Two groups of GPs have written to two primary care trusts (PCTs) in London expressing concern about the potential effect on the quality of care after a second contract to run a general practice has been awarded to a private company rather than to local GPs.
Camden Primary Care Trust announced in late January that it had awarded the tender to run three GP surgeries—King’s Cross Road Practice, Camden Road Practice, and Brunswick Medical Centre—to UnitedHealth Primary Care (BMJ 2008;336:295, 9 Feb doi: 10.1136/bmj.39481.889155.C2).
Four local GPs who bid for Brunswick Medical Centre, which they had been managing successfully for the previous six months, have written to Camden PCT expressing their concern that “patient care will suffer.” They believe that the decision was based “purely on cost, as opposed to quality.”
Previously, another London PCT, Tower Hamlets, awarded a tender to run St Paul’s Way Medical Centre to Atos Origin, an international information technology services company. Again, local GPs who had bid to run the practice were unsuccessful.
Tower Hamlets Local Medical Committee (LMC), which represents practices in the area, wrote to the PCT outlining its “loss of confidence in the PCT’s commitment to providing good quality primary care.” It said, “The LMC is concerned that factors such as continuity of care and the doctor-patient relationship will ultimately have to be sidelined in order to meet the financial targets put forward by Atos Origin.”
The GPs bidding for the Brunswick Centre practice said that their bid had initially been approved by Camden PCT as “affordable” and was judged to be of higher quality in some areas than the bid from UnitedHealth. Camden PCT scored the group of GPs higher than UnitedHealth in clinical areas, with 468/550 points (85%) for core services and 37/50 points (74%) for clinical governance. UnitedHealth scored 360/550 (65%) and 31/50 (62%) in these areas. The GPs also scored higher in the service development plan total, with a score of 761/950 (80%), against UnitedHealth’s 645.5/950 (68%).
The trust’s service specification stated that submitted bids would need to achieve a minimum of 80% of points available in each section in order to be shortlisted. Even though neither of the two bidders achieved this (although the GPs scored just over 80% overall), both groups continued to the next stage.
The trust then added a value for money measure, which the GPs said had not been mentioned to them in the specification, by comparing the service development plan total with the proposed baseline price. This gave a total score for the GPs of 7.61, against 8.62 for UnitedHealth, and the trust gave the contract to UnitedHealth.
One of the group of GPs, Stephen Graham, said that because they had costed their bid on the basis of providing services that scored as high as possible in terms of quality of care, their bid had inevitably been more expensive. He said, “It appears that cost cutting has won hands down over quality of service provision.”
Another of the GPs, Richard Halvorsen, added, “This is another example of a cut price privatised service being imposed on patients against their will. I fear that patients will suffer as a result of this cut price privatisation.”
In response Peter Smith, director of primary care at UnitedHealth, said, “UnitedHealth’s focus in delivering primary care services is to strengthen the quality and availability of health care where it’s needed most. Like all GPs we are contracted by the local PCT to deliver high quality care, and we can only succeed if we meet the targets demanded of us. We use our experience to understand the unique needs of community and develop services to meet these identified needs in partnership with patients, staff, and local PCTs.”
The local medical committees remain concerned that GPs missed out in the PCTs’ decisions. Stephen Amiel, chairman of Camden and Islington LMC and a GP in Kentish Town, London, said, “There was clear evidence that the bid accepted did not score the highest on quality markers.” He said that the value for money measure used by Camden PCT should be made public to ensure that the decision making process is completely transparent.
Sella Shanmugadasan, chairman of Tower Hamlets LMC, expressed similar concerns about the decision on the St Paul’s Way practice. He said, “Local practices were actively encouraged to apply for the provision of this practice by the PCT. However, it has become clear that the PCT is only concerned with the bidder able to offer the best value for money.”
Commenting on its decision Camden PCT said, “It was clear from the start that we were looking for the best bid at the best value. This is standard procurement practice.”
It further said, “Camden PCT’s procurement policy is to ensure that contracts offer both high quality services for local people and good value for money for the taxpayer, in line with current procurement legislation. We are unaware of any specific DH/SHA [Department of Health and strategic health authority] guidance that requires contracts to be awarded in any way other than that described above.”
