Government reforms to primary care have shifted professional control away from general practitioners and financial control away from government, argue senior doctors in this week's BMJ.
The changes raise important questions about public accountability, they warn.
Since 2003 the UK government has created a market in primary care, write Professor Allyson Pollock and colleagues. This means that general practitioners are no longer contracted directly to the NHS and primary care services can now be purchased from corporate contractors using commercial contracts.
In March 2007 about 30 companies held commercial contracts to provide primary care services in England. These include general practitioner owned and operated companies; international healthcare corporations, including drug companies; and companies providing catering, cleaning, and laundry services under private hospital contracts.
But the authors warn that decisions about services have shifted from general practitioners to contractors. Commercial contracts, they say, have implications for service planning, public accountability, access to health care, and government control.
Market forces have also changed the legal basis of service provision and have replaced government regulation as the principal regulatory control. This allows alternative providers considerable freedom with respect to staff terms and conditions and the way in which care is provided.
Finally, they argue that the introduction of commercial contracts will see the jurisdiction for healthcare policy and law move away from national government to the European Union, even though the EU's mandate is trade and commerce and not public health.
The government has allowed more firms to provide NHS funded primary and community care because it believes that competition will improve the public health, write the authors. But nothing is yet known about the consequences for access, costs, quality, and accountability. It is surely time to evaluate the policy, they conclude.