The launch of an NHS healthcare centre and GP branch surgery in a Boots the Chemists store in Poole, Dorset, is being hailed as an innovative way of making health services more accessible to patients.
Although the company, Alliance Boots, is only leasing the space to the local primary care trust (PCT), this is the first time that the NHS has worked with a high-street retailer to provide patient services in a town-centre store.
The move has provoked comment because it has coincided with the government's announcement of plans to open up the provision of GP services to a whole range of new providers, which could include supermarkets and retail pharmacies.
Some fear this is a backdoor way of privatising the NHS, which could spell the end of traditional general practice. But others argue that if the services are commissioned responsibly they could improve access to primary care, particularly where it is badly needed in underdoctored areas.
Location, location, location
Bournemouth and Poole PCT says its new instore healthcare centre ticks all the right policy boxes and delivers considerable benefits to patients. It argues that locating the centre at the heart of a busy shopping centre provides several benefits:
It is also providing much-needed space for a branch surgery for a cramped town-centre practice: the Carlisle House Medical Centre.
The healthcare centre occupies an empty clinical space, which became redundant a few years ago when Boots closed a loss-making private dentistry and chiropody suite.
Located on the first floor, above the store, the centre has nine consulting rooms housing the branch surgery, plus clinics providing phlebotomy, heart ultrasound, back pain and stop-smoking services, dietetics, podiatry, physiotherapy and an orthopaedic medical service.
The deal has worked well for everyone. It has solved a problem for the PCT, which was looking to provide more services outside hospital but owned few suitable premises in the town. Most GP surgeries, especially those in the Poole Town area, have been unable to provide new services because they too are experiencing space pressures. A proposal to redevelop a former hospital site would have cost around £4–6m.
Boots refurbished the premises to a high standard at no cost to the PCT, and is charging an attractive rent.
The company anticipates that the healthcare centre, expected to provide 60,000 patient appointments within two years, will increase footfall in the shop as well as the volume of prescriptions dispensed by the instore pharmacy.
The Carlisle House Medical Centre is also happy because it now has the space to expand its services.
The branch surgery opens from 8.30am to 5pm, in line with the store's opening hours. Healthcare staff see around 120 patients a week, and deal with about 30 telephone consultations. It offers easy access for people with disabilities, as there is a lift from the store.
Practice manager Hugh Marsden says the new health centre is a pleasant place to work, and has been welcomed by patients: "This is a service that people want and need, and is right where they want it. The accommodation is very pleasant, clean and smart.
"Patient feedback has been very positive in the main, as the store is in the centre of Poole and many can walk there either from the bus station or directly from the car park without getting wet."
He adds that there have been no drawbacks, although he does admit that despite their best efforts to inform everybody that they are still an NHS practice, there has been some confusion as to whether Boots is actually running the practice.
Rob Payne, the PCT's elective and diagnostics commissioning manager, says that pulling together all the stakeholders involved in the project was hard work. "The challenge was to get a number of services to work together in a way they have not done in the past," he says. "During the planning stages we had to work out the logistics of having six to eight different services all working together under one roof."
Mr Payne is adamant that there has been no blurring of the line between the commercial sector and the NHS. "Early on, we built our relationship with Boots, being very clear about what the NHS wanted to achieve and what Boots wanted to achieve. Our aim all along has been to improve the provision of services to meet local needs."
He adds that there has been no local criticism of the project, and that local GPs, hospital managers and local people have been involved and consulted with from the outset. "We have achieved a consensus and it has worked out extremely well," he says.
Alliance Boots has been delighted with the pilot in Poole and, according to media reports, the company now plans to roll out GP surgeries in up to 150 stores. Alex Gourlay, Boots healthcare director, told The Sunday Telegraph: "There is a lot of interest".
In a press release, he comments that the project is an excellent example of the way pharmacy can become involved in the wider provision of healthcare. "The pharmacy is more than just a place to pick up prescriptions, and we hope that this development will help demonstrate the increasing role that the pharmacy can play in people's lives. As modern life means people lead busier lives, Boots has the aim of making healthcare more accessible and convenient."
While most commentators have no problem with private companies renting space to GP surgeries, some are concerned about the prospect of retail pharmacies and supermarkets taking over contracts to provide GP services.
Since March, the government has been inviting bids from new providers – such as existing entrepreneurial GPs, social enterprises and corporate independent providers – to provide services in specified underdoctored areas.
Dr Hamish Meldrum, chairman of the British Medical Association (BMA), insists that existing GPs have a cost-effective track record of providing top-quality services for patients, and must be allowed to bid for the new resources on an equal footing with any newcomers to the market. "What we don't want to see is any attempt to use this announcement as a backdoor way of privatising the NHS," he warns.
