Dr Elizabeth Barrett MB, BCh, MRCGP 62, High Street, Warsop, Notts. NG20 0BZ

Dr Barrett’s later reflections

4.2.06

Background: Concerns about the service in Langwith

I have been a GP in Shirebrook for nearly twenty years. We have the largest practice in North East Derbyshire PCT. I have been lead GP for patient involvement since we set up our Patient Liaison Group several years ago. For quite some time, concerns have been expressed about the primary care service in Langwith village, which is on the edge of our catchment area. Langwith is in the historically anomalous position of being a branch surgery for Creswell, three miles away. The transport links between Langwith and Creswell are not good, and there is no natural social relationship between the two villages. Langwith patients felt that they were getting a second class service, and this view was supported by statements from various involved professionals and representatives of the public. Last year, Shirebrook surgery was asked, by Scarcliffe Parish Council, if it could register all the patients, because of these concerns. Because Shirebrook already has the largest practice in the PCT, and has a branch surgery in Warsop as well, the practice declined, on the basis that such a move would be detrimental to its own existing services. Langwith and Shirebrook contain six of the ten poorest wards in the PCT. It is a big challenge to provide services for a cluster of deprivation like this. The Parish Council had written to the Chief Executive of the PCT on several occasions and had never received a reply. Langwith patients seemed to be in an impossible position.

Our involvement

In March of last year, I approached Martin McShane, the Chief Executive of North East Derbyshire PCT, and told him that I would like to form a multi-disciplinary clinical team to look after the patients in Langwith. I would leave my existing practice and involve myself, totally, in this project. This team would be small but highly focused on the needs of the patients in Langwith. The team comprised myself, a prescribing pharmacist (Mark Thompson), a part-time practice manager (Jonathan Cummins) and a part-time nurse. My semi-retired husband was going to take on the role of a flexible ‘spare driver’. Among our team, we had lengthy local experience: three of our team are school governors for local primary schools; Frank (my husband) has served on a variety of local community regeneration projects, including the Meden Valley Partnership; I have written a monthly health article for the local free newspaper for several years; I am GP advisor to the local Village Companies Care Co-operative. In other words, we are firmly rooted in the community. As well as this, we have academic credibility. I am a GP trainer for the Chesterfield Vocational Training Scheme. I am also a GP appraiser for the PCT. I did Quality and Outcome Framework assessments in the first year of the new contract, and am a GP representative on the Medicines Management Committee. I have specialist skills in Dermatology and Family Planning and a special interest in Diabetes and Primary Care Team education. Our pharmacist is one of the first three pharmacist prescribers in Derbyshire and has close links with Sheffield University. He has a clinical role in the care of Diabetes in my current practice and anticipated being able to take the lead role in the management of chronic disease, drug misuse and the monitoring of all prescribing.

Detailed plans. Involving local people

Scarcliffe Parish Council did a door-to-door survey which supported the idea of a separate, small surgery for Langwith. We were prepared to borrow money to build a new surgery, as the small three-roomed building is not fit for purpose in the modern health climate. We took the view that our small, cohesive, team could offer simplicity of access and holistic care. We could develop clear pathways and clear delineation of roles. We had a flat-structured team that could communicate meaningfully, and continuously with its local community. We felt that we could re-engage this community back into its health care. We had links with Social Services and would work closely with care providers. We would bring the highly successful ‘exercise on prescription’ to the local Community Centre, and we would try and optimize health promotion activities. We would re-engage the Welfare Benefits Advisory service and work with the Job Centre. We would be open from 8.30am to 6pm and could offer a wide variety of skills. We would optimize performance because of commitment to the ideals of the NHS, professional enthusiasm and professional development. We would involve patients, right from the start. We didn’t just know what we had to do: we knew, and had the confidence of, the individuals who would be involved.

