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At the heart of general practice since 1960

Can primary care benefit from private sector involvement?

Emma Wilkinson looks at the evidence for claims private involvement will raise NHS standards.

Emma Wilkinson looks at the evidence for claims private involvement will raise NHS standards.

The NHS and the private sector is one of those volatile combinations on which everyone seems to have a view.

On one hand, campaigners take to the streets to protest against privatisation. On the other, the National Audit Office chastises PCTs for being too cautious in their use of APMS.

But although the opinions are robust, the evidence on which they are based is less so. Does anyone really know whether the private sector will improve the NHS?

Primary care is a relative newcomer to the debate. The guinea pigs were independent sector treatment centres in secondary care, and it is only here that the policy drive has been formally evaluated.

Those evaluations, though, have been inconclusive. A health select committee report in 2006 concluded there was no evidence the centres had increased NHS capacity or improved quality of care. And earlier this year, a University of Edinburgh analysis questioned the basis for continuing the programme.

But although the Government seems to have gone cool on private provision in secondary care, it is continuing apace with its plans for general practice.

There is a fair amount of catching up to do, with 4% of secondary care provided by the private sector, but only 1.2% of primary care, according to data obtained by Pulse under the Freedom of Information Act.

The NAO recently criticised trusts for their slow progress on use of APMS, after finding nearly 80% had implemented none of the contracts to date.

By the end of this year, every trust in the country will be expected to have plans for an APMS-led health centre, and 38 underdoctored areas are to have a further 100 APMS practices.

Open to question

How much that policy drive is evidence-based is open to question. Dr Robert Morley, executive secretary of Birmingham LMC, is among those who warn that meaningful evidence of benefits is hard to come by.

He asks: ‘How do you define quality?

It is unmeasurable and you can't draw a concrete conclusion from QOF scores.'

Dr Morley adds that many of the contracts up for tender are in previously poorly scoring practices with little recent investment, making improvements almost inevitable, whoever takes them on.

Nevertheless, some private companies are keen to highlight their success at improving care under APMS.

In September 2006, UnitedHealth signed one of the first APMS contracts between the NHS and a private firm, taking over the Normanton Medical Centre in Derby after a GP retired.

UnitedHealth has since been announced as the preferred bidder for a second practice in Derby and three in Camden in London, and a report recently presented at a Derby City PCT board meeting paints a glowing picture of progress under the company.

It claims UnitedHealth has made ‘considerable improvements to patient care, the patient experience and staff morale', with the practice increasing its list by 30%, raising QOF scores from 81 to 94% and extending opening hours.

Dr Peter Smith, director of primary care at UnitedHealth UK, says: ‘Improvements at Normanton include the recruitment of two permanent GPs, a nurse practitioner and a practice nurse.

'We've also been working to identify patients with long-term conditions such as asthma, heart disease and diabetes and calling them into the surgery. This is the type of work that will help us deliver to patients the care they need and expect.'

Dr John Grenville, chair of Derbyshire LMC, admits UnitedHealth has done a good job with the practice in a potentially tricky deprived area.

But he remains sceptical, believing as a large organisation it can run the practice as a ‘loss leader', and that private providers may also be getting more money from PCTs than other practices.

These suspicions appear to be supported by a response from Derbyshire County PCT to a Freedom of Information Act request, showing a recent contract with private firm ChilversMcCrea Healthcare for services at Creswell and Langwith was worth £84 per patient – well above the area's average.

Dr John Ashcroft, a GP in Ilkeston, Derbyshire, who put in the FOI request, says his practice only receives £60 per patient under its core GMS contract. ‘Why should one set of patients receive 40% more funding for their care than others? Theirs is a fairly deprived coal-mining area, but so is mine. We've lost nurses to PMS practices and can see that potential from APMS too.'

But Dr Rory McCrea, former GP and chair of ChilversMcCrea, says the comparison is unfair. ‘You can't judge on price per patient as the contracts are not like for like with GMS. For example, lots are being set up with extended hours.'

He says doctors had been recruited and information systems set up. ‘We're confident improvements will be made.'

ChilversMcCrea also runs three practices in Nottingham – one specifically set up for hard-to-reach patients, such as those who are homeless or suffer drug addiction.

More recently in Nottinghamshire, another GP-led company was announced as the preferred bidder for a contract in Kirkby-in-Ashfield, with proposals for a further three practices in underdoctored areas plus a GP-led walk-in centre.

Dr Greg Place, chair of Nottingham LMC, says the new Kirkby-in-Ashfield practice will indeed increase capacity, but warns that as it has no list, it will be poaching from its neighbours.

He also believes the exercise has already had an indirect and detrimental impact on patient care, by tying up GP time in the procurement exercise. ‘It was a phenomenal amount of work that took up resources,' he says.

Dr Place adds: ‘There is a role for APMS in inner-city areas where the PCT can't get anyone else in. But mainstay GMS is being left behind. We must get the basics right or we'll lose the foundation of primary care.'

In other areas of the country, too, feelings are raw over the Government's proposals for APMS health centres.

Dr Sue Roberts, a GP in Bridgwater, Somerset, says there is such concern that 68 of 73 GPs placed an advertisement in the local paper warning patients of the potential risks.

‘What might be right for areas that don't have good GP provision is not necessarily right for Somerset,' she says. ‘Private firms' interests are profits. Patients are not going to get to see a GP who knows their family.'

Continuity of care

A study of almost 2,000 patients by Dr Peter Bower, a reader at the National Primary Care Research and Development Centre, suggests any loss of continuity of care would be keenly felt by patients, who valued seeing a doctor they knew more highly than convenience of access.

‘The focus is on access at present but this study shows continuity is a major issue,' he warns.

But Dr James Heath, managing director of Aston Healthcare, which runs eight practices in Liverpool and Mansfield, says continuity of care can be achieved without a patient necessarily seeing the same doctor.

‘One way to look at continuity of care is the patient pathway – making sure we have full protocols in place,' he insists.

Dr Heath also cautions against making a snap judgment over APMS providers, warning that it can take years to turn round failing, rundown practices.

But it is not in such poorly performing practices that us eof AMPS is controversial.

Dr Richard Vautrey, deputy chair of the GPC, says: ‘What we are concerned about is areas where that isn't the case and where existing GPs want to fill that service. This is where it is a problem, with local practices having to compete with outside providers.'

Whether such competition will galvanise primary care, or merely fragment it, is another question still to be answered.

Case study

How a GP-led APMS scheme can work

Dr James Heath says when his company Aston Healthcare took over one practice in South Knowsley, Liverpool, four years ago, it was in a dire state.

‘It was a singlehanded practice in a converted council house. It had a list size of 1,600 patients,
ran one surgery a day, and had no nurses, no IT and no recall system for cervical smears or vaccinations.

‘Once you have it stable and safe you can then look at developing the practice. We refurbished the building – with the PCT's support – even though we were moving to a new LIFT building in six months.

‘We now have one full-time GP, a nurse clinician and a practice nurse. And we open 8am to 8pm four days a week. The list size is up to 2,000 patients and we now run our own ultrasound service, osteoporosis screening service and minor surgery clinic.'

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