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At the heart of general practice since 1960

How the APMS drive is gaining speed

As Lord Darzi meets 15 firms to discuss running GP-led health centres, PCTs are desperate to keep pace

By Gareth Iacobucci

As Lord Darzi meets 15 firms to discuss running GP-led health centres, PCTs are desperate to keep pace

Word on the street after Gordon Brown came to power was that he might put the brakes on private sector expansion in the health service.

Like most political predictions, that myth has been shot to pieces in recent weeks, while GPs have taken to the streets to protest at what some see as the rampant privatisation of primary care.

Just six months ago only a fraction of PCTs reported any activity in the so-called alternative provider medical services (APMS) arena.

But now at least 15 different companies have held direct talks with health minister Lord Darzi about running GP-led health centres and other APMS practices across the country, while PCTs desperately try to keep pace with Government desire to expose general practice to private competition.

Whether it is in driving up patient choice, increasing GP hours or reducing costs, APMS has become the Government's weapon of choice, with ‘stimulating the market' the new buzz phrase.

APMS is already having huge implication for GPs, with different models emerging, pitting GP against private company and even GP against GP.

Although it has laid broad guidelines, the Government insists it is up to PCTs to decide which bids offer best value for money. But that hasn't stopped persistent accusations of bias towards private bidders, with a Pulse investigation revealing 91% of APMS contracts had been won by private firms.

Empire building

United Health, which recently won a bid to run three practices in north London, has since defeated opposition from GPs, other private companies and even a combined bid from Boots and local GPs, to extend its empire further, this time in Derby.

Boots, a company which originally rejected the APMS model outright, now finds itself pitted against a whole range of private companies in trying to woo GPs, including tycoon Richard Branson's Virgin empire.

At the same time as trying to buy Northern Rock, he claims to have come up with a GP-friendly model by providing the bricks and mortar for new surgeries under his Virgin Healthcare arm but, like Boots, allowing GPs to keep their GMS contracts.

Yet Virgin executives have been given a rough ride by GPs attending roadshows up and down the country. Not only has there been unhappiness at the prospect of losing control of all non-clinical staff to the company, but GPs have given a frosty reception to plans to undergo Vigin customer training and aim for quality marks set in a Virgin quality framework. A VQF, on top of the QOF, for some, is too much to bear.

Yet amid the videos of Sir Richard's outstretched arms, perhaps the most controversial aspect is plans by the company to offer GPs ‘kickbacks' to join them.

Some GPs who attended the roadshows claim they have been offered 10% profit share of other paid-for services in the centres.

Dr Caimin Hardiman, a GP in Norwich who attended a Virgin roadshow in Norwich, says: ‘Where it sits uncomfortably is that in local commissioning, we may want to commission a service, let's say physiotherapy. How would that lie then when you've got a private physiotherapist next door? There is a conflict of interest there.'

A Virgin Spokesperson says: ‘There could be kickback linked to that. I'm sure examples may be quoted at road shows, but they will be discussed and negotiated on an individual practice level. Yes, there will be profit share at our centre but we can't provide detail on the figures.'

No threat?

Yet GPC chair Dr Laurence Buckman says he believes the Virgin model is far less threatening to general practices than others. ‘They're not interesting in damaging practices or running practices themselves. I must say, if Virgin came to me with nice new premises that were conveniently situated near my practice area, I might think twice about going to them. I don't see them as a threat at all,' he says.

The GPC, however, has become increasingly strong in its warnings against the APMS tendering process, recently predicting that all 150 of Lord Darzi's new GP led centres would fall into private hands.

But it is not just private companies which are attracting the wrath of GPs over their enthusiasm for APMS. The prospect of GPs being pitted against GPs is also increasingly raising its head. Privately, several GPs who have taken part in bids as consortia against private companies have admitted they have been forced to cut costs to the bone in order to compete, and then not always successfully.

Successes like that of CNCS, a Nottinghamshire social enterprise collective who recently won a tendering process under the Government's Fairness in Primary Care Procurement scheme, prove multi-national companies will not have it all their own way in APMS.

Anita Dixon, chief executive of CNCS, said the community was pleased it had been chosen ahead of multinational private providers, as yet unveiled, to run the new Kirkby Medical centre, although she described it as ‘the hardest thing we've ever done'. She believes smaller groups of GPs will find it hard to successfully win an APMS contract without coming together and employing a management team.

Yet Dr Charles Zuckerman, medical secretary of Birmingham LMC and a GP in the city, says it doesn't matter who take over a surgery if it is transferred to APMS: ‘It's still local practices that are going to get screwed. If a local practice goes out of business, the partners aren't going to feel reassured that they've gone out of business to a consortia of colleagues or United Health,' he said.

While the different models of APMS stoke up controversy among GPs, PCTs, true to form, are busy panicking about how to introduce the Government's plans. All 150 of them have been given until the end of this month to come up with plans to spend £1m each on a new APMS-run GP health centre.

The 38 most under-doctored areas have been given an identical timeframe to come up with plans for 100 new APMS practices. The Government wants GP-led centres open 8 until 8 and GP practices offering at least five hours extended opening.

Daunting timescale

Yet it has given PCT s only until the end of the year to have the contracts signed sealed and delivered. Jill Norton, assistant director of primary care provider services at Medway PCT, one of the 38 areas in question, admits it will be ‘extremely difficult for some PCTs to meet the targets' due to the daunting timescale and ‘absolutely intense' workload.

In Manchester, Trafford PCT, in discussing its plans for a GP-led centre, admitted that consultation with doctors, via the local PEC board, had been minimal because of the ‘restrictive timescale'.

In a BMJ editorial which cites Pulse's recent APMS investigation, Professor Chris Salisbury, a GP and professor of primary healthcare at the University of Bristol, questions the long-term wisdom of introducing private providers ‘at great speed with minimal consultation'.

While he concedes that the drive ‘could have potential benefits of increasing the pace of innovation', he says it poses ‘serious risks of damaging doctor-patient relationships, increasing inequities in provision, and weakening the professional autonomy of general practitioners'.

Increased accessibility, he argues, will come at the cost of reduced personal care.

At £1m per clinic, let's hope he is wrong.

Dr Moona Rashid takes to the streets after her local consortium lost out to a private contractor on an APMS contract APMS protester Competing models to run general practice Competing models to run general practice

The Boots model


Pros
- GPs retain control over services, and can expand their premises.
- Greater links between GPs and pharmacists.
Cons
- GPs may feel their priorities conflict with Boots's as a private company.

The Virgin model


Pros
- GPs retain existing terms of contract and be offered shiny new premises, a profit-share from other paid-for services in Virgin Health centres and extra quality payments.
Cons
- By employing all non-clinical staff, Virgin will take away some of GPs autonomy in running a practice.
- Profit share may lead to conflicts of interest fears
- GPs and staff will have to undergo Virgin customer training and be subject to a Virgin quality framework.

The United Health model


Pros
- Capacity to increase and improve GP provision and services in some ‘under-doctored areas'
Cons
- Private companies accused of undercutting GP bidders by up to 25% leading to concerns over quality of core services.

The GP-commercial model


Pros
- GPs develop greater managerial expertise, financial muscle and resources to compete with large corporate bids.
- Prevents practices falling into the hands of large multi-nationals.
Cons
- Threaten existence of smaller practices and single-handed GPs
- Are they any better than a ‘private provider'?

The local GP model


Pros
- Strong relationship with patients and local community.
- Preservation of continuity of care.
- Patient-care before profits.
Cons
- GPs may also be forced to slash cost of bids in order to compete with private bidders, meaning they are unable to offer the required quality of service.

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