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At the heart of general practice since 1960

Will competition from commercial providers be a threat or boon?

Under certain circumstances commercial competition could benefit general practice says Dr Brian Keighley

– but on balance he feels it would be a bad thing

As we cope with the biggest contractual change since 1948, a new player has appeared on the general practice scene. Who would have thought a Labour government, with its history of opposition to the purchaser/ provider split, would be keen to reintroduce commerce within primary care?

The new contract always included the possibility of alternative providers, but now we have the introduction of the sale of goodwill for all services beyond the rump of those deemed 'essential'. GPs must consider whether this concept is a welcome innovation that will fill the gaps in a service under unprecedented demand pressure, or something that will destroy traditional practice.

The most fertile areas for commercial providers are in towns and cities where PCOs will consider the millions they are pouring into walk-in centres under Government diktat and will see further commercial opportunities. For example, economies of scale in nursing provision, ancillary staff support and centralised premises might become very attractive financially, especially if such an infrastructure can be linked to new out-of-hours responsibilities.

A welcome prospect?

Doctors in practices under strain might actually welcome shedding the responsibility for finding a partner in a time of shortage, or being able to forget about paying the staff or fixing the gutters. And some failing practices – three partners, two about to retire, can't find anyone to recruit – might welcome the prospect of being bought outright by a commercial operator.

Again go-getting young doctors, first-class clinicians who are reluctant to commit themselves to partnership, might see opportunities for promotion and salary enhancement in a corporate environment that is denied those who opt for the flat remuneration profile of a traditional partnership. They might at first find such an environment exciting too.

So under certain circumstances commercial competition might seem quite attractive to some members of the profession. Remuneration open to market forces, management drudgery handed over to others, regular hours, proper infrastructure support – it sounds like heaven. Until, that is, one begins to think through the implications.

Whatever services the commercial sector take over, their commissioning PCOs will be subject to the same cost pressures as always. PCOs will only be able to pay a plc the same sum as their traditional GP competitors.

Initially, of course, companies will be able to make some savings by economies of scale, especially in the cities. But as time goes on they will be subjected to exactly the same problems as their public sector managerial colleagues – rising service delivery demands and a static budget. How will they cope?

Their biggest overhead will be staff salaries. No compunction here about status or professional tribalism. Ruthless 'skill mix' will be applied, followed swiftly by direction of labour. 'Sorry, doctor, I know you have a booked surgery here, but our East End branch is two GPs down, you will be working there until the end of the month.'

With prescribing and referrals likely to be included in any commercial contract, we can expect direction in those areas too.

From a rural perspective, especially in more remote areas, the concept of commercial competition seems less likely – financially it just isn't viable. Fewer professional staff, geographically dispersed patients and little opportunity to coalesce infrastructure mean there is unlikely to be a big commercial threat to rural practices.

Finally, therefore, I have to return to my own question – will commercial competition to general practice be a boon or a threat? The answer is both.

Plugging crucial gaps

In the short-term, commercial entrepreneurs will see opportunities and, by exploiting them to the full, may well be able to plug the crucial gaps we see developing in some areas. Equally, there will be short-term advantages for individual GPs – some are already enjoying life as freelance locums.

But most of us believe the business of general practice is the longitudinal care of a defined population. Over a longer period doctors seek stability for themselves and their families and as they get older the commercial world of annual, rolling contracts, direction of professional activity and the profit motive eventually begin to pall.

This is not even to mention the value of the NHS pension at a time when most firms are abandoning final salary schemes.

On balance, I believe commercialism is a threat to the profession, a threat that can be managed by the fixed price of the contract under which it will operate, but one that promises to challenge the autonomy we have always prized.

Brian Keighley is a GP in Balfron, Stirlingshire, and treasurer of the Defence Fund (GPDF Ltd)

Pros and cons of competition

Areas where commercial competition could do harm to GPs

lCommercial concerns could take work away from GPs (eg, bidding for enhanced services)

lCommercial concerns could compete for salaried or locum doctors

lCommercial concerns could lure in salaried doctors and then treat them badly

Areas where commercial competition could benefit GPs

lCould be a blessing in under-doctored inner-city areas

lMight 'save' a disintegrating practice

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