be given access to all patients. They do not particularly want a surgery in, say, Birmingham, as this will not be particularly profitable for them. What they want is access to everybody – and thus be able to work with the more profitable patients in special, more lucrative, ways.
The best way they can get this is to have access to GP records. This is why we are all busy summarising notes, attending to the Information Management and Technology directed enhanced service (IM&T DES), and awaiting GP2GP.
Once a sufficient number of records are available and accessible wherever there is a computer, patients can be treated anywhere – by any GP or other provider. The second stage of the electronic prescribing project will begin to wean patients out of the surgeries in large numbers.
If any reader remains sceptical that the government has such intentions they need to realise that in the 1995 trade round, as part of the General Agreement in Trade in Services, the World Trade Organization agreed that public healthcare was to be opened up to the private sector.(4) This is part of an international agenda, and a change of government is highly unlikely to alter it – it is happening whether one likes it or not. You have no choice.
"Choice" is merely a tool in enabling fullscale privatisation of the healthcare system. Watch this space – readers of this magazine will be required to help prepare the ground ahead of its introduction.
1. Department of Health. Practice-based commissioning: promoting clinical engagement. London: The Stationery
2. Department of Health. Framework for procuring External Support for Commissioners (FESC). London: The Stationery Office; 2007. Available from: http://www.dh.gov.uk/en/Publicationsand
3. Humphreys SJ. Primary care – time to get ethical. General Practice On-line [homepage on the internet]. August 2007. Available from: http://www.priory.com/medicine/Primary_Care_Ethics.htm
4. Pollock AM. NHS plc: the privatisation of our health care. London: Verso; 2004.