Dr Kailash Chand, a GP in Ashton under Lyne and a member of the BMA's General Practice Committee, objects to supermarkets running GP services because, he says, their central aim would not be the interests of patients, but to make a profit.
"These supermarkets would want to employ salaried GPs who would not be able to provide continuity of care, and this would not be convenient for some patients – for example, those with mental health or chronic disease conditions who prefer to see a doctor they know," Dr Chand says.
He fears that allowing the private corporate sector to run primary care services could spell the end of traditional general practice: "The danger is that we could sleepwalk into this, and then suddenly, as has happened with corner shops, we won't see small general practices any more."
The Department of Health's national clinical director for primary care, Dr David Colin-Thome, dismisses these concerns. Speaking on a Downing Street webchat, he says: "I think the answer lies in our own hands as GPs. We know we provide in general an excellent service to our patients and we seem to be much-loved, so any commissioner would want to encourage what has been the heritage of British general practice.
"Private providers may want to own and manage practices, but the PCT will ensure that the quality of care, which includes continuity, will not be damaged."(1)
Checkout the reaction
Patients themselves are not overly enthusiastic about the prospect of seeing a GP in a supermarket. In a poll of 729 adults in July last year, Opinion Health, an online market research company, found only just over a third (37%) of patients would be prepared to visit a GP surgery in a supermarket, and only 16% thought privately run surgeries at supermarkets would offer a better service than their current GP surgery.
Neither does it appear that supermarkets are jumping in feet first. Only Sainsbury's admitted to Management in Practice that it was actively considering the idea.
A spokesman for the supermarket said: "We have responded positively to the government's interest in GP surgeries. We are committed to working with them on delivering at least one GP surgery instore, and we are currently looking for potential sites."
Tesco says they have provided health centres alongside some of their stores, and their 200 instore pharmacies also now provide a range of services to support GPs: from smoking cessation and dietary advice to minor ailments and medicines. But a spokesman insisted: "We currently have no plans to offer GP surgeries instore."
David Stout, PCT network director of the NHS Confederation, says any move by the government to improve access to primary care is to be welcomed, but whether the idea will take off with the corporate sector is hard to say.
"You can't just wander off the street and start running primary care services," he says. "Health services would have to be procured, and would have to meet certain specifications and quality and governance requirements. PCTs would have to be confident that any of these innovative new services were safe and effective."
Dr James Kingsland, chairman of the National Association of Primary Care, says in principle he has no issue with new providers offering primary care services as long as they are commissioned for the right reasons, they increase capacity and that patients are included in any decisions made at a local level.
"You can't just employ a couple of doctors and nurses and say: 'Hey presto, here is a general practice'. Delivering high-quality primary care is more complex than that; it's all about how you build your team, how you assess and service local needs. It is not about salaried doctors and nurses measuring blood pressure and giving injections in Boots," Dr Kingsland says.
He continues: "The enigma for me is how Tesco or Boots think they will somehow make a profit from the NHS. This is an internal market; it's not a real market and is a cash-limited system, delivered through taxpayers' money. The only way independent contractors in general practice succeed is by improving on a fixed contract by managing their expenses well."
New Forest GP Dr Nigel Watson, who is chief executive of Wessex Local Medical Committee, which represents general practices in the Poole area, comments: "Our issue was not with Boots being a landlord – a lot of third-party developers have developed surgeries or chemists next door to their stores, and the synergy of two working together can be helpful. The idea of stores or pharmacies working as landlords in cities where there is no building space for general practice makes some sense."
But, he says, their worry was that a corporate giant like Sainsbury's would be interested in capitalising long-term, and would have the resources to open a practice as a loss leader, which could put neighbouring practices out of business.
However, he adds that there may be nothing to worry about – a couple of supermarkets he has spoken to have told him they would not be interested in running GP surgeries in their stores because they could make more profit from shelf space.
Michael Sobanja, chief executive of the NHS Alliance, points out that general practice is already run by private providers, and if any new corporate providers come along and offer a good service to patients that should not be a concern.
But, he warns, GPs and practice managers should be aware that the world is changing: "I have every confidence that GPs and everyone working in general practice can meet this challenge. Providing primary care services is not an easy job to do and general practice does it very well at the moment," he says.
"If supermarkets or anybody else think that there are easy pickings here, they have got news coming to them. But neither is it an option for GP practices to just sit there and put their heads in the sand."
1. 10 Downing Street website. Transcript of Dr Colin-Thome webchat. 6 February 2006. Available from: www.pm.gov.uk/output/Page9014.asp