Dealing with risks

This project presented some risks to the team. However, we felt that we could capitalize on our quality, improved access and the desire that patients have for continuity, and that we could build up our list and provide an element of competition that would encourage everyone to ‘up their act’. It is worth pointing out that the two smallest practices in the PCT consistently score highest in patient satisfaction surveys. They seem to provide what patients want.

We knew that there was a budget available, via the Strategic Health Authority, to invest in Primary Care in deprived areas. The Parish Council offered us free land for building. We secured an offer of a loan from the bank. We did everything to address predictable other risks: we arranged a ‘buddy practice’ relationship with another practice: we were offered inclusion in a variety of commissioning consortia: we felt we had the support of the community and the support of our NHS colleagues, as well. Everyone we talked to felt that the plan was good, and would be good for Langwith.

At the end of August, I wrote a discussion document detailing the background to our plans and our views on how to manage risks. I sent this to the PCT. On the advice of the secretary of the Local Medical Committee, Dr John Grenville, I wrote to Creswell PCC and asked if they would consider divesting themselves of the branch surgery in Langwith. There was no reply.

The process of our bid

At the beginning of October, when the PCT decided not to extend the contract for the existing Creswell PCC, the advertisement was placed in national papers. The PCT were prepared to offer Creswell PCC as a whole practice (Creswell and Langwith together) or as separate surgeries, because of our interest in Langwith on its own. However, concerns were expressed about the size of the proposed practice, and I was in no doubt that we were going against the trend for ever larger practices and ‘consortia’. Nevertheless, I was also in no doubt that we were hitting all the buttons on the NHS new agenda; the bid was patient orientated and was, clearly, what the public wanted; it was local and accessible: it would give the patients an opportunity to exercise choice, and would improve their access to health care: it would do much to reverse the ‘Inverse Care Law’, which states that patients who are most in need of health care are least likely to get it; Practice Based Commissioning was not yet structured and we had time, in hand, to make those relationships.

When we filled the application form, there were eleven criteria, against which we had to evidence our experience and our achievements. We could satisfy them all, although it was difficult to evidence in the category of Practice Based Commissioning as this is not yet set up in our area. We expressed our intention to build the necessary relationships, however. We were aware that our bid could not be the cheapest because of the experience of our team. Nevertheless, we felt that our team would provide good value for money.

The PCT was not specific about the contract value and advised us to cost our bid according to our plans. They would take that as a starting point for negotiations in the event of being selected. Our highly experienced practice manager drew up detailed costing and we submitted our bid on 9th of December.

The decision

On 23rd of December, in a press release entitled ‘Good News for Creswell’, the PCT told us that UnitedHealth Europe was their ‘preferred provider’ (a misuse of an American HMO term). No-one in the area had ever heard of UHE. We were told that this was a ‘young British company’. A basic search on the Internet revealed that this was, in fact, the largest private health corporation in the US. There had been no public discussion about the implications of this decision, either locally or nationally. This seemed to be a major change in NHS direction, and many people were disturbed when they checked on the details. Bear in mind that it was at least five weeks before the pending White Paper and, although the enabling legislation had been put in place for Alternative Providers of Medical Services (eg private providers) there had been no public or parliamentary debate. The concept of bringing a global player into the NHS took everyone by surprise. While there was some general talk of the possibility of ‘supermarket style’ primary care, some time in the future, there had been no real debate within the various professions in the NHS, and no attempt to assist existing NHS professionals in the mechanics of dealing with the challenge of the entry of global health care players into the NHS.

Finding out

Under FOIA, one of my colleagues obtained the interview marks. Six bidders had been shortlisted: five of these were private companies, and one was an NHS practice in Eckington (Moss Valley). We discovered that UHE had scored the highest marks in ‘record of engagement with public and patients’. It was not clear how they could have evidenced that score. UHE scored the highest marks on the criterion of ‘proven track record of providing medical services’ on the basis that they have one part-time GP on their management team (a GP in Kingston-upon-Thames); apart from this one GP in Kingston, there was no clinical team and UHE had yet to advertise. UHE, as an organisation, had no actual clinical team and no record of practice in UK Primary Care. It would appear that UHE was negotiating as a management company. Enquiries were directed to their media office in London.

