A very short letter from a Tory MP in response to a detailed and serious letter from a constituent raising concerns about the government’s proposed NHS reforms:
Thank you.
Are GPs private contractors?
Should they be nationalised and made salaried state employees?
Sir Peter Bottomley MP
To answer a constituent’s seriously considered letter of concern with a rhetorical question is bad enough, two rhetorical questions borders on contempt.
Nevertheless the first ‘question’ pops up quite frequently, though usually as a statement, “GPs are private providers! (ah ha, I bet you never thought of that, all your arguments against privatisation are now null and void!”) Usually that is the breadth and depth of their contribution to the debate.
The first ‘question’. Yes GPs are private business, but …
A GP working in private practice sees private (non NHS) patients. That is people who prefer to have a different service (longer appointments, unusual hours) or do not qualify for NHS care, eg. diplomatic staff, etc. The majority of GPs work to NHS contracts, follow NHS guidelines and see NHS patients. They do not compete for patients, or profit in the way competitive providers of healthcare do.
GPs services are increasingly being run on APMS (Alternative Provider of Medical Services) contracts. The ‘traditional contract’ is GMS (General Medical Services). GMS terms are set nationally and renegotiated from time to time with GPs. APMS contracts were introduced in 2004 by New Labour to allow some ‘constructive discomfort’ for existing providers by encouraging ‘any willing providers’ to run primary care services. The ‘privatisation of the NHS‘ was started years before the present government, hence the reforms are ‘evolutionary’. The pace, the restructuring and the cuts mean that they are also ‘revolutionary’.
There have been two main consequences of opening up general practice via APMS.
The first was the introduction of ‘alternative providers’. These are the private health companies who had been lobbying the department of health, private equity companies looking for new profits, and entrepreneurial GPs. They include Richard Branson’s Virgin group who operate at least 350 GP surgeries and Sainsburys who have 6 GP ‘surgeries’ and are planning to open more in-store surgeries. Opening up the NHS also helps MPs with private healthcare business interests. These are described in detail in the book, The Plot Against the NHS.
The second was to allow practices, including all their patients, to be treated as commodities to be bought and sold for profit. Chilvers McCrea was set up in 2003 by GP Rory McCrea and Nurse Sarah Chilvers. The company began with the management of a failing GP practice in Chelmsford, Essex and by 2009 had APMS contracts for over 35 GP surgeries and three walk-in centres. They were bought by another private company, The Practice in 2010, thanks to investment from venture capitalists, MMC Ventures. They have been criticised for their staff contracts and for closing a practice in Camden this year. This year the UK branch of US health insurance giant UnitedHealth, UnitedHealthUK sold its six practices to The Practice.
Traditional general practice is a cottage industry. The old system of independent GP surgeries allowed GPs to provide a long-term stable service to a community and over the years build up a detailed knowledge of their patients and the local area. In my own practice, the retiring partner has been here for 28 years and there are over 100 years of combined experience amongst the other 5 partners. We have personally invested in the practice and the community. General practice for us is a ‘labour of love’ more than it is a business opportunity.
Comparing traditional general practice with the new private players may be like comparing Arthur’s cafe with Starbucks. It may not matter if your barista changes every couple of months, but for people with long-term conditions, a long term relationship with a GP is vital. There are already examples in general practice. International IT company, Atos origin won a tender for a GP practice in East London after bidding against established local surgeries. They lost the tender only 3 years into a 10year contract because they could not provide the service needed at the unrealistically low price they had bid. Too much emphasis was placed on cost and too little on local knowledge. Patients complained that there was a high turnover of salaried doctors and continuity of care was very poor. Atos have also had severe criticism for theirwork capability assessments.
Reasons to support ‘alternative providers’.
One reason supporters of NHS reform give for ‘alternative providers’ is that they want to introduce competition and break up the NHS monopoly. There is no monopoly in General Practice. Or at least there was not until the APMS contracts started. Now The Practice are running nearly 60 surgeries. This is unprecedented in the history of the NHS. Private company Care UK run 13 GP surgeries. They were bought by private equity company Bridgepoint last year.Very soon there will be more consolidations and fewer independent GP practices as this report from the NHS federation details. Before long, your local GP with a long-term committment will be replaced with the part-time salaried employee of a global giant and there will be very limited or no choice at all. This will be a disaster for continuity of care on which our most vulnerable patients depend.
It is very uncommon for a traditional GP surgery to go bust and be forced to close, but large corporations do so with alarming frequency. Circle Health is Europe’s largest healthcare partnership and has been given the contract to run Hitchinbrook hospital. Uncritical journalists and politicians fall over themselves to laud it as the saviour of the NHS, but as an article published today reveals, it is in dire financial straights. Richardblogger goes further with his analysis. Southern Cross runs 752 elderly care homes with 31000 residents, and is in a desperate bid to avoid administration.