It added that the winning bidder scored highest against the overall selection criteria communicated to all bidders. “The successful bidder will be contractually required to deliver the service specification in its entirety and not a percentage of it.”
Rob Larkman, the trust’s chief executive, said, “This has been a very rigorous process, and we are satisfied that Camden PCT has secured excellent services for the patients of these three practices. We will be working with the practices, staff, patients, and UnitedHealth to ensure a smooth transition for everyone.”
But doctors’ leaders fear that GPs are doomed to fail in bids to run practices. Dr Amiel said, “The dice are loaded against GPs in lots of ways. Even when they have demonstrated quality in the practice they are bidding for, with the advantage of local experience and knowledge, they are unable to compete.”
The GPs who had been running the Brunswick Medical Centre had increased the practice’s opening hours from 36 to 45 hours a week and set up several new initiatives designed to meet local needs. These included weekly antenatal clinics, a diabetes clinic, and a Bengali clinic (the practice has a high proportion of Bengali speaking patients), at the same time as reducing the costs of prescribed drugs.
And GPs bidding for the St Paul’s Way practice had previously been praised by the PCT for their high standards of care, Tower Hamlets LMC said.
Dr Shanmugadasan considers that further bids to run practices will be awarded to private companies rather than to GPs. “The LMC is concerned about the implications for the future . . . especially [about the fact that] six practices are still currently managed by the PCT and that these could potentially be awarded to private organisations.”
Laurence Buckman, chairman of the BMA’s General Practitioners Committee, said, “There has to be a level playing field in the bidding process for GP practices, and it must be fair and totally transparent. We are very worried that PCTs are being put under pressure to opt for private providers. Our concern is that large, corporate firms will put profits and the needs of their shareholders before patients and their quality of care. I hope the service that patients get will continue at the level of care they were used to.”
Dr Amiel warned, “The financial muscle means that GPs start at a huge disadvantage to a large private company. These organisations have staff that put bids together all the time, while GPs have to do it in their spare time.”
Camden PCT said that it made the decision after a review of bids for the three practices that was based on a specification developed after a public consultation in the borough. It said that the decision was based on quality of services and value for money. In a statement it said, “UnitedHealth already provides family doctor services elsewhere and has delivered improvements in care, extended opening hours from 8 am to 8 pm, increased opportunities for patients to have their say in the way services are shaped, and introduced a wider range of services to local people.”
UnitedHealth Europe took over the management of the Normanton Medical Centre in Derbyshire in 2006 in one of the first contracts for primary care services between the NHS and a private provider (BMJ 2006;332:194 doi: 10.1136/bmj.332.7535.194-b). Since taking over, UnitedHealth has “made considerable improvements to patient care, the patient experience and staff morale,” report minutes from a recent meeting of Derby City PCT.
UnitedHealth’s Dr Smith said, “The improvements we’ve been able to deliver at Normanton include the recruitment of a permanent GP and nurse practitioner to the practice. We have extended opening hours so the surgery is now open from 8 am to 8 pm Monday to Friday, in direct response to patient need. We have also been working with the local community to identify those patients with long term conditions such as asthma, heart disease, and diabetes and have been proactively calling them into the surgery to identify potential problems before they occur.”
He added, “Proactively managing and identifying those patients with chronic conditions has been a crucial area of development, and all chronic patients now get a regular call from one of our team to check on their progress. This is the type of work that will help us deliver to patients the care they need and expect within their local community—and is the reason that in the first year of our work at the Normanton practice our list has grown by over 1000 individuals and the QOF [quality and outcomes framework] score improved from 81% to 93.7%.”
The PCTs that decide on bids for practices are managed by teams of executive directors, together with non-executive directors appointed after open advertisement. They are charged with delivering health care for their local areas, but their financing and much of their agenda are determined largely by directives from the local strategic health authority and the Department of Health. The department has increasingly been encouraging a market with competition between different types of provider, including private companies, in its primary care contracting programme.
The chairman of Camden PCT is John Carrier, who lives locally and is a senior lecturer at the London School of Economics. In a book he recently published, Health and the National Health Service, he reviewed the recent responses to the apparent failure of health care in the United Kingdom and concluded that the NHS had successfully met the challenges it faced when founded more than 60 years ago and was likely to continue to meet the changing health needs of the population.