I have requested information about the shortlisting process under FOIA, and expect to receive this within the next ten days.

The concerns

My concerns can be summarized in the following categories;

  • The consultation process
  • Misleading presentation
  • Level playing field
  • The future for Langwith
  • The future of the NHS
  • Ethics

Concerns about consultation

Patricia Hewitt has made it clear that she wants patients to ‘be in control… patients will be in the driving seat’. She wants services that are accessible and close to people’s homes.

To make choices, people need information, and they need time to consider the given options. There was no consultation with patients in Langwith, or with Scarcliffe Parish Council. The first they heard of the decision was their Parish Council meeting on 17th of January.

The lack of consultation process with patients is currently the subject of a legal challenge.

At this late stage, the public is now involved in the issue, but it is forced into the position of challenging the decision through judicial review. They should not have had to do this. There was no clear mechanism to allow them to be involved in the decision in the first place. The public has now had an opportunity for its first, thoroughly worthwhile, debate, but this is retrospective to a decision already made.

NHS personnel seem unaware of these developments. No-one, to whom I have spoken, appears to know anything about UHE, or what sort of organisation it is; all have expressed surprise and concern. The step seems alarming and demoralizing to NHS staff – most of who subscribe, sincerely, to the public service ethos of the NHS.

Far from consulting and enabling the local community, the process of appointing UHE as ‘preferred’ bidder has been clandestine and surreptitious. There are issues which are of enormous importance to the public and to all health professionals, not just the ones that are in the immediate vicinity. A change of this nature is unprecedented within the NHS.

Concerns about presentation.

Private status of GPs. Economical with the truth?

Since the public announcement of the choice of UHE, there has been a consistent attempt to portray NHS General Practitioners as being ‘private’ and ‘profit-making’. General Practitioners are, indeed, small businesses. Their private contractor status was conferred, at the inception of the NHS, as a way of allowing doctors to work within the NHS but remain, simultaneously, a self-regulating profession. Our profits, however, are our wages, and are roughly commensurate with what the Government intends us to have, although remuneration varies from practice to practice. GPs use profits to pay themselves and their staff, and to invest in buildings and services. GPs do not have share-holders; their first responsibility is to patients.

Proponents of privatisation, however, repeatedly focus on the ‘private’ status of GPs, presumably so that the shift to UHE will be seen as conferring no great change. This is disingenuous. The status of UHE, as a private, profit-making company, is remarkably different from that of GPs. The first responsibility of share-holding companies is to their share-holders. Their financial affairs will be protected by commercial secrecy.

Legal rights of patients under private companies vs NHS GP practices:

In a recent article in the British Medical Journal, two lawyers expressed concerns that private companies might not be subject to judicial review in the same way as public bodies. This is because their activities are governed by contract law rather than by statute. The law is unclear as to the rights of patients to challenge decisions made by private companies. The lawyers who wrote this article went on to say that ‘In this era, committed to the agenda of choice, well informed patients might choose to be served by public authorities that are unambiguously subject to judicial review, freedom of information, and the Human Rights Act’.

A private company could cut or change services on commercial grounds, and could claim commercial sensitivity as a way of protecting the decision from scrutiny. This should be worrying everyone.

Is UHE British?

UHE describes itself as a ‘young British company’. This could be mere sleight of hand, and possibly not as serious as the former point; it is, nevertheless, untrue: UHE is a subsidiary of the giant UnitedHealth Group of America, that last year made profits of more than $5.4 billion.

Concerns about a level playing field.

Although it was becoming clear that the Government was going to allow private firms to start providing primary care, the speed at which this was going to take place and the extent to which this could disadvantage NHS bidders was not immediately obvious.

