More competition medicine - now it's your GP's turn

GPs are the most cost-effective part of England's NHS - so why is the government so keen to make radical changes to address the lack of 'competition'?

Deborah Colvin
9 September 2013

Image: Vaguely Artistic / Flickr. Some rights reserved.

Health regulator Monitor - whose primary duty is to investigate anti-competitive behaviour - is currently consulting on the “competitiveness” of General Practice and primary care in general. In particular, Monitor is calling for any evidence that lack of competition acts against the interest of patients. Alongside this, NHS England is consulting on improving primary care through such things as ‘stretching ambitions’, more ‘choice’ and different ‘contracts’.

Continuous improvement is a laudable goal - but not if it results in the destruction of something that is already working very well. So what is the shocking state of affairs that is causing Monitor and NHS England such concern?

Nine out of ten people are satisfied with primary care, they report.

GPs are spaced out across the country, ensuring equal coverage across the population. The amount of money flowing in to each practice is roughly similar so that all practices can offer patients the same quality of care. Patients are free to change GP to find someone that suits them.

Mortality rates are falling. Care is shifting from secondary to primary care, meaning people get treatment in the community and do not have to go to hospital.

This care is being extremely efficiently delivered - despite the fact that funding is not following patients into primary care.

General practice uses a remarkably low proportion of the NHS budget cake - looking after one person for a year costs £146 (compare that to approximately £100 per attendance in Accident and Emergency).

But Monitor and NHS England aren’t satisfied.

Monitor’s consultation focuses on how Clinical Commissioning Groups (CCGs) decide whether to commission from general practice. Monitor is questioning how strong the ‘market’ is in general practice.


Health economist Arnold Relman, writing recently in the New York Review of Books, outlines the consequences of a market in health care. Reviewing David Goldhill’s Catastrophic Care and Steven Brill’s A Bitter Pill, Relman asks “How should Obamacare be fixed?”. Relman concludes that the cheapest and safest system would be one that sounds very like the NHS - one of the cheapest and most effective health care systems in the developed world, with general practice at its heart.

Relman shows that competition in health leads to rocketing prices and deteriorating quality. Money flows into advertising, chief executive pay and transaction costs. To concentrate on improving health, you cannot see good health as a commodity to be bought by the highest bidder and to be used to make a profit out of. That way the rich and corrupt live off the ill-health and misfortune of others.

So why is the government is so keen to pay Monitor to undertake this enquiry? Why is its priority to expose the supposed lack of competition in primary care?

I then spend an hour responding to NHS England’s extraordinarily detailed consultation. Years of responding to these have left me feeling cynical - that the outcome has already been decided upon.

Again, NHS England concludes that primary care is amazingly productive and successful. It goes on to outline, however, that general practice is now reaching crisis point with serious workforce issues.

And the key question NHS England asks?

‘‘How do we best roll out new models of patient choice?’’.

 Is this the priority? We cannot constantly increase patient choice without having extra capacity in the system in order to allow choice. Extra capacity costs more because staff have to be idle some of the time waiting for a patient to choose their organisation. The only alternative is that health workers pay goes down in order to fund staff being idle in order to be able to respond, further contributing to the demoralisation NHS England have previously mentioned.

NHS England goes on to ask “How do we stimulate stretching ambitions for primary care?” ‘‘What can be done to increase GP involvement in planning and strategizing?” There are questions about putting GPs at the heart of more integrated primary care, giving us greater responsibility for out-of-hours care and care for people with complex needs.

Do they want us to come up with plans to encourage GPs already on their knees with work overload to do this voluntarily? Or are they considering some sort of reward system, either money or additional cover when we are attending the meetings needed to do this?

 I fear the former.  NHS England asks how we can stimulate improvements in efficiency. At £146 per patient per year I would say we have a very efficient system already.

NHS England asks how we can ‘stimulate more convenient routine access to general practice services’?

This is disingenuous. Patient consultation rates have risen steadily. 20 years ago the average patient saw their GP twice a year. Now GP practices handle an average of 12 consultations per patient per year (7 with the GP and 5 with a nurse practitioner). Perhaps we should be asking “How can we help the public become more health literate and support them in using their NHS wisely?”?

The consultation enquires about the role of different contracts in ‘stimulating’ primary care. This is where I begin to suspect the motive in their madness.

It appears the model that has worked so well for so many years with such a tiny share of the overall budget must be thrown out on the assertion there is sure to be a better one - in spite of the wealth of peer-reviewed academic research showing that the NHS, with general practice at its heart, is one of the most efficient models in the world. One wonders why they want to replace it rather than work on the few weaker areas to improve them.

The answer to all these questions is extremely simple: fund general practice so that each full time GP has a list size that is half of the present and then you will be able to truly achieve wonders.

If we, the public, are not satisfied enough with the extraordinarily good value service we have then perhaps to get more we need to pay a bit more.

To expect that some sleight of hand, some brilliant new way of doing things or extraordinary productivity drive will solve the problems of an underfunded service is dishonest. All that will happen is that primary care will be driven into the ground.

The evidence is already mounting. GPs are working longer hours, they are leaving the profession - or the country - and young doctors are not going in to general practice, leaving a looming shortage of GPs.

What improves a service is professionalism. Allow those that do the work to figure out new ways of delivering. Improvement does not come through remote managers designing a new ‘breakthrough’ in care delivery. It comes through the people at the coal face working steadily with small incremental steps that gradually make things better. The NHS has improved steadily ever since its inception. Opening it up to unbridled competition whilst starving it of funds is not the way to continue to improve.

These consultations continue the assault on the NHS and on primary care in particular. It asks the wrong questions, in spite of all the evidence they already have that the main problem is under-funding. They don’t want to admit that on the whole the NHS is doing a good job and that in order to meet rising demand and increase costs of drugs and equipment they need to put more money in.

Behind the hand-wringing and caring words, there is a fundamental dishonesty in both reviews.

Primary care is cheap, efficient and safe. If you want more, pay for it. Instead money continues to flow to secondary care and the spiralling costs of administration and re-organisation costs whilst primary care is publically criticised for not being up to the job.

The double speak of those in power continues to amaze.

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