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At the heart of general practice since 1960

Should GPs compete for patients?

Competition between GPs for patients is an essential driver of innovation and quality and good practices should have nothing to fear from it, says Dr James Kingsland. But Dr Prit Buttar doubts whether practices will attract patients by improving quality of care - arguing they are likely to just offer extended hours instead.

Competition between GPs for patients is an essential driver of innovation and quality and good practices should have nothing to fear from it, says Dr James Kingsland. But Dr Prit Buttar doubts whether practices will attract patients by improving quality of care - arguing they are likely to just offer extended hours instead.



Yes

Our society flourishes on competition. Nature thrives on it. Innovation, the drive to improve and the demonstration of quality is dependent on a competitive culture.

So why should general practice be averse to – or fearful of – working in a competitive market?

A one-size-fits-all approach to delivering services – and the denial of competition in an attempt to equalise quality – more often than not leads to a dumbing-down of healthcare, prompts investment in failure and stifles entrepreneurialism.

A competitive spirit needs to be nurtured within our NHS while being mindful of health inequalities. Indeed, this is the environment in which health inequalities can be addressed.

Equity in a service is about providing equal opportunity to develop care without bias to any provider – unlike development of independent sector treatment centres – and delivering the diversity through which quality can be improved.

Whether we recognise it or not, GPs have always been inherently competitive, from trying to gain a place in medical school, winning vocational training posts, partnerships or – more recently – benchmarking their quality of service against other practices.

Almost 20 years ago, in my first week as a partner, I remember phoning a local GP colleague about the transfer of a patient.

Wishing to maintain a good relationship within the local GP community at that very early stage of my career, I had telephoned him because one of his patients was transferring to our list without change of address.

Out of courtesy, I thought, I would call, explain the situation and ask whether the patient had any immediate healthcare needs.

I was bluntly told by the GP that for every one of his patients that joined my practice list, he would hope to take one of mine.

Wake-up call

It was an early wake-up call to one particular view in general practice, but not a unique one, as I've subsequently discovered.

More recently there has been a debate, prompted by Government ministers, as to whether there are ‘gentlemen's agreements' between local GPs not to accept patients who choose to move from each other's list – an inappropriate practice that denies patients choice and prevents competition.

Some practices are becoming increasingly concerned about competition from the commercial sector.

But the self-employed, independent contractor GP could rightly be regarded as part of the private sector.

With the advent of ‘Darzi' access centres, tendering for new general practices and the urban myths surrounding polyclinics, there is increasing concern that patients may choose to move away from their current practice, with potential loss of revenue.

But there should be no better understanding of the ‘business' of general practice than by the independent contractor GP.

Inherently there should be – and in most cases is – expertise that is second-to-none in providing GP services, including managing the GP organisation and estates, being a fair employer and developing a cohesive and quality-focused primary healthcare team.

National surveys show that satisfaction remains very high with the established GP service and there is a considerable history – predating the birth of the NHS – of loyalty from patients to their local practice.

So it's difficult to understand why a satisfied customer in a well-ordered practice, delivering high-quality care, would want to move merely because there is competition or an alternative provider available.

Customers normally seek alternatives because of a lack of satisfaction with their current service.

In general practice most patients change doctors because they move area or are told to do so by their practice.

Good practices need not fear a developing competitive service, and indeed should look on this competition as a stimulant to review their current practice and continue to strive to improve.

It's very difficult to convincingly argue against competition, choice, patient empowerment and moves to drive up quality and satisfaction.

Dr James Kingsland is chair of the National Association of Primary Care and a GP in Wallasey, Merseyside


No

Competition is at the heart of Western society, whether in the sports arena or the supermarket. The drive to do better than others has played a huge part in shaping our history and culture.

So why should GPs not compete with each other for patients?

Well, there are several reasons why competition for patients between practices is a bad idea.

To begin with, it's worth looking at your own practice, and your closest neighbour. What would you have to do if you wanted to attract patients from your neighbour?

Would you show what excellent care you provide for your patients with chronic illness? Would you highlight all the educational meetings you've attended and show how you've worked hard to keep yourself up to date?

Or would you simply try to offer more appointments, perhaps in the evening and at weekends, in order to make yourself more ‘accessible'?

Here is one of the fundamental problems: the features that we rightly regard as important cornerstones of our profession – continuity of care, high-quality care of those with long-term illnesses, ongoing medical education – are not the issues that patients will use to judge us.

Patients who prize these features – particularly continuity of care – are already prepared to wait to see the doctor of their choice and aren't likely to be attracted away to other practices.

Patients who are more inclined to switch practice will be those who place their own convenience at greatest importance.

Convenience over continuity

And – given limited resources – attempting to compete by offering greater convenience will be at the cost of better continuity of care.

Offering appointments every evening and through the weekend is certain to reduce the chances of seeing the same doctor every time.

The second problem is one of resources. Imagine two neighbouring practices, both offering excellent care. If one mounts a successful campaign to recruit patients from the other practice, the practice that now has fewer patients would presumably lose funding.

Would it then be able to carry on offering the same high quality of care that it had offered in the past?

Remember, too, that it is likely to be left with the patients least likely to move practice – the old and those with long-term illnesses.

Competing for a fixed amount of funding will encourage practices to adopt a culture in which they attempt to recruit as many patients as possible, though not necessarily with any regard to providing them all with the same high-quality service.

It will encourage a ‘stack 'em high, sell 'em cheap' culture, in which quality of care will take second place.

This is not to say that I am against competition.

I believe that we are a very competitive profession, and the way that GPs rose to the challenge of the QOF and delivered results far in excess of the Government's expectations show that we are good at adapting to change.

But the difference is this: if all practices achieve high QOF scores, they all benefit. It is not at the cost of other practices.

Consequently, I believe the way forward is to define, very clearly and publicly, the factors that we as a profession regard as important measures of good practice.

If others choose to use these factors to create ‘league tables,' and if some patients use these tables to choose between practices, that's fine.

Because this is not competition between practices – it is competition against an agreed standard.

In the context of general practice, it is the only competition that I believe makes sense.

Dr Prit Buttar is chair of the GPC communications group and a GP in Abingdon, Oxfordshire

Should GPs compete for patients? Dr James Kingsland

A satisfied patient would not move just because there was an alternative

Dr Prit Buttar

The cornerstones of our profession are not what patients will judge us on.

Dr James Kingsland, chair of the NAPC Dr James Kingsland, chair of the NAPC

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