Political head-start:

UnitedHealth Europe has, as its president, Simon Stevens, who was advisor on Health Policy to Downing Street for seven years until he left to take over his senior role in UHE. Not only did he have in-depth advance knowledge of the thrust of the new White Paper, he must have played a part in designing the legislation. The question needs to be asked as to whether the playing field can ever be level under these circumstances. It doesn’t matter how excellent an NHS practice is, it has not had the opportunity to walk the corridors of power in this way.

US health informatics resources:

UnitedHealth Europe has access to the vast health informatics resources of its parent company in the US. NHS practices struggle with the impending chaos of the reorganization of the PCTs; accurate data is difficult to extract and, in our practice at least, we have waited nearly two years for our new computers under NPfIT. UnitedHealth has had a contract to analyse data concerning chronic disease in Trent Strategic Health Authority. While UHE say that they did not use any of this data in their bid, it is obvious that they have sophisticated data analysis tools at their disposal, and a vast expertise in risk modelling, imported from its US parent.

Criteria:

Applications were assessed against eleven criteria. We have the final marks of the applicants who were shortlisted, but we do not yet have the marks given in the shortlisting process. Neither do we, as yet, have any insight into how these marks were reached. I have already drawn attention to the fact that UHE scored highest on two criteria where it would seem difficult that it could score anything (public involvement and record of providing good medical services). When asked, at a recent meeting, what was the key ‘edge’ that made UHE stand out from the other applicants, Martin McShane replied that it was their strategic vision. It might seem that UHE were picked for its knowledge of the future White Paper and its alignment with the future plans for the NHS. This is an advantage that NHS practices don’t have. If this situation continues to pertain, it is probable that the private sector will take over vacant practices one by one. UHE has expressed its intention to do precisely this.

A further point about the selection process is whether criteria were weighted. It is not possible to know, from any information we have yet received, whether the criteria relating to policies, such as Practice Based Commissioning and awareness of health policy, were weighted in any way to support the entry of the private sector wherever possible. Neither do we know what pressures the PCTs are under to prefer private bidders. Such things should be transparent.

The future for Langwith

It is not surprising that Langwith patients, and their elected representatives on Scarcliffe Parish Council, are unhappy at the prospect of remaining as a branch of Creswell surgery. This status has not served them well over the years. Not only will they not have a surgery of their own, the parent surgery is, itself, going to be under the control of a management company in London. This is an entirely new way of providing primary care, and a forthcoming judicial review will consider this.

Premises

Richard Smith, at a public meeting last week, was asked whether UHE would build new premises or extend the existing one. His answer was surprising: UHE owns no premises and has no intentions of doing so; they even rent their own headquarters. The question is: how UHE can improve local health provision and extend the range of services that are offered, if they do not have appropriate premises? Langwith surgery is far from adequate. It would be important to know how much their intentions, in this regard, have been explored. As those of us who work in primary care know, accommodation is a major factor in the delivery of good health care. It is difficult to see UHE offering a wide range of services and a range of differently skilled people, if premises are cramped and inappropriate. Is this not something that should have been explored by the PCT?

A couple of other thoughts also come to mind on this: is this a policy that is designed to make it easy to cut and run? Do they intend to close the branch surgery in Langwith, once they have centralized most of the services to somewhere else?

If UHE do not intend to own any premises, are they going to use the controversial Private Finance Initiative to build for them? This could represent yet another way of draining resources from the NHS.

Long term relationships?

Richard Smith tried to reassure the people of Langwith that UHE will be in the NHS for the long haul. He said that he could offer continuity of relationship to the people of Langwith. However, UHE has, as yet, no staff. It is not in its gift to ensure that future employed staff stay in a particular community for meaningful lengths of time, and one of the public’s concerns is that clinical staff may change frequently, so that there is no opportunity to develop the relationships that are so valued in British general practice. One of the advantages of organisations like UHE is, presumably, the ability to move around staff where they are needed, and to balance skills. One of the great strengths of British general practice has been the long term commitment inherent in the investment that GPs make in their buildings and in the community, as well as their local, easily visible accountability.

