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Andy Jones: Lower margins, lower quality

The NHS is getting more complicated. More and more time is being spent away from patient care, embroiled in bureaucracy, trying to hit targets ­ and trying to get one's head around new buzzwords. The latest of these is 'contestability'.

Contestability means new services, and perhaps even existing services, being put up for grabs. It means a battle of the lowest bidder.A few years ago, when a struggling practice started to fail, PCTs had a very real problem. Salaried GPs would be parachuted in as a temporary measure and the PCT would try to patch up the situation.

Things are now very different. Now the PCT simply has to place an advert asking for tenders from interested parties.Recently there was a case in Derby where two practices were approached for takeover. There were apparently 28 expressions of interest by various outfits. Perhaps unsurprisingly the organisation with the most clout and the glossiest brochures won.

It comes as no surprise that big medical organisations are looking for easy pickings in inner-city areas and looking for substantial profits too. They argue that medical competition will improve patient options ­ and so it will. But will it improve quality of care?Last year PCTs drew up a couple of sides of A4 for each local enhanced service. There wasn't much to negotiate and practices signed up, partly because they were grateful that a compromise was on offer, partly to show willing after the new contract windfall.

The climate has now changed. Now we are being asked to tender for services. I have one such request on my desk. It is thicker than this edition of Pulse and among other things asks me to describe eight areas of warfarin care.

One of the strengths of primary care is the comprehensive nature of the attention given to patients. I doubt if anybody bothers to work out in precise detail how much a baby clinic is subsidising nursing home care, for example. By the time professional hours, pensions, room cost, equipment and consumables are considered, a great many areas of primary care would turn out not to be viable.

But now, under contestability, everything will be priced to the nth degree, everything will be judged as 'effective' purely on financial terms.It has been famously said of America's space shuttle: 'How comfortable would you be sitting on top of 535,000 gallons of liquid hydrogen and oxygen and millions of moving parts all provided by the lowest bidder?'The same jibe could apply to health care.

We are going to see increasingly reduced margins for the bolt-on areas to primary care. We don't know how this new health care world will be regulated. So one can't help concluding that the result will be lower quality.

Dr Andy Jones is a GP in Stamford, Lincolnshire

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