Sunday, 2 September 2007

From the Financial Times

Like a beast put into our cage'
By Margaret McCartney

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 cash flow
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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