Richard Smith made much of the previous problems of Creswell PCC. There is no reason, however, to suppose that Creswell PCC’s problems could only be solved by a provider like UHE. There were many possible solutions within the context of the NHS, which could still preserve the key strengths that are rightly valued by British people.

The future of the NHS.

The internal market

It is not difficult to see why local health economies want large commissioning powers to compete against hospitals. Fundamentally, one has to be sympathetic to the predicament of PCTs who are faced with the need to balance their books, when the local hospitals have made profits. This year, Chesterfield Royal Hospital made a profit of £2.7 million, while the PCTs are overspent. In Nottingham, it is the other way round: the hospitals are overspent and the PCTs have made profits. However, if the move to global health providers is being made to balance this power, it is a dangerous game. To bring in an organisation such as UHE, with all the attendant risks, in this clandestine way seems immoral and undemocratic, even if the motivation can be defended as being good. It could be regarded as a highly dysfunctional response to the self-inflicted problem of the increasingly bullish and confrontational internal market.

Risk analysis

We live in an ‘evidence-based’ medical world. New products and procedures should be researched, piloted and evaluated. It seems that major health service change does not need to go through this process. These changes are either naïve and ideologically driven, or they are a cynical attempt to divest the Government of responsibility for the operation of the NHS. If it is the former, it is incompetence of breathtaking proportions; if it is the latter, it is a cynical disregard for the wishes of the public, which has consistently expressed its loyalty to the NHS as a public service. The public has supported the NHS despite what appears, at times, to be concerted efforts to discredit the NHS public service ethos, and portray it as bureaucratic, wasteful and inefficient. A demoralized and divided workforce has almost lost the ability to defend itself.

Power balance

There is a very real risk that corporate giants, like UHE, could get a stranglehold on the NHS. If the PCT had difficulty enforcing a contract with the previous proprietors of Creswell PCC, it is difficult to see it being able to take on the Teflon anonymity, and the legal machine of an organisation such as UHE. Getting large, international, firms to own their deficiencies or mistakes is extremely difficult, as anyone who has an argument with a mobile phone company or an internet provider will agree.

While the desire to drive up standards and introduce competition is laudable, the introduction of a multi-national company could be regarded as overkill. Large providers could eventually hold the NHS to ransom.

It is not at all difficult to envisage Primary Care being provided by a few multi-national chains, while a permanent war between different providers, and between providers and purchasers, destroys what is left of the ethics governing clinicians’ requirement to put the needs of patients first. We are already seeing the erosion of clinical relationships between hospital consultants and GPs, as suspicions deepen and the battle for budgets intensifies.

On a local level, it is easy to envisage that, once UHE has got into a practice and are welcomed by the PCT for their commissioning expertise, we will all be ‘encouraged’ into a consortium with them and will, effectively, become ‘UHE practices’. This may seem fanciful, but anyone studying the pace of change in the micro-climate of the current NHS will realize that power politics are changing by the month, if not by the week. What we were talking about six months ago seems light years away, now.

Health care and social care are integrally involved with each other. It is the government’s intention that the agencies should work more closely together, and this is entirely sensible. It would, however, seem wise to be aware of UHE’s plans for the provision or management of social care and whether they intend to enter the social care market, too. The risks of a developing a stranglehold on these combined areas need to be examined.

US-style health care. A clean bill of health?

It will be very difficult for any NHS practice, be it nurse-led or GP-led to compete against multi-nationals. If practices go, by default, to multi-nationals, we will, indeed, see the end of our current primary care culture. Under the guise of choice, competition and high-tech solutions, we will lose the very things that are valued so highly – public service ethos and continuity of care. Primary Care is collapsing in the US, and we are importing their ‘secrets’, simply because we are not there to see the mess that they have made of their own medical services. A recent report by a Reuter’s correspondent in Washington reported that the American College of Physicians predicts that American Primary Care is about ‘to collapse’. Most young physicians are looking for an ‘exit strategy’. A Swiss doctor, in a personal e-mail to a colleague in this country, wrote about the lack of altruism in American medical care. He says ‘There will never be a resolution to the health care crisis here because the primary incentive of every profession is almost always money: not the practice of medicine, not the care of the patient…uncontrolled privatization is a neocon ideology’.

