Abstract
The road is now clear for supermarkets and retail pharmacies to directly provide GP services—but is this “24-7 healthcare” really likely? Lynn Eaton assesses the odds.
The government announced proposals last week to open up the provision of GP services, particularly in under doctored areas, to new providers—including, potentially, supermarkets and retail pharmacies.
Health secretary Patricia Hewitt said the move was to ensure all patients would be able to gain access to health services. She wanted to attract a “broad range of providers, from existing entrepreneurial GPs to social enterprises and” —here's the rub—“corporate independent providers.”
Boots the Chemist, which has just opened a GP surgery at a store in Poole, Dorset, welcomed this as “good news.” “We know from the success in Poole, and our experience of offering a chlamydia screening service in London, that accessibility to health services, especially in the evenings and at the weekend, is important,” said Alex Gourley, its director of healthcare. “We will be exploring these new opportunities with the NHS both nationally and locally.”
But Hamish Meldrum, chairman of the BMA's General Practitioners Committee, was less happy: “What we don't want to see is any attempt to use this announcement as a back door way of privatising the NHS.”
An underlying worry is that “corporate independent providers” could include the likes of Boots the Chemist, Asda, or Sainsbury's, for example. It's understandable that general practitioners might fear this new face of primary care as a threat to their business. Could the 24-7 culture be foisted on them by the big supermarkets, muscling in on areas where individual general practices aren't able to meet patients' perceived needs?
It's not even clear whether Boots and Asda would ever want to take on direct provision of primary care—or, indeed, to do business with the NHS. Although they are interested in having GP surgeries within their stores, so far neither company has voiced any intention of being direct providers of primary care. If anything, they want to steer clear of it, insisting they are merely renting out empty space to others.
Renting space to NHS providers
When Boots the Chemist opened a surgery on the upstairs floor of its city centre store in Poole, Dorset, in February, it was adamant that it was merely renting the space to an NHS provider. “We are basically acting as a landlord,” says company spokesperson, Claire Stafford.
Although the store is open late and on Sundays, the GP surgery—a satellite surgery of an existing GP practice—is currently opening conventional surgery hours. In response to patients' requests, the surgery also offers physiotherapy and phlebotomy services.
Rob Payne, project manager with Bournemouth and Poole PCT, emphasises that the venture is definitely not “backdoor privatisation”: “These are NHS services, free at the point of delivery. It's about trying to add value. We were very open and transparent about what we were doing, and we got strong support from the local GPs.”
Boots, meanwhile, believes it makes commercial sense. “It's obviously a benefit for the company,” says Graham Webster, a pharmacist and director of Boots' western region, which covers Poole. But, he adds: “I don't think we'd go down the model of employing GPs ourselves. In any case, why would a GP want to move from their own independent practitioner status?”
Using underused retail space
ASDA, a subsidiary of the American retail giant Wal-Mart, is currently negotiating with primary care trusts for out of hours, walk-in surgeries in several of their 24 hour stores. The chain is negotiating with the NHS through a third party (who it would not name, other than to say it is the same organisation that found sites for NHS walk-in centres).
John Evans, superintendent pharmacist with Asda, said the idea was to use underused retail space: “We are not going to employ GPs. That is probably a step too far. Working with GPs could be difficult because we don't have the expertise at the moment. We are just looking to use areas we don't use at night, such as the optician's or pharmacy.”
But even if the BMA is merely sabre rattling about backdoor privatisation, GPs cannot afford to be complacent about the potential threat, warns Dr Michael Dixon, chair of the NHS Alliance.
“It's a wake-up call for the profession,” he says. “If supermarkets are going to open surgeries with longer hours, it's going to put pressure on GPs to open longer too.”
There is, though, an acknowledgement within government circles that current primary care provision could be improved—as outlined in the recent white paper Our Health, Our Care, Our Say. The national clinical director for primary care, David Colin-Thomé, believes that shifting GP surgeries into supermarkets is, potentially, a good idea. “What I think we have got to do is to unclutter our minds into what would be good for patients. If the patients are happy with that model, what's to stop them?”
He points out that, should it ever reach the point where supermarkets directly provided GP services and employed the GPs themselves, they would still have to answer to the primary care trust (PCT) for the standard of care provided.
Like Michael Dixon, he sees this “threat” as healthy competition: “I speak as a GP—a bit of competition does sharpen up things. I have no problem with it. But you need to keep the principles of good general practice.”
And big business, he suggests, might be a better manager of primary care than many GPs: “As GPs, many of us quite like the flexibility that [the current model] brings us as clinicians. But as for the management side, other organisations might well do it better.”
So how real is the threat of backdoor privatisation of primary care?
Real enough, if you look at what has happened in social care in the last decade. Although we've yet to see a high street giant like Marks & Spencer provide home helps along with bed linen, the face of care provision has changed beyond recognition.
Voluntary sector organisations sit alongside multinationals offering services that were once in the hands of local government. Care homes are run by anyone from big companies like BUPA through to local entrepreneurs who set up a single, 20 bed residential home. What's to say primary care won't go the same way?
Nigel Edwards, director of policy with the NHS Confederation, points out the flaw in the “backdoor privatisation” argument. NHS primary care provision is already privatised, he reminds us, and has been since the inception of the NHS in 1948. “GP practices are independent businesses run by independent people,” he says.
However, as one commentator put it, primary care is currently provided on a rather cosy small business model, more akin to the high street of a small French town, with individuals running their own, distinct business concerns, than to the US shopping mall.
So maybe the real question is not whether primary care services will be privatised (they already are). It's whether we might now see the corporate heavyweights—the chains and multinationals that grace our shopping centres—muscling in on the primary care act.
While a range of providers might increase patient (or, should we say, consumer) choice, the supermarket model is a step too far for most doctors. “We have to ask whether [supermarkets] are the right places to provide care,” said Vivienne Nathanson, head of science and ethics, at the BMA's Annual Representative Meeting last summer.
At the same meeting, GP Kailash Chand added: “The notion that nicotine and alcohol may be sold where primary care services are to be is anathema to the medical profession.”
To date, the only two independent providers to have won primary care contracts are both specialist providers. Last year, Barking and Dagenham PCT commissioned Care UK to provide a new GP practice and walk in centre. And City and Hackney PCT has commissioned Mercury Health to provide facilities in the Stamford Hill area. It's hardly a takeover by high street superstores.
However, Michael Dixon does see change ahead, as PCTs try to provide patients with the longer opening hours and Saturday morning surgeries.
“Unless, as a GP, you are a real businessman, you will need to get into bed with somebody [in order to do this]. The question is about getting into bed with somebody who doesn't want to take you over.”
Maybe the threat of corporate takeover is a bit far off at the moment. But, warns Dr Dixon: “There is pressure on GP practices to shape up. The government has tried the command and control method, but they can't do that because GPs are independent practitioners. The next thing was to bribe us—which was the new GP contract.
“The last thing is to create the big bad wolf of open competition—which is what we are beginning to see now.”
“The notion that nicotine and alcohol may be sold where primary care services are to be is anathema to the medical profession.”