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A faulty production line

Opening general practice to private providers 'may have worsened patient care'

Traditional models of general practice continue to provide the best patient care while APMS providers seek to transfer costs to secondary care through higher numbers of referrals and exception reporting, new research has found.

A study published in Journal of the Royal Society of Medicine found that APMS practices provided worse quality care than practices on GMS or PMS contracts, even when the demographical differences such as age and deprivation were taken into account.

It concluded that opening up the NHS to competition from private providers ‘may have even led to worse care’, and calls on commissioners to hold APMS practices to the same standards as GMS and PMS practices.

The study comes as Pulse reported last year that NHS England said it would replace all closed practices with APMS contracts, a vow they seemingly backtracked on, but there remains a drive to increase numbers of APMS practices.

GP leaders said that the opening up of general practice to competition has been an ‘unmitigated disaster’.

The researchers intended to look at the effect of allowing new entrants, including private companies, into the primary care market under APMS contracts in 2004.

The study identified a total of 347 current APMS providers, 4.1% of the 8,300 GP providers in England, and assessed their performance across 17 national quality indicators drawn from the GP patient survey and QOF.

The results showed that APMS providers performed significantly worse across 13 out of the 17 indicators (p=<0.01 in each) in each year from 2008/09 and 2012/13, and were significantly worse than traditional general practice in three out of the five years for a further two indicators.

APMS practices were found to have scored worse than traditional practices on:

  • Total QOF scores;
  • Clinical QOF scores;
  • Total exception reporting;
  • BP control in hypertensive patients;
  • Exception reporting of hypertensive patients;
  • HbA1c control in diabetes patients;
  • Exception reporting of diabetes patients;
  • Cervical screening coverage;
  • Cervical screening exception reporting; 
  • Ambulatory care sensitive condition admission rate;
  • Tonsillectomy admission rate;
  • Patients’ ability to get appointment;
  • Patients’ ability to see preferred doctor;
  • Recommending GP;
  • Overall patient satisfaction.

The study did identify a higher percentage of patient satisfaction with opening hours in APMS practices for four of the five years sampled, and a higher percentage of low-cost statin prescribing than GMS or PMS practices in three out of five years.

But it concluded: ‘Taken together, these findings suggest that allowing new alternative providers into the primary care market in England has not led to better care for patients – and may have even resulted in worse care.’

The researchers said that APMS practices’ ‘higher levels of exclusions from a national pay-for-performance programme and higher referrals of ambulatory sensitive conditions to secondary care’ warranted further examination.

They added: ‘These latter two findings raise the possibility that APMS providers may be acting to maximise profit from pay-for-performance systems and shifting costs from primary care to secondary care.’

Dr Christopher Millett, lead author of the study, from the School of Public Health at Imperial said that new providers were allowed to enter the market ‘to stimulate competition’, but their findings suggest ‘that their introduction has not led to improvements in quality and may have resulted in worse care’.

He adds: ‘The lesson is that increasing diversity does not necessarily lead to better quality. Regulators should ensure that new providers of NHS services are performing to adequate standards and at least as well as traditional providers.’

Dr Robert Morley, who chairs the GPC’s contracts and regulations subcommittee said the results were ‘no surprise whatsoever’, and that commercial partners are handing contracts back because they ‘can’t make enough money out of them’, leading to patients being left without a GP.

He added: ‘So the whole thing has been an unmitigated disaster. And yet we still have NHS England with a default position that if a practice closes or a contract is terminated, this has got to go out to APMS procurement because they’re frightened of any sort of challenge over the competition regulations.’

JRSM Open; available online 24 April 2015

Readers' comments (28)

  • So the research shows that GMS partnerships offer the best care.

    Such a shame that the partnership model has been killed off. It is now beyond resurrection, just when people realise what they have lost.

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  • The bears have returned to the already full woods to find the corpse of general practice and just decided to s*** on it instead.

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  • The turnover of newly qualified inexperienced GPs in our neighbouring practice means that the patients can have no continuity of care and the GPs can have no useful support from experienced peers. This is one of the few times you dont get what you pay for.

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  • 7:21am.

    I totally disagree with your statement that the newly qualified inexperienced GPs could be the reason.

    Do you think that the partners who are perennially lazy, forever work part-time and who hang on to their jobs even when some of them cannot even keep up to date with the latest guidelines - could improve patient care.

    The main reason for General Practice to be getting worse day by day is the outdated and useless partnership model which is still sadly present in the UK.

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  • @7.31

    I'm sad for you that you appear to be so unhappy in your job. In our surgery the Partners work harder and longer than the salaried doctors (as it should be). I wouldn't say that any group is clinically better than another group. Perhaps find a better surgery to work in?

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  • I do not agree with 7:21. If you work in a practice with lazy partners that is your fault. There are jobs a plenty! Great practices with great dynamic partners. There are also several practices which do not use salaried only partners so everyone shares the burdens and successes equally.

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  • above comment was meant for @7:31

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  • Wow
    The above comments scream out the problem and offer no solution.
    Don't offer or accept salaried and the problem goes away.
    This then closes off the ability to exploit (except 10 years to parity ;0 ) and if I was young I'd start salaried now!
    Oops - no solution

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  • 'The main reason for General Practice to be getting worse day by day is the outdated and useless partnership model which is still sadly present in the UK.'

    Were you paid to write this? The reason for problems with general practice relates to a decade of cuts to its funding, a recruitment crisis, over-regulation and constant political interference buy a government hell-bent on privatizing the NHS via the back door.

    Partners work hard and do masses of management that private companies will never be able to deliver with current funding. GPs shoulder a huge burden of risk that the private providers just aren't prepared to swallow. When APMS contracts fail, the patients are just cut loose with nowhere to go whereas partnerships tend to be more flexible and robust.

    If you don't like your present job, find another but denigrating your colleagues who are propping up the NHS is just plain spiteful.

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  • General practice can only survive within a partnership model.

    There are plenty of excellent high earning practices, but even they are struggling to recruit. Because young GP's are scared off and often have no understanding of the business aspects of being a partner.

    Historically you would learn this under the wings of a Senior Partner. However in my role now many young salaried GP's treat the Job as a shift job and want to clock on and then off.

    Primary care needs to support and nurture partnerships - everything else falls apart otherwise.

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