Why does a company the size of UHE want a practice the size of Creswell/Langwith?

It is difficult to accept UHE’s argument that its dream is to provide high quality care in deprived areas. Critics argue that there are plenty of poor people in the US who are in need of health care, and the collapse of the levees in New Orleans amply demonstrated to the world that all was not well in the deprived communities of the US.

Critics argue that UHE needs a foothold into practices in order to get a hold of the lucrative commissioning budget in the NHS, worth billions of pounds. Commissioning, in the NHS, accounts for 80% of the NHS budget. The potential to manipulate this budget is huge. American corporations are unlikely to be in this business to provide our deprived areas with tender, loving care. One doesn’t have to be a cynic to realize that lower wages and ‘rationalisation’ of services will be needed to service shareholders’ profits. What will the British public feel when they see their precious NHS budget going to multi-national shareholders instead of being re-invested in patient care?

How will profits be made and where will they go?

UHE is absolutely clear that it is a profit-making organisation. This means that any efficiency savings that they make on health care will be extracted from the NHS as profits. Savings could be made by providing resources to keep ‘revolving door’ patients at home. Whereas this might seem a good thing, it could raise conflicts of interest in deciding where patients could best be cared for. It is clear that UHE has data analysis tools that will help in the management of long-term conditions. Economies from these methods, however, may not be enough. It will be necessary to make savings on wages. Any sensible multi-national will try to make savings by employing the cheapest possible people to do particular jobs. Although this may not sound a bad thing, we only have to look at some of the cost-containing practices in private nursing homes to see the effects this has on quality. Much valuable holistic care could be lost through fragmentation of medical care. While no-one could argue that there is no waste in the NHS, the tools that UHE have imported from the US could be used to save money to invest back into UK health care, rather than be paid to shareholders. Giving UHE the opportunity to take profits from the NHS seems a curious way of solving the problems of escalating costs. We will still be paying the bill decades from now. There may be short-term gain, but at a huge and tragic long-term cost.

Importantly, it would be difficult to persuade the British public of the rationale behind allowing substantial tranches of the NHS budget to go into the hands of multi-national shareholders.

The next generation of doctors and nurses. Training and pensions.

While it is inevitable that everything changes, I think that most people would regret if our young doctors and nurse were being trained, by the NHS, to work for global profit-making organizations. The ethos of the NHS has provided motivation to generations of staff, and its effect is inestimable. All of us know staff, who give extra hours and weeks to the NHS because they believe in public service and they have a passion to care for patients.

It is not clear how, or if, UHE will involve themselves in training young clinicians. Before awarding contracts to UHE, and allowing them to take over practices one by one, surely someone should be asking what are UHE’s intentions with regard to clinical education? Is the drive to privatization so urgent that no-one has time to think or ask any questions? Surely we should be given time to prepare our future generation of doctors, nurses and managers for the aggressive entrepreneurialism of the future?

Of concern is that UHE will not be offering access to the NHS pension scheme. While this is a generous scheme, and one that might be regarded as too expensive to sustain, NHS staff need to know this.

Conclusion

Those responsible for the current decisions about the NHS have become used to the idea of involving profit-making multi-nationals directly in the NHS. Ordinary people, however, still have an instinctive dislike of treating patients, and health care, as commodities to be traded. Those in positions of power are denying this reality. This could be described as ‘ethics creep’; it no longer seems strange; they can justify it to themselves. Driven by ideology, they don’t want to see the risks. In the arrogance of power, they see no need to explain anything, or seek consent.