The consequence of ‘alternative providers’ is that some will become ‘too big to fail’, raising the ugly spectre of massive multinational corporations having to be bailed out with taxpayers money. All over again. The alternative is that they will be ‘too big to save’.
The second reason supporters of the government’s NHS reforms give for allowing ‘alternative providers’ is to allow entrepeurism. One such entrepreneur is Dr Paul Charlson. According to Spinwatch,
Dr Paul Charlson, is indeed a GP in favour of Lansley’s reforms. He also runs a private centre which specialises in cosmetic anti aging treatments (Botox), not typical of most GPs. Charlson is also spokesperson for a lobby group called Doctors for Reform, which is supported by the free-market think tank, Reform. Funding for Reform has come from the UK’s largest private hospital group, General Healthcare Group and other private health companies set to benefit from Lansley’s reforms.
Dr Charlson and I both spoke to the Health Committee last year,
Dr Tomlinson: I don’t believe that it is in patients’ interests to have lots of people competing to do your blood test. Why do not all of my patients have it in my surgery? Why have somebody open up, next door, for instance, saying, “Blood tests. Come here and get them done even quicker than DrTomlinson”? What’s the point of that?
Dr Paul Charlson: It is innovation. That’s the point. It is encouraging innovation. That’s what you need because that’s why we have been stuck …Okay, but the fact is we have been stuck, for years and years and years, not being able to innovate. I am a real innovator and I have been incredibly frustrated by the restraint of what we have at the moment. We just cannot innovate and provide better services for patients. That’s what it is about.
For Dr Charlson and others, entrepreneurism means profiting. It has nothing to do with addressing the needs of vulnerable people. Private companies are not queuing up to provide drug and alcohol rehab or psychological treatment to people around here. I know a lot of innovative GPs who are not ‘incredibly frustrated’. Many GMS surgeries already offer a wide range of services that patients need that were previously only available in hospital, like physiotherapy, psychotherapy, minor surgery, blood tests, heart tracings and so on. None of the GPs I know would consider replicating or cherry picking a perfectly good service just because they could make some money. None of them believe that patients are consumers or that health and healthcare should be treated like commodities to be traded for profit. All of them are committed to improving patient care.
In answer to Sir Peter Bottomley MP’s second question, I would say, ‘possibly’. The advantages of a cottage industry of independent GPs is most eloquently argued in this essay by an American GP (Family Practitioner) David Loxterkamp, The Dream of Home Ownership. He contrasts the traditional model with the corporate model where GP surgeries are owned by large corporations or hospital networks. This is what we should be comparing, because whether I believe that nationalised, salaried general practice is preferable to the traditional model or not, it is not the choice we have, or are likely to have in the near future.
Updates
US study finds smaller, physician-owned practices have lower rates of hospital admissions. (link to study) 19/08/2014
When the privatisation of GP practices goes wrong Guardian 19.12.2012
The Rise of the Corporate Physician, and the “Metastasis of Big Corporations”
Healthcare renewal blog, “Public discussion has raised more questions over the last few months about physicians taking care of patients as corporate employees”
08.02.2012
Private firm closes flagship GP practice in north London Camden New Jounal
GP practices in north London have been told they must absorb 4,700 patients in the next two months after the leading private health provider The Practice Plc announced it will close a high-profile GP practice less than a year after taking over the service. The Camden Road Surgery – a long-standing GP practice which has been at the centre of the NHS privatisation debate ever since it was taken over by US health giant UnitedHealth in 2008 – will close its doors in April, with plans in place for a ‘mutual termination’ of its APMS contract with NHS North Central London.
No plans to open new surgery Camden New Journal Feb 16th 2012
Dr Douglas Russell, medical director of the North Central London sector NHS trust, was speaking at an emergency debate at the Town Hall last Thursday about the closure of the Camden Road Practice.
Its private operators, The Practice Plc, announced last week that the surgery will close in April leaving 4,700 patients astounded.
Dr Russell said that under government reforms the NHS could no longer employ its own doctors or buy new premises for a new surgery in the area.
He added that tendering for a replacement would simply invite more private firms looking to profit from the NHS in Camden.
Dr Russell said: “I am struggling to understand what the alternative action is. We don’t provide services directly, we are not allowed to any more.
“A few years ago, we would have been able to take the practice over ourselves and directly employ staff and doctors.We are no longer allowed to do that.Surely you are not asking us to go through another tendering exercise – are you? Be careful what you wish for.
“My experience is that other providers find it incredibly difficult to make a success of general practice.”
It’s is very rare indeed that a ‘traditional’ GP surgery closes.
Patient protest at troubled surgery run by Concordia Health Isle of Thanet Gazette June 22nd 2012
