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Are entrepreneurial GPs good for general practice?

Entrepreneurial GPs are essential to modern general practice, mixing knowledge of care with the business nous to keep the private sector at bay, says Dr Thomas Reichhelm. But Dr Louise Irvine says too many of the new wave of GP organisations prioritise profits over professional standards and are damaging patient care

Entrepreneurial GPs are essential to modern general practice, mixing knowledge of care with the business nous to keep the private sector at bay, says Dr Thomas Reichhelm. But Dr Louise Irvine says too many of the new wave of GP organisations prioritise profits over professional standards and are damaging patient care

Private firms have their strengths at running medical contracts, but on balance GPs are best placed to deliver primary care. My own group of practices is fast growing into a large company, but I still believe general practice is a highly personal matter, best managed and delivered by those who know most about it. Despite what policy makers seem to believe, the immeasurables of general practice far outweigh the target-oriented measurables.

But if GPs are to take a key role in delivering APMS contracts and not be swept aside by the private sector, it is essential we take up the challenge thrown down by the tendering processes. GP practices must actively pursue contracts and submit professional, well-researched bids.

GPs, nurses and practice managers are quick learners. I'm sure where there may be an initial disadvantage - in terms of organisational structure and managerial governance - this will be overcome quickly and organisations such as ours will acquire the necessary skills to survive in a competitive market. But general practice must make an active effort to adopt these new managerial practices. Without them we will not be able to drive improvement, or to carve out our space in the market and stem the advances of private firms.

West Malling Group Practice in Kent recently bid for and won a contract almost 200 miles away in Weston-Super-Mare, Somerset. However, this situation is not akin to the contract having been won by a private firm - a GP-led organisation such as ours can offer the best of both worlds, delivering efficient, professionally planned services while keeping the doctor-patient relationship central. However much we expand, we aim to maintain a personal touch and our own personal frontline involvement, which I am convinced will always set us apart. I suspect local GPs might also find it easier and less alien to deal with their peers from another part of the country than with a private company, although this is still to be proven.

Patients' requirements are far greater and more complex than could ever be captured by performance indicators and who better to know than ourselves? We are often bidding against organisations that employ bid writers and scores of consultants, but nobody is better placed than grassroots GPs, nurses and practice managers to understand what is needed.

On the subject of profit versus best care, I suspect a GP collaborative organisation like mine will still keep going if the profits aren't what they were expected to be. Organisations such as ours do not have to answer to anyone else in terms of finance and are not likely to be under pressure from private equity backers, something which should also reassure PCTs.

PCTs are often under-resourced and may find the prospect of dealing with large companies daunting. But GP-led organisations such as West Malling have worked constructively with trusts in areas such as practice-based commissioning and have also taken part in integrated working with other agencies such as charities.

Entrepreneurial GPs are not only vital to take private companies on at their own game in the competitive primary care market, but they are also capable of drawing from the best that the private sector has to offer, in order to drive improvement, innovation and real benefit for patients.

Dr Thomas Reichhelm is a GP in West Malling, Kent, and medical director of Malling Health

There are fears that general practice could be damaged by private firms winning APMS contracts for GP services. Concerns centre on the primacy of the profit motive, the reliance on salaried doctors, the loss of continuity of care and the replacement of professional values with commercial ones. The Government responded by reassuring us that most APMS contracts were going to GPs. We breathed a collective sigh of relief and the BMA delayed phase two of its Support Your Surgery campaign.

But a closer look at the GP organisations winning contracts reveals a mixed bunch. Some are normal GP practices or locally based consortiums. Others are formed by so-called 'entrepreneurial GPs' - either as companies in their own right or as joint ventures with commercial organisations.

The GP owners do not usually work in these practices - in fact some run them from distant locations. Many are GPs in name only, providing no direct patient care. This is new and there is no research on how these organisations are functioning. But as a programme director for GP training in south-east London, and through personal experience, I have anecdotal evidence that although some entrepreneurial GPs are good employers providing good standards of care, others exhibit the worst practices of the private sector.

In some organisations salaried doctors are forced to work long surgeries and antisocial hours (affecting female doctors with young families hardest). A high nurse-to-doctor ratio and patient triage means doctors see only complex cases, but with only 10 minutes to do so (reportedly 7.5 at one GP company). Doctors may be moved around three or four practices at short notice, with little chance of getting to know either the patients or the area. Continuity of care is jeopardised. Often there is no senior colleague working alongside younger doctors, few clinical or team meetings, no study leave, no autonomy, no prospect of career advancement for salaried doctors and much worse pay and conditions than the standard BMA contract.

To what extent these are just bad apples or represent a fundamental threat to general practice is difficult to know. While such employment methods can be found in some traditional GP practices, they seem more a feature of the commercial sector (GP or non-GP). The more an organisation is driven by the requirement to maximise profits, the more it will be compelled to minimise costs in the way it deploys staff.

The impact on patient care is a serious cause for concern. Patient safety may be put at risk and the quality of consultations diminished. Continuity of care needs doctors to stay in an area for a long time, but some practices have become notorious for high staff turnover and reliance on locums. GPs are expected to demonstrate 'community orientation' and contribute to improvements in local health services. What hope is there of such doctors developing those skills? It takes time to get to know a community.

This knowledge is fundamental to our patient advocacy role. When inexperienced doctors work under pressure it is risky, unsatisfying for patient and doctor and inefficient - leading to more investigations, prescribing and referrals. A workforce of recently qualified doctors misses the exchange of experience that can occur when younger and older doctors work side by side. A two-tier system, where one group of doctors exploits a sub-grade, will undermine the profession. My worry is that these developments are already having an impact and may be part of the explanation for the fall in applications for GP training in some areas and reduction in applications for GP jobs.

The important distinction is not between 'GP organisations' and 'private firms' but between organisations driven by commercial values and by professional ones. We need to develop models that preserve our professional standards and develop the GP role in all its dimensions, so the brightest, most committed young doctors continue to be attracted to the profession. Our patients deserve no less.

Dr Louise Irvine is a GP in Lewisham, south London, and a programme director for the Lewisham-wide GP training scheme

Are entreneurial GPs good for general practice? yes no

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