Even if there were no ethics involved, we must think of the future and imagine the NHS, ten years from now, unable to re-invest in, and direct, its own health and social care.

Thank you for bringing my concerns to the attention of your colleagues. These issues must be debated. These changes will come in, unopposed, ‘if good men do nothing’.

Yours Sincerely

Dr E D Barrett

Smith v North East Derbyshire Primary Care Trust [2006] EWCA Civ 1291

Like a beast put into our cage’

By Margaret McCartney

Published : September 1 2007 03:00 Financial Times

You might have heard of the strange case of Creswell, in north-east Derbyshire. Last year, the general practice there went out to tender, a government initiative designed to increase competition among potential healthcare providers. The contract for running Creswell’s general practice was won by the multinational “diversified health and wellbeing company” UnitedHealth Europe.

However, a local woman named Pam Smith challenged this decision and, after initially losing her case at the High Court, successfully applied to the Appeal Court, arguing that the community had not been adequately consulted in the tender process.

The Department of Health then intervened, saying that there was no need to consult the community. So after the appeal was upheld in August 2006, the whole thing went out to tender again and, in February this year, was won by another private company that provides healthcare, Chilvers McCrea.

Seven months on, Chilvers McCrea has yet to sign the contract and yet to start work. It was due to sign the contract on June 4 but, three days beforehand, was advised that it had no lease for the building. While all this has been going on, the Creswell practice has been run by the Derbyshire Primary Care Trust, surviving through a mixture of locums.

The minutes from a meeting in July of the primary care trust, which was responsible for holding the tender process, note that “this tender has proved a costly exercise” and that Chilvers McCrea “are actively recruiting permanent medical staff, though have expressed concern that this is proving difficult”.

Chilvers McCrea has now recruited permanent staff. But instability appears to be an inevitable part of such tendering processes, which seem to place remarkably little emphasis on who will be doing the work. To illustrate: companies applying to tender to Creswell were required to provide documentation in support of their applications, including cashflow projections; but what seems not to have been asked, in the first round at least, is which people would actually be providing the frontline care.

Am I alone in thinking that if I was running this process I’d want, as a matter of priority, to know who was actually going to be seeing patients? I would want to know the qualifications of the staff, their range of abilities and experiences. I might even want to meet and interview them. I might also want to know about the location, the building and transport links but, surely, the quality of the frontline medical care would trump just about everything else.

The irony is that within Creswell there were a number of local GPs who wanted to provide medical services to the community, including a group of locums prepared to become permanent. Dr Elizabeth Barrett is a GP well known within the area. She had the support of her parish council to the extent that they were willing to give her practice free land for a new purpose- designed building. This was not enough for her to succeed in the tender process.

Should competition apply to providing quality, cost-effective healthcare? Continuity of care is one of the markers of good, safe and satisfying patient care. The fragmentation of a coherent, doctor-led general practice service is therefore an enormous change in the way we get healthcare and one that seems to have escaped public scrutiny.

Those in favour of privatised contractors taking over primary care, point out that GPs are for the most part self-employed contractors to the NHS. It is true that some GPs are – or become – self-interested but it is also true that most still care about professionalism and patient satisfaction and work as a stable cottage industry, with little ambition to conquer neighbouring practices. When I talked to Dr Barrett, she told me: “In general practice we have probably become complacent and the private sector has been put like a beast in our cage. We need to be committed and responsive to the customer.”

For Dr Barrett, “the choice is of a market-based system or a community-oriented collaborative process. Do we really want general practice run like a supermarket chain or a mechanistic production line? Primary care is far more than that,” she says.

Let’s agree that general practice has to be innovative and responsive to the needs of patients. The question then is how we want to do this. If we model healthcare on businesses, we may be able to count and shift units – or patients – very well. However, if this is all we are willing to pay for, we haven’t begun to think about what the cost to the patients might be.

Margaret McCartney is a GP in Glasgow.

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