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Private firms will save the NHS

The entry of private companies into primary care will improve care for all, says UnitedHealth Europe's Dr Richard Smith

The drive to introduce the private sector into the NHS is occurring for a range of different reasons, with the policy designed to inject competition, increase the capacity of the health service and bring in new ways of delivering care.

England is not short of GPs, but they are poorly distributed. The most deprived populations have the fewest GPs1-4, and some PCTs have twice as many per weighted population as others5. This inequity has persisted since the NHS began and is now getting worse. Professor Hugh Gravelle of the National Primary Care Research and Development Centre has shown inequities in the supply of GPs have been increasing since 1985 – despite there being a 40% increase in the number of GPs since 1975. In other words, having more GPs is associated with greater inequity not less. Professor Gravelle has also shown growing inequity in outcomes.It's clearly time to try something different, and one response is the introduction of APMS contracts. Practices are usually tendered in deprived areas where PCTs have been unable to persuade local practices to take over practices that have collapsed. These tenders now receive many responses from a wide range of organisations, including private companies, social enterprise companies, companies formed by GPs and local groups of GPs spurred into action by competition. We saw this with dozens of organisations responding to the tender to provide primary care in north-east Derbyshire. Suddenly there is a lot of interest in practices in deprived areas.

Improving practices' quality

We have evidence that private companies can rapidly increase the quality of these practices. For example, in our practice in central Derby, where three-quarters of the patients are from ethnic minorities, the number of patients has in the first six months increased by more than 10% and the QOF score has jumped from 80% to more than 90%. And local practices, which all had closed lists, have opened them. Soon we will extend opening hours, and many local practices will probably follow. Competition is improving services for deprived populations.If the NHS is to be kept alive, there will also need to be an increase in the capacity of primary care, because it will be essential to shift services out of hospital. Health policy advisers are now beginning to recognise that this shift of specialist services, outpatient services and diagnostics is only going to be possible with the growth of larger practices5. Not all practices will need to be big, but some will do – we will need to see some with 20,000 to 50,000 patients. Such practices are already emerging, but the entry of private companies with management capacity, advanced information technology and access to capital is likely to speed the process.New entrants into primary care can also bring new ways of doing things – better ways to understand the needs of patients, new protocols for patient management, advanced technology, greater use of specialists and superior understanding of skill mix. Some will bring benefits to patients, and some won't. But if patients are supplied with ever better information on the range and quality of services offered and the outcomes for different practices – as they surely will be – then innovation plus competition will mean better services for patients.GPs rightly worry that the introduction of choice and competition will lead to increasing inequities, worse even than now. It's therefore crucial that private companies stick to the core values of the NHS, including universal coverage and care being free at the point of delivery. There must also be regulation of the market, and with good regulation we can avoid the current state of affairs where those who need care most are the least well catered for. I'm confident that the entry of private companies into primary care can improve care for all, but particularly for the poorest. Otherwise, I wouldn't want anything to do with it.

Dr Richard Smith is executive director of UnitedHealth Europe and former editor of the BMJ

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