The involvement of private companies in NHS general practice

Abstract

May improve access but weakens the foundation of primary care in the NHS

The involvement of private companies in the National Health Service always generates controversy. Some people believe that only commercial interests can bring innovation and efficiency to modernise the NHS. Others assume that the profit motive is incompatible with the pursuit of excellence in health care.

This debate has been reignited by the announcement that United Health Europe, a subsidiary of a large American health company, has won a contract to run three NHS general practices in London. This is the latest in a series of similar acquisitions by commercial companies throughout England. The government is also investing £250m (€335m; $487m) in establishing at least 150 new health centres, many of which will probably be run by private companies.¹

These developments are meant to increase access to primary health care in areas where existing contractual arrangements have not provided adequate services.² The establishment of new health centres is linked to the aim of developing large polyclinics that offer extended services and wide opening hours.³ However, these changes are also part of the broad policy direction to encourage a market within the NHS, with greater managerial control and competition between different types of provider, including private companies.²

Those in favour of private sector involvement argue that it brings entrepreneurial energy and ideas, backed by good management, which encourage innovation and challenge entrenched ways of working. The profit motive should ensure greater efficiency and a focus on the wishes of consumers. Opponents highlight the negative experiences of other countries, including higher overall health service costs, manipulation of the market, and “cream skimming” to select low cost patients. Rather than spreading innovation, new approaches to the delivery of care are copyrighted, branded, and marketed, with little regard for evidence or partnership. Perhaps most importantly, private provision can create conflicts for doctors between what is best for patients and best for profits, and this can undermine trust between patients and doctors.

What are the implications for patients of privately run general practices? They may be able to obtain care that is more easily accessible, of more consistent quality, and more “consumer friendly” than is sometimes the case within the NHS. The investment in new health centres will make a wider range of services available outside hospitals in smart new facilities, although these benefits would be evident whether they were run by commercial or non-profit organisations.

But this increased accessibility is likely to be at the cost of reduced personal care. Commercial companies seem to have won some contracts partly on the basis of price.^{4 5} Because the greatest proportion of expenditure in general practice is on doctors’ pay, their involvement in consultations will probably be reduced by triaging requests for appointments and using nurses and healthcare assistants to provide most care.⁶ In addition, lower paid salaried doctors working in shifts, who are not subject to national agreements about pensions or employment rights, will probably be employed. Such posts will be more attractive to doctors who want short term sessional work with no commitment to the area or the practice. Some patients, especially young, healthy, and infrequent users of the service, value convenience and accessibility over a relationship with a particular doctor, which is generally more important to elderly patients and those with long term conditions.⁷ Critics will point out that it is precisely this first group of patients that private providers will want to attract.⁶

For doctors, the potential effect on professional autonomy is perhaps the most profound. General practice in the United Kingdom has a strong professional identity and primary health care is well established. This forms the foundation for the equity, efficiency, and effectiveness of the NHS. The registered patient list system promotes a sense of responsibility for individual patients and local communities. Although variations in quality and problems with accessibility do occur in some areas, most practices are well organised and highly valued by their patients. Unlike in most other countries, the status and salaries of primary care doctors and specialists in the UK are comparable. Consequently, general practice attracts many of the best doctors, who are often motivated by getting to know their patients and being able to influence how care is provided rather than working in a large impersonal organisation. If privately run practices reduce costs by employing doctors as shift workers without recognising what motivates them, then general practice will again become the refuge for those who have “fallen off the ladder” towards a specialist medical career.⁸ The consequences for patients and for overall healthcare costs, as well as for doctors, will be poor.

Where will these changes ultimately lead? Privately run practices could act as catalysts for change, permanently at the margins of mainstream general practice. But it is more likely that private companies view their first health centres as “loss leaders.” General practice may follow the pattern established in the UK by pharmacists, opticians, accountants, and other professions, with independent practices being gradually taken over by corporations until the market is dominated by large commercial chains. These developments have potential benefits of increasing the pace of innovation but also serious risks of damaging doctor-patient relationships, increasing inequities in provision, and weakening the professional autonomy of general practitioners. The current direction of change is being driven at great speed with minimal consultation and often in the face of strong local opposition. It is time for a serious public debate about the type of general practice that people want and need.