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At the heart of general practice since 1960

Should GPs sign up with private firms?

The NHS is changing rapidly, and GPs cannot afford to shun private sector partners if they wish to compete successfully, argues Dr Julian Neal. Not so, counters the RCGP's Dr Clare Gerada, who insists the private sector does not hold a monopoly on innovation and efficiency.

The NHS is changing rapidly, and GPs cannot afford to shun private sector partners if they wish to compete successfully, argues Dr Julian Neal. Not so, counters the RCGP's Dr Clare Gerada, who insists the private sector does not hold a monopoly on innovation and efficiency.

Yes

The NHS, until recently a huge monolithic state medical industry, is being deliberately shaken up by a Government that strives to break up monopoly provision through competition while encouraging integration of care.

Large multinational companies are beginning to move into primary care having already attained permanent footholds in secondary care.

There are immense threats to traditional NHS general practice.

Against this backdrop, a common view among GPs is that the private sector is a wicked, profit-driven predator and should not be engaged with. This atavistic view is a touch illogical but above all unsustainable.

It is illogical because the vast majority of NHS GPs are private, independent contractors who run medical businesses for profit by delivering contracted medical services for the NHS.

Profits from these contracts help to clothe and feed GPs and their families as well as the thousands of staff employed by GPs.

So, no ethical objections to profit here, and I don't see many objections when GPs charge their registered patients for non-NHS services such as providing private insurance reports.

So having addressed the general point about profit and private enterprise, let me turn to my more pressing contention – that if GPs are to remain in control of their professional destiny and increase the range and quality of their services, it is unsustainable to avoid developing their businesses in partnership so they can head off the challenges from others by delivering even better care.

The choice for GPs is stark. If they want to compete, they will have to either find a private provider partner, or partner with other clinicians to reach the scale and management capacity necessary to grow their practices.

I'll illustrate my contention by recounting how my local GP provider organisation, Spinnaker Health Ltd, joined the national Circle partnership.

With the advent of practice-based commissioning, putative GP provider groups are springing up everywhere for two main reasons – defensively, so that large umbrella organisations can give their members a sense of protection, and proactively, in an attempt to maximise the opportunities through PBC by shifting services from secondary to primary care.

But Spinnaker Health Ltd, like many other primary care provider organisations, was unable to gain PCT contracts on its own.

Unsustainable

It was vulnerable to the accusation that it was an unsustainable provider without corporate support.

After 18 months of examination and due diligence assessment of eight potential private partners, Spinnaker Health shareholders finally decided to join Circle, the largest and fastest growing partnership of clinicians since the inception of the NHS.

We did so because Circle is created, run and co-owned by clinicians with the single aim of providing excellent care.

Equally importantly, Circle did not threaten the independence and integrity of Spinnaker Health's shareholding GP practices.

With the administrative, managerial, contractual, IT and Choose and Book interface support that Circle brings, Spinnaker Health Ltd can now enter into discussions with PCTs, secure in the knowledge that we are Healthcare Commission compliant.

We thus have the ability, should we wish, to establish community services as an Any Willing Provider through the Free Choice Network.

It was significant for us that Circle has no intention of bidding alone for APMS list-based services and no intention of taking over the employment of GP practice staff.

This tale of Spinnaker Health Ltd's search for a partner illustrates my central point.

GPs can find a partner that supports the profession and gives them a strong voice at a time of huge change within the NHS.

Dr Julian Neal is chair of Spinnaker Health in Portsmouth and a Circle GP partner


No

The NHS works because of general practice and general practice works because of GPs.

That private firms can provide general practice services more efficiently or even, more importantly, to a higher standard than traditional NHS GPs is a myth we need to stamp on – rapidly and emphatically.

Two years ago, the Hurley Group in south London won, after competitive tender, a poorly performing PCT-run practice.

The practice is in the heart of Peckham – an area becoming famous for the number of young black boys falling victim to violent knife crime.

The practice was failing its population on any measure of quality, from QOF scores to access, generic prescribing rate or public health achievements.

Within two years, the practice had been turned around dramatically – achieving 100% in the QOF, a cervical smear rate of 91% and a flu vaccination rate of 76%.

The only issue we found hard to crack was the low childhood immunisation rate – which was probably related to the number of children taken abroad to live during their early childhood.

So how was the worst turned, quoting a PCT manager, into a ‘beacon in Peckham'?

There really is no magic in this. No secret weapon. It is all about hard work and a commitment to change, which are factors that private sector organisations do not have a monopoly on.

The practice provided public health services on Saturdays and targeted hard-to-reach groups (women for smears, elderly people for flu vaccinations, Asian men for blood pressure checks).

Daytime access was increased and extra doctors and nurses recruited to provide extra time for the patients – the ‘unworried unwell' – who all had unmet needs.

We also improved the physical environment for staff and patients. The new surgery was launched on a bright autumn day, with patients invited to attend alongside local dignitaries.

Meeting local needs

A passing DJ provided the musical backdrop (it could only happen in Peckham). The practice may not fit the Darzi vision of an all-singing, all-dancing polyclinic, but it works for the local population and provides the majority of services that patients need.

Private providers have suggested that access could be improved by offering more appointments during extended hours, employing nurse practitioners at the expense of GPs to achieve this.

NHS practices have deployed different, and I would argue, better strategies to improve access.

Local practices have embraced telephone appointments, email prescription requests and online booking of appointments, all of which have made a real difference to the way patients access our services and the way we work.

The NHS can innovate with the best of them. We struggle to see how an alliance with private firms could have done better.

All over the country, NHS primary care is delivering and indeed overperforming against Government targets.

Rather than promote private as best and NHS as bad, we need to celebrate the achievements of UK GPs and support the excellence currently being delivered by them, while dealing with the tiny minority who are not performing.

Our turnaround was achieved by NHS GPs, working through an NHS PMS contract, delivering services in a traditional manner.

No gimmicks, no offers to staff of private health insurance, no inducements to patients to register.

Whatever the enticement to doctors to hand over their practice to private providers or to work with them as salaried doctors, beware.

Private companies are in this game for profit, and do not be led to believe anything else. These profits will be considerable and will come at the expense of patient care.

Autonomy to shape the direction of practices will disappear in a swoop and we will become a mere cog in a multibillion-pound industry.

We should be uniting with our neighbouring practices, forming federations and sharing resources, expertise and services, not jumping ship and forming alliances with the private sector.

This month, the NHS is 60 years old. Pray it continues.

Dr Gerada is vice chair of the RCGP and a GP at the Sternhall Lane Practice in Peckham. She acknowledges the help of Dr Janaka Pieris and all the GPs at the practice in writing the article

Hands shaking on a deal Dr Julian Neal

If GPs want to compete, they have to find a private provider partner

Dr Clare Gerada

I struggle to see how an alliance with private firms could do better

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