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At the heart of general practice since 1960

What is the lure of private firms for GPs?

Where exactly do GPs fit within the complex world of the NHS? Are GPs at the heart of a nationalised health service, as many feel, or as independent contractors are they in effect private concerns, just like Boots and UnitedHealth?

By Gareth Iacobucci

Where exactly do GPs fit within the complex world of the NHS? Are GPs at the heart of a nationalised health service, as many feel, or as independent contractors are they in effect private concerns, just like Boots and UnitedHealth?

The exact nature of general practice has been the subject of debate ever since the advent of the NHS, but what was once a largely theoretical discussion is now becoming a concrete choice for thousands of GPs, as the march of the private sector gathers pace.

Pulse survey's of over 400 GP reveals getting on for a third have already been asked by asked by private companies to team up on the provision of services - with one in ten planning to take up such an offer. Overall, a third of GPs say they will be prepared to work directly for a private firm.

While 80% of GPs are against the Government's policy of introducing competition from the private sector, GPs are resigned to it, with 72 % believing major retailers will be running GP practices in five years time.

GPs are being offered a host of incentives to join up with private firms, with companies such as Chilvers McCrea Healthcare, US giant UnitedHealth and Atos Healthcare already employing salaried GPs at a growing number of APMS practices across England.

But with increasing numbers of GPs signing up with private partners to safeguard their careers and livelihoods, is it inevitable that this will always lead to loss of control over their practice? Or are there alternatives out there, allowing GPs to retain autonomy over their business and profits?

One school of thought says GPs can retain control over their clinical practice while receiving back-office, financial and IT support from a private sector partner. One company with this model is Circle Health, which has already signed up 600 GPs to its nationwide partnership, and hopes to have 2,000 by the end of the year.

GPs sign up to the partnership, which also has 1,200 consultant members, non-exclusively, allowing them to work with other partners if they wish.

GPs signing up receive a welcoming gift of 300 shares in the company each year, (which currently have a value of about £3.50 each), and a non-repayable grant of £2.00 per registered patient, to be spent on additional services to be pursued jointly with Circle.

Dr Julian Neal, a Circle GP partner and a member of the company's primary care development team, says: ‘We're about providing practices with the opportunity if they wish, to develop new services which are certainly not just PMS/GMS.'

The company is also planning to develop a network of polyclinics across the country, where consultants and GPs will work alongside each other.

Dr Neal, who is chair of the Portsmouth GP-company Spinnaker Health, whose 160 members recently voted unanimously to join Circle, hopes that GPs will play an active role in developing ‘more secondary work in the community'.

‘If you're happy to continue doing your general practice and nothing else, that's fine. If on the other hand you want to get involved with Circle national partnership to create new care pathways, you'll be rewarded through shares.'

Like Circle, Assura is another firm offering GPs shares in return for joining up. But GPs who work with Assura do so through locally agreed Limited Liability Partnerships, with profits split 50/50 between GPs, who have full control over clinical services, and Assura, who provide administrative and IT support.

Although it has been at the centre of national patient protests about privatisation of the NHS, Sir Richard Branson's Virgin Healthcare is another firm that says it will allow GPs to keep their GMS contracts while offering them a share of profits from other paid-for-services in their new polyclinics.

Other firms such as Serco and Care UK employ large numbers of GPs in a range of settings, but say they are also open to partnership agreements.

Dr Mark Hunt is managing director of primary care services at Care UK, which claims to offer ‘a pipeline of doctors at PCTs' disposal' and has been involved in APMS services, independent sector treatment centres and out-of-hours services.

He says the company is attractive to GPs because it allows them to concentrate on clinical matters. ‘Our conditions are pretty attractive, which is why GPs choose to work for us. We have a model where GPs can spend time on clinical practice rather than have the administrative burden they would in other environments.'

Zafar Raja, managing director at Serco, claims the arrival of polyclinics will lead to a wide variety of new private contracts with GPs. ‘Clearly, it depends on where GPs are in their career. A lot of them prefer to be on a salaried basis, and yes, that approach will be fine with us. Equally, some of the younger, more entrepreneurial GPs want to work on a different basis and we're again happy to accommodate that.

‘The key to making polyclinics a success is that there is no fixed model in terms of services or people. There isn't a fixed model where everyone's going to be salaried.'

But some GPs believe getting into bed with private firms will mean giving a way far more than just administrative headaches. ‘There is no free lunch here,' says Dr Chaand Nagpaul, GPC negotiator and a GP in Stanmore, Middlesex.

‘While companies have a variety of ways of getting involved in general practice, including those that appear not to be predatory, all of them have a longer term agenda behind the initial innocuous offers.'

Dr Nagpaul also warns GPs who enter into salaried arrangements with private companies will be subject to ‘highly variable' terms and working conditions, ‘very much subject to market forces'.

Dr Richard Fieldhouse, vice chair of the National Association of Sessional GPs, cautions that the initial ‘squeaky clean' image of private sector employment might not be the reality in the long term. He says: ‘The problems we get with salaried GPs tend to be two to three years down the line, when they've not had pay rises, and practices are unilaterally changing contracts and really pushing the limit.'

Dr Fieldhouse's claim is fiercely denied by the likes of UnitedHealth. A spokesman for the company says it aims to make the transition for GPs into the private sector ‘as seamless as possible', including following BMA guidance on salaried GPs.

GPs who shun any form of commercial partner may at least have to commit to collaborating more with their colleagues, with the Government increasingly looking to larger more financially robust providers.

What is certain is that GPs cannot afford to ignore the presence of the private sector.

Dr Neal says: ‘It's a paradox, but I believe the only way you're going to maintain the important things about general practice is to pool resources and get bigger.'

So is bigger, better or can small still be beautiful? In the answer to that brief question lies the future of general practice.

Dr Chaand Nagpaul: no free lunch when it comes to working for private firms Dr Chaand Nagpaul: no free lunch when it comes to working for private firms Dr Mark Hunt, managing director of primary care services at Care UK Dr Mark Hunt, managing director of primary care services at Care UK

Our conditions are pretty attractive, which is why GPs choose to work for us

What's on the table: What's on the table:

Circle:
- Currently largest partnership of clinical doctors in the UK. Says services could include telehealth, enhanced diabetic services, urological services, day case surgery, endoscopy, community-based ENT or ophthalmic services.
- GPs continue on normal contracts, and can either develop additional services with Circle's help or act as ‘sleeping partners'
- A welcoming gift of 300 shares in the company each year, (which currently have a nominal value of about £3.50)
- A non-repayable grant of £2.00 per registered patient, to be spent on additional services to be pursued jointly with Circle.

Assura
- Locally agreed Limited Liability Partnerships (Assura GP Provider Companies)
- Profits split 50/50 between GPs and Assura
- GPs run clinical services
- Assura provides accommodation, IT and data storage, back-office support and bidding expertise, and incurs any potential losses

Virgin

- GPs retain existing terms of contract and offered new premises
- A profit-share from other paid-for services in Virgin Health centres and extra quality payments.
- Virgin will employ all non clinical staff.
- GPs and staff will have to undergo Virgin customer training and be subject to a Virgin quality framework.
The salaried option
- Private companies employ GPs under APMS contracts
- Private firms currently employing GPs under this model include Chilvers McCrea, Care UK, Serco Health, United Health and Atos Healthcare

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