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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Why should the NHS maintain a monopoly position allowing only existing GP organisations to compete for patients?

Filed Under (Competition, GPs, Primary Care Trusts, Third party provision) by Paul on 11-05-2011

By all accounts Dr Clare Gerada, from the RCGP, is not just a good medical politician but also a first class GP. And one the good things about the reforms in GP services up until now is that very good doctors have been able to provide good services for more patients because they have won tenders to provide those services. The tendering process has ensured that the commissioners of NHS care have the opportunity to get the best services for their local people and it is through competition that this has been achieved.

Dr Gerada is one of the leading GPs in the Hurley Group. The Hurley Group provide primary care services across a wide range of very different communities. One of the ways in which they gain the right to deliver those good services is by occasionally winning competitive tenders.

Two years ago today Pulse magazine ran an article about how three different GP groups were improving their positions. The first of these was the Hurley Group,

“The Hurley Group, a fast-expanding group of practices based in south London, has been busy tendering for new services, recently winning a bid for one of the capital’s first GP-led health centres.

But Dr Gerada says the way the group has geared its different surgeries to meet local demands is the real reason behind its financial and, more importantly, medical success. At each surgery, salaried GPs are employed – working to a profit-related bonus scheme – to help identify local priorities and maximise revenue.

The empire includes the Sternhall Lane Surgery, a small, previously rundown inner-city practice in Peckham, which has changed beyond recognition since being taken over from the PCT. Its performance in public health areas ranging from flu to smears and even childhood vaccination have all dramatically improved. Dr Gerada says it is all down to changing the culture of the surgery to one geared to proactively face up to the community’s needs, from the attitude of the lowliest member of practice staff to the salaried GP put in charge and handed an equity stake.

Less than a mile and half away the Riverside Medical Centre, based in Vauxhall’s plush St George Wharf, deals with an exclusive bunch of patients. For these professionals, having extended hours services on Saturday to match their busy working lives was higher on the agenda.

‘These practices might as well be on a different continent,’ says Dr Gerada, one of a dozen partners in the group.

The Hurley Group’s latest project, after winning the tender to turn the Lister surgery, in Southwark, into one of Lord Darzi’s GP-led health centres, is a new direction, and not without opposition from those who resent the ambition of GP entrepreneurs. But Dr Gerada says: ‘GPs aren’t like the Royal Bank of Scotland.

GPs are not driven by money – they are driven by the chance to make change.’

My point in raising this is not to make what would be a false charge of hypocrisy. There is no way in which Dr Gerada is hypocritical about competition.  Throughout the publicity surrounding the RCGP statement on 9th May Dr Gerada made it clear that she was not against competition. She has clearly and publicly said that she is in favour of the process that has grown her successful business.

The RCGP know that a lot of their members’ organisation of care is bound up with their right to expand by taking over new registered lists. As the above article states, these are GP entrepreneurs, and they are ambitious.  They would recognise that competition has led to improvement of care. But the RCGP document does not seem to believe that this is the case

“Despite the increased use of market forces in the health service over the last two decades, the evidence that this policy improves outcomes is very limited. A recent review of the evidence finds that there is no conclusive evidence that market competition has any effect on the quality, equity or efficiency of healthcare delivery.” (para 3.20)

I would claim that the services that have been won by the Hurley group through competitive tender have genuinely improved the health outcomes of their new patients. I would expect that the Hurley Group can provide evidence for this (as mentioned in the 2009 story above). As Pulse says,

“The empire includes the Sternhall Lane Surgery, a small, previously rundown inner-city practice in Peckham, which has changed beyond recognition since being taken over from the PCT . Its performance in public health areas ranging from flu to smears and even childhood vaccination have all dramatically improved.”

The surgery has ‘changed beyond recognition’ (which presumably must signify some form of improvement in service delivery) “since being taken over from the PCT”.   If a surgery has moved from being run by the PCT to being run by a private sector organisation it looks to me like a form of privatisation.

So it’s a great thing that the Hurley group win tenders and it’s a great thing that they introduce the private sector to services previously run by the PCT.

And what is wrong with that if patients have better services as a result?

What I find disappointing is that the RCGP seems to want to limit the right to compete for NHS patients to those organisations currently within the NHS. Their document doesn’t say this but Monday’s media story specifically talked about the anxieties of opening up the NHS to competition from charities – and the private sector.

It is not difficult to see what the RCGP is worried about.

I can easily imagine a charity setting up an organisation through a Community Interest Company that would employ, in the same manner as the Hurley group, some salaried GPs who would be incentivised to improve services through some form of surplus (Profit) sharing.

Such an organisation would then be in a position to compete with existing GP led organisations to gain NHS patients.

What in terms of policy or morality is wrong with that?

Why should NHS patients be denied that possibility?

I am sure that on many occasions tenders would be won by existing NHS organisations, but if only once in ten times it was won by the charity, why block that competition?

Why block that opportunity for improvement?

If the PCT had insisted in continuing to run the Sternhall Lane Surgery and not allowed a takeover there, those patients would not have experienced their services improving beyond recognition.

All seems like a good idea to me.

Comments:

2 Responses to “Why should the NHS maintain a monopoly position allowing only existing GP organisations to compete for patients?”


  1. The experience in of ATOS in Tower Hamlets ought to give pause for thought: http://www.guardian.co.uk/society/2011/apr/12/nhs-privatisation-future-policy
    My experience of bidding for and winning the contract for a GP lead health centre was that it cost £40k and took 9 months and took away 2 of our senior doctors away from their patients. Few surgeries can afford to do this and even fewer can do it repeatedly, including us, since it will take us several years to recoup the costs. We only bid for the practice because we were already running it for the PCT and they were forced to tender it as a GP led health centre. If we had not bid, it most likely would have gone to a private provider and our doctors, who we had trained and supported for nearly 3 years would have lost their jobs or their terms and conditions. Organisations like ATOS and Virgin have budgets of millions and have little experience of primary care (as the Tower Hamlets fiasco demonstrates) Already private equity firms like Bridgepoint are buying up GP conglomerates http://www.gponline.com/News/article/987972/Virgin-breaks-primary-care-Assura-acquisition/
    Very quickly NHS GPs will sell up to organisations will NO local knowledge or interest, and retire on their substantial profits.
    That sounds like a bad idea to me.


  2. Paul – Can I suggest the debate around the role of competition is more nuanced than you present it in this post?

    Lansley’s reforms see competition as a major driver for innovation and efficiency (via Monitor’s new role, AQP/cherry picking, more market exits, EU competition law disrupting local clinical relationships). An alternative vision sees a role for some competition alongside other incentives and national standards.

    A full throttle market, plus financial squeeze, is likely to encourage cost-cutting, with an agenda of “quality” marginalised. Just look at local authority social care over the next two years.

    Lansley’s version of competition has become discredited amongst much of NHS staff and the public, as they do not trust the motives of the Coalition. Cameron’s public services reform speech in January, made clear his support for unbridled competition.

    Claire Gerada by the way, should be commended for her leadership and support for what the NHS has achieved, in contrast to her